SCIENTIFIC
Appalachian Constellation : Type 3C Diabetes as the Link Between Diabetes and Chronic Pancreatitis
AUTHORS :
Justin Fletcher , MD WVU Medicine , Department of Family Medicine
Kendra Unger , MD , FAAMA WVU Medicine , Department of Family Medicine
CASE PRESENTATION
A 52-year-old male presented to the emergency department ( ED ) of a university hospital in West Virginia ( WV ) with acute and worsening epigastric pain associated with nausea , poor oral intake , and chest tightness for the previous three days . He had a five-year history of chronic abdominal pain and recurrent pancreatitis , gastroesophageal reflux disease , and hypertension . The chronic abdominal pain originally began following a cholecystectomy five years ago and persisted despite multiple treatments . He was hospitalized on five separate occasions across a six-month period with similar symptoms consistent with acute on chronic pancreatitis . Evaluation in the ED revealed that he had tachycardia , a low-grade fever , and epigastric pain on examination . Table 1 summarizes the results of his laboratory studies . A computerized tomography ( CT ) scan of his abdomen revealed mild fat stranding around the head of the pancreas consistent with acute pancreatitis .
The patient was treated for hyperglycemia and pancreatitis with intravenous ( IV ) hydration , IV insulin , and pain medication . Within 24 hours , his pain and nausea were much improved , he was tolerating a clear liquid diet , and his laboratory markers returned to a normal range . He did not receive additional insulin , and his glucose ranged from 107 mg / dL to 252 mg / dL . His hemoglobin A1c ( Hb A1c ) was 8.1 % ( as compared to 5.6 % nine months earlier ). The patient was presumed to have type 2 diabetes due to his elevated HbA1c . Treatment with metformin hydrochloride was initiated along with nutritional counseling for suspected diagnosis of type 2 diabetes .
ABSTRACT
Additional chart review revealed a magnetic resonance imaging ( MRI ) within the last six months that showed atrophy of the tail of the pancreas . Table 2 summarizes additional laboratory studies performed .
On hospital day three , the patient ’ s glucose remained elevated ( averaging 200-220 mg / dL ) without significant fluctuation , and his abdominal pain improved . He was discharged and continued on metformin hydrochloride twice daily as well as oral pancreatic enzymes three times per day with meals . Numerous attempts to follow up with the patient by phone , email , and mail were unsuccessful . Three months later , the patient returned to the ED with acute on chronic abdominal pain and was found to be non-adherent to his prescribed medications . His HbA1c had increased to 10.1 %.
DISCUSSION
Diabetes mellitus ( DM ) is a group of diseases characterized by elevated glucose levels . Type 2 is most prevalent and caused by insulin sensitivity , but other forms may develop as a direct consequence of other disease processes . This case illustrates the relationship between the chronic inflammation of the pancreas and its effect on glucose control . Type 3c diabetes warrants consideration in any patient presenting with recurrent or chronic pancreatitis and should be monitored for the development of hyperglycemia by measuring fasting glucose and HgA1c . 2 , 4 Despite this link ,
Diabetes of the exocrine pancreas , also known as type 3c diabetes , is caused by a variety of underlying mechanisms , most commonly chronic pancreatitis . Type 3c diabetes leads to chronic inflammation of the pancreas and results in frequent episodes of hypo- or hyperglycemia , and patients are commonly misdiagnosed as having type 2 diabetes . We report the case of a 52-year-old man from rural West Virginia ( WV ) who presented with a five-year history of chronic abdominal pain and recurrent pancreatitis . His physical examination , laboratory , and radiologic studies revealed an acute pancreatitis flare , and his elevated serum glucose level indicated new-onset diabetes , leading to a diagnosis of type 3c diabetes . Given the disproportionate rate of diabetes in WV , it is critical for healthcare providers to learn to recognize patients with diabetes with underlying pancreatic disease and to treat those patients appropriately .
DM following pancreatic disease is frequently misdiagnosed as type 2 diabetes .
Diabetes of the exocrine pancreas , also known as type 3c diabetes , is a complex syndrome that results in hyperglycemia . The most common cause of this disorder is chronic pancreatitis , 1 , 2 but other causes include acute pancreatitis , pancreatic ductal carcinoma , cystic fibrosis , and pancreatic surgery . 1 Research suggests that this syndrome may be present in 5-10 % of all individuals with diabetes in western populations . 2 Type 3c diabetes makes up about 9 % of hospitalized patients with diabetes , 3 of whom an estimated 40 % are misdiagnosed with type 2 . 3 Despite the prevalence of this disease , many providers do not recognize the symptoms and misdiagnose it . 2
Type 3c diabetes is a condition involving both exocrine and endocrine functions in the pancreas . Inflammation secondary to chronic pancreatitis leads to increased cytokine concentrations within the parenchyma of the pancreas . As inflammation progresses , the tissue undergoes fibrosis and scarring and results in the destruction of pancreatic islet cells and beta-cell function . In response to this damage , the exocrine pancreas decreases release of pancreatic enzymes , leading to malabsorption of nutrients . This impaired nutrient absorption reduces the response from the incretin system , which leads to decreased postprandial insulin secretion and epi-
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