El Hadidy Mohamad El Hadidy
Professor of Internal Medicine & Endocrinology
MIS is a non smoker Egyptian male patient
66 years old from Mansoura suffered from
hypertension since 10 years and was well
controlled on Natrilex SR once daily.
He developed diabetes mellitus since one
year and was well controlled on Amaryl 3
mg once daily.
He presented with gradual loss of weight
since the appearance of diabetes with loss
He also had food induced abdominal
discomfort with all varieties of food.
There was constipation since one year. There
was no other GIT symptoms.
There was no other symptoms referable to
There was no FH of DM or HTN.
The patient appeared cachectic , fully
conscious, well oriented. Pulse 90/min
regular, RR 15/min. temp. 37 C, BP 130/75
mmHg. Height 184 cm, weight 70 kgm.
There was pallor. There was apparent
decrease of muscle mass and prominent
bones of shoulder and pelvic girdles.
General examination was otherwise
Abdominal examination revealed
Enlarged mildly tender liver with liver span of
about 16 cm.
There was deep epigastric mass of more or
less firm consistency with mild tenderness
over the epigastrium.
There was no other remarkable abdominal
Chest and heart examination revealed
Clinical impression and DD ??
Ask for investigations?
Radiologic study revealed:
Spiral triphasic multislice CT
Diffusely swollen pancreas with
heterogeneous hypodensity with areas of
degeneration and dilated main pancreatic
duct with encasement of celiac trunk, main
portal vein, SMV and SMA. Also infiltrating
the surrounding fat. No calcification.
Multiple enlarged LNs in porta hepatic,
aortocaval and para aortic regions.
Dilated CBD 18 mm diameter, common
pancreatic duct 10mm diameter
Marked dilataion of intrahepatic biliary
radicles with gas density inside.
Enlarged non cirrhotic liver with multiple well
defined enhancing areas in both lobes. On
triphasic study they show arterial
enhancement…..likely cholangitis with
starting chalngitic abcesses.
Laboratory work up revealed:
Urinalysis : no abnormal findings.
CBC: Hb 11gm% microcytic hypochromic morphology.
TLC 23000/cmm ( N 49%, E 3%, B 1%, L 43%
M2%, Band 2% Platelets 434000/cmm.
ESR 105/ 130 mm ( 1st/2nd h).
FBS 116 mg %
SGOT, SGPT : 55u, 47 u/L
Bilirubin 1.3 mg %
s. creatinin 1.4 mg %
Serum Ca : 6.2 mg%
Serum lipase 91 u/l ( N less than 200 )
Serum amylase 72 u/l ( N less than 86)
CEA 0.2 ng/ml ( N lees than 3.4 )
CA 19.9 27 u/ml (N 0-39 ).
Ig G 1529 mg % ( N 700- 1600 mg
Ig G4 128 mg% ( 8-140 mg%).%)
Diagnosis & management
The patient was advised to see a surgeon.
But the patient refused any intervention.
The patient was given conservative
Oral digestive enzymes
Prednisolone oral 30mg\day
Alphachemotripsin IM daily
Premixed insulin MDI
Response to conservative ttt:
The patient resumed good appetite with no
more food induced abdominal discomfort.
He started to gain body weight with fair
improvement of the general conditions.
The epigastric mass becomes hardly
Abdominal Ct and laboratory work up were
asked after one month of the conservative
Follow up Ct Report :
Large well defined hypodense soft tissue mass
7x5 cm. with hererogenous enhancement after
contrast and air density inside. The mass infiltrates
head and neck of pancreas encasing splenic and
hepatic arteries without attenuating their lumin.
Dilated CBD & pancreatic ducts. Evidence of air in
IHBR ( suggesting fistula formation ). Multiple
porta hepatic LNs.
Conclusion : infiltrating mass mostly malignant, for
Follow up ct abdomen:
Cont.Ct. abdomen follow up:
Follow up Lab Report:
TLC 27000/mm with PMN 47%
s. creatinine 0.9 mg%
SGPT 29 u/ml
SGOT 87 u/ml
S.albumin 3.4 gm%
S.bilirubin 0.8 mg %
Diagnosis ( suggested ):
Auto immune pancreatitis ?
( inflammatory pseudotumor )
Cholangitis with biliary enteric fistula