A case presentation on chronic pancreatitis

1. WelcomeWelcome
To The weeklyTo The weekly
clinical meeTingclinical meeTing

2. A 60 years old lady
presented with upper
abdominal pain
Presented by-
Dr. Jheelam Biswas
Intern doctor
MU- 6

3. ParTiculars of The
PaTienT
Name: Mrs. Hasi
Age: 60 years
Sex: Female
Religion: Islam
Occupation: Housewife
Marital status: Married
Address:
Rupnagar,Narayanganj
Date of Admission: 24.01.2014
Date of Examination: 24.01.2014

4. chief comPlainTs
 Recurrent pain in the epigastrium
for 2 years

5. hisTory of PresenT
illness
According to statement of the patient she
was reasonably well 2 years back. Then
she developed recurrent pain in the
epigastrium which was constant dull
aching in nature, radiated to back,
aggravated by taking fatty food and
relived by bending forward and taking

6. medication. The pain had no periodicity.
The pain was sometimes associated
with nausea and vomiting, which
occurred after taking food, and
contained undigested food particles. In
some occasion the pain became
sudden, severe and agonizing in
nature and didn’t relived by taking
analgesics.

7. For that reason she was admitted to
hospital 3 times and was treated
conservatively. She gave no history of
fever, jaundice, heart burn, chest pain,
respiratory distress, no history of intake
of any NSAID before the onset of pain,
haematomesis or melena or weight

8. loss or passage of loose stool. She was
normotensive and non-diabetic. Her
bowel and bladder habits were
normal.

9. hisTory of PasT illness
She had undergone hysterectomy 10
years back and had surgery for ovarian
tumor 8 years back.

10. TreaTmenT hisTory
She was admitted in local Upazilla
hospital 3 times and was treated
conservatively.

11. family hisTory
She is the 3rd issue of a non-
consanguinous marriage. Her oldest
sister died due to hepatocellular
carcinoma. Her second sister has same
type of illness, but her youngest sister
is healthy and alive.

12. Personal hisTory
She is non alcoholic, non smoker and
doesn’t take betel nuts or betel leaf.
She is accustomed to the normal
Bangladeshi diet.

13. socioeconomic
hisTory
She belongs to a low socioeconomic
condition . Monthly income of her
family is about 5000 tk. She lives in a
tin-shed house, drinks boiled water,
and uses sanitary latrine.

14. Allergic History

15. MenstruAl History

16. She never used any contraceptives.

17. generAl exAMinAtion
O Appearance: Ill-looking
O Body Build: Average
O BMI: 28 kg/m2
O Decubitus: on choice
O Co-operation: Cooperative
O Anemia: Severely anemic
O Jaundice: Absent
O Cyanosis: Absent

18. O Clubbing: Absent
O Koilonychia: Absent
O Leukonychia: Absent
O Edema: Absent
O Dehydration: Absent
O Pulse: 86beats/min.
O Blood Pressure: 120/70 mmHg
O Temperature: 98 F⁰

19. O Respiratory Rate: 20 breaths/min
O Skin condition: Scar mark present in
the left lower paramedian region of
lower abdomen
O Lymph Nodes: Not palpable
O Thyroid Gland: Not enlarged
O JVP : Not raised

20. AliMentAry systeM
O Oral cavity, gums, teeth :
appeared normal.
O On inspection : abdomen was
normal in shape. Umbilicus was
centrally placed, inverted. There was
two scar marks in the left lower
paramedian region. Her hair
distribution and

21. external genetalia was normal.
On superficial palpation: Local
temperature was normal, Tenderness
was present in the epigastrium, muscle
guard and muscle rigidity were present
in the epigastric region.
On deep palpation:
Liver and spleen were not palpable.

22. Both Kidneys were not palpable or
ballotable.
Murphy’s sign was negative.
Fluid thrill was absent.
On percussion: Percussion note was
tympanitic all over the abdomen.
Shifting dullness was absent.
On auscultation: Bowel sound
present.

23. cArdiovAsculAr systeM
All peripheral pulses were present in
all four limbs symmetrically, in all areas,
with normal rhythm and volume.
Palpation: Apex beat was felt at the left
5th
ICS 9cm from mid-line. Apical thrill
and para-sternal heave were absent.

24. On auscultation:
S1 and S2 was audible normally in all
four areas and there was no added
sound.

25. respirAtory systeM
On inspection chest movement was
symmetrical. No deformity present.
On Palpation: Trachea was central in
position and apex beat was felt in the left
5th
ICS 9cm from midline. Vocal fremitus
and chest expansibility was normal.

26. On Percussion resonant in all
intercostal spaces.
On Auscultation breath sound was
bronchial on both lung fields. Vocal
resonance were normal, and there
were no added sounds.

27. Nervous system
Higher psychic function: Normal.
Cranial Nerves were all Intact.
Motor system: Intact
Sensory System was normal.
Signs of meningeal Irritation was
absent.

28. salieNt Features
Mrs. Hasi, 60 years old, normotensive,
non smoker Muslim married female,
hailing from Rupnagar, Narayanganj was
admitted to this hospital on 24/1/2014
with the complaints of recurrent pain in
the epigastrium for 2 years.
According to the statement of the patient

29. she was reasonably well 2 years back.
Then she developed recurrent pain in
the epigastrium which was dull aching,
constant, radiated to back, aggravated
by taking fatty food and relived by
bending forward and taking medication,
had no periodicity, and was associated

30. With occasional nausea and vomiting
which occurred after taking meal, and
contained undigested food particles. In
some occasion the pain became so
severe, constant and agonizing in nature
that she had to be admitted to local
hospital 3 times and was treated
conservatively. She gave no history of

31. of fever, jaundice, hematemesis, chest
pain, heart burn or respiratory distress,
no intake of NSAID, haematomesis or
melena, no weight loss or passage of
loose fatty stool. She had undergone
hysterectomy 10 years back and had
surgery for overian tumor 8 years back.
She was habituated to normal

32. Bangladeshi diet. Her oldest sister died
due to ovarian carcinoma, and her
second sister was suffering from same
type of illness. She was non diabetic and
non alcoholic. Her bowel and bladder
habits were normal.
On examination she was severely anemic

33. with BMI 28 kg/m2
, her pulse was 86
b/min, BP 120/70 mmHg, respiratory
rate 20 b/min, temperature 98 F.⁰
There was two scar marks present in
the left lower paramedian region. There
was tenderness, and muscle guard
present in the epigastrium, but no
organomegaly, or ascetics was present.

34. Her other system examination revealed
no abnormalities.

35. ProvisionalProvisional
DiagnosisDiagnosis
??

36. Chronic pancreatitis

37. DiFFereNtial
DiagNosis
 Chronic cholecystitis
 Peptic ulcer disease

38. Investigations Findings
Complete Blood Count
(on 9.1. 14)
Hb%
ESR
WBC
Neutrophil
Lymphocyte
Monocyte
Eosinophil
4.8gm/dl
65 mm in 1st
hour
6500/ cumm
55%
35%
06%
4%

39. Investigations
(on 9.1.14)
Findings
RBS 5.5 mmol/l
Serum creatinine 0.9 mg/dl
S. lipase 478 U/L (upto 190 U/L)
S. amylase 43 U/L (upto 95 U/L)
Peripheral blood film Microcytic hypochromic
anemia possibly due to iron
deficiency

40. Investigations
(on 11.1.14)
Findings
Serum iron Profile
ALT 40 U/L (Upto 34 U/L)

41. Investigations
(on 11.1.14)
Findings
Fasting Lipid
Profile
Total Cholesterol
Triglyceride
HDL
LDL
105 mg/dl (<200)
100 mg/dl (<200)
<20 mg/dl (>40)
60 mg/dl (<150)
ALT 40 U/L (Upto 34 U/L)

42. Investigations
(on 14. 1. 14)
Findings
TSH 3.6 U/L (.0.4- 5.5)
S. bilirubin 0.7 mg/dl
S. calcium 10.1 mg/dl (8.10- 10.40)
Urine R/E Normal study
Blood Group B positive

43. Investigations Findings
ECG Normal study
Echocardiogram Normal 2D/M mode
echo with good LV
systolic function

44. Chest X ray (p/a View)

45. plane X ray abdomen ereCt
posture

46. usG of whole abdomen
Echogenicity in pancreatic
parenchyma with irregular
outline. MPD mildly
dilated.
Spleen mildly enlarged (12.8
cm along long axis)
Liver normal with
homogenous
echogenicity., with no focal
lesion.
Suggestive of chronic

47. Ct sCan of upper abdomen

49. Confirmatory
diaGnosis
Chronic pancreatitis due to
pancreatic calculi with iron
deficiency anemia