54 CLINICAL FOCUS
54 CLINICAL FOCUS
4 AUGUST 2023 ausdoc . com . au
AUSDOC ’ S TOP FIVE CLINICAL ARTICLES
Case Report
A pancreatic puzzler
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A retiree ’ s vague epigastric and periumbilical burning pain presents a diagnostic challenge .
Dr Liz Fraser GP in Canberra , ACT .
ANDREW is a 69-year-old retired public servant who presents with vague epigastric and periumbilical burning pain that has kept him awake at night for the past few weeks .
There is no obvious relationship to meals , and symptoms are minimal during the day . OTC esomeprazole has provided short-term relief and improved sleep . Andrew reports no recent weight loss , nausea or change of bowel habits . He is usually well , has no significant medical history and takes no medications . He is a long-term ex-smoker and drinks socially , with two alcohol-free days a week .
A colonoscopy eight years ago found a tubular adenoma ; however , Andrew did not attend the recommended follow-up colonoscopy at five years . He had a negative FOBT six months previously . His family history includes a pancreatic problem in his paternal grandfather , although the exact diagnosis is unknown .
On examination , Andrew ’ s appearance suggests good health . He weighs 81kg , his BMI is 26kg / m2 and his vital signs are within normal limits . There are no signs of anaemia or jaundice . He has minor tenderness above the umbilicus and no abdominal masses .
Investigations
The GP organises another FOBT , urea breath test and general pathology , including lipase , and provides a short-term prescription for famotidine .
While most results are unremarkable , the lipase is elevated . Findings of an urgent abdominal ultrasound include mild fatty liver and a gall bladder polyp . While the common bile duct is not dilated , the pancreas appears slightly irregular .
An immediate abdominal CT is recommended by the reporting radiologist . This notes mild peripancreatic fat stranding but no obvious mass , collection or pancreatic necrosis . The findings are reported to be suggestive of pancreatitis . A repeat lipase within the week remains elevated .
Given these findings , the GP refers Andrew to a gastroenterologist , who reviews him promptly . The initial impression is early chronic pancreatitis , and Andrew is advised to stop all alcohol .
Further investigation reveals elevations of immunoglobulin G4 ( IgG4 ) at 2.8g / L ( normal : 0.02 – 2.01 ) and CA 19-9 at 92U / mL ( normal : less than 37 ). Panendoscopy and colonoscopy reveal minor gastritis and another colonic tubular adenoma , with no indication of biliary or pancreatic pathology .
In view of the elevated IgG4 , the specialist revises the diagnosis to autoimmune
pancreatitis ( AIP ) and initiates prednisone 25mg , with a plan to reduce the dose in 5mg increments over the following weeks and months .
Progress
One month later , Andrew re-presents to his GP with sudden-onset painless obstructive jaundice and is hospitalised urgently . Endoscopic retrograde cholangiopancreatography reveals
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