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John Murphy is a 37-year-old male who has been hospitalized more than 10 times for pancreatitis. He is following up from his last hospitalization with a new primary care doctor due to moving from his former home in a rural setting to Louisville.
He explains that his first episode of pancreatitis occurred in at age 16 and was thought to be due to viral causes.
After another bout at age 17, imaging studies were performed to evaluate for an anatomic abnormality and were negative.
He was hospitalized for 2 weeks last month for a pancreatitis flare, which presented with its usual symptoms of belly pain, vomiting, and intolerance of any intake. He was managed with pain control, IV fluids and jejunal feeds and gradually improved. He was discharged home when he was able to tolerate his maintenance fluid requirements via the J-tube and able to be kept comfortable with enteral pain medicines.
He and his family were told that it could recur and that the cause was unknown.
His biggest ongoing issue currently is trying to maintain a healthy weight. Since leaving the hospital, he has pain if he tries to eat too much in a sitting and so has to have many small meals throughout the day. He has several bulky stools a day and has tried dietary modification on his own to eliminate dairy, soy, wheat, without having any improvement.
Pancreatitis episodes as above
During one severe bout of pancreatitis, he experienced ‘lung failure’ that took months to recover from.
Gastro-jejunal feeding tube, which he only uses now if he is in a bout of pancreatitis.
Hydrocodone/acetaminophen 5/500 every 6 hours as needed. He tries not to take the pain pills during the day so he can drive and work.
He is the oldest of 4 children and 3 of the 4 have also had recurrent bouts of pancreatitis. When asked about a history of cystic fibrosis, he reports he has been tested repeatedly with sweat tests as well as blood tests and has been told that is not the cause of his recurrent pancreatitis.
He is married He and his wife purchased a home with his income, but he is very worried about their future as he has read online that recurrent pancreatitis could cause pancreatic cancer. He avoids alcohol because he feels like it precipitated the previous severe bout of pancreatitis with lung failure.
Exam: T 98.1 HR 85 BP 100/70 sitting SpO2 99% on room air. Weight 128 lbs., Height 5’11”, BMI 17.9
Gen: cachectic appearing, no acute distress
HEENT: oropharynx, conjunctiva and pupils, tympanic membranes and ear canals normal. Neck veins visible when lying down flat.
Chest: no murmurs or rubs, lungs clear
Abdomen: soft, nondistended, mildly tender to palpation and percussion, active bowel sounds
Rectal/GU: brown stool, guaiac negative, normal tone
Extremities: warm, skin appears dry and flaky
You obtain his records from his recent hospitalization and note the following significant findings on his labs performed on the day of discharge from the hospital:
| Test | Value |
|---|---|
|
Hgb |
14.4 g/dL |
|
Sodium |
134 mEq/L |
|
Potassium |
4.1 mEq/L |
|
Chloride |
110 |
|
Bicarbonate |
16 mmol/L |
|
BUN |
5 mg/dL |
|
Creatinine |
0.7 mg/dL |
|
Glucose |
231 mg/dL |
|
Calcium |
12.7 mg/dL |
|
AST |
28 units/L |
|
ALT |
30 units/L |
|
Bilirubin |
0.5 mg/dL |
|
Serum amylase |
20 u/dL |
|
Serum lipase |
150 u/dL |
|
PT/INR |
28 sec/3.5 |
|
PTT |
50 sec |
| Test | Value |
|---|---|
|
pH |
7.35 |
|
PaCO2 |
30 |
|
PaO2 |
95 |
|
HCO3- |
16 |
The appearance of his pancreas is shown on the CT performed at admission for this hospitalization, below:
After reviewing the hospital records and listening to John’s concerns, you order follow-up labs and arrange for him to see the office dietician. He is advised on strategies to avoid flares and given options for potentially definitive treatment. He is appreciative of the thorough assessment and education and will consider new treatment options and return in 1 month to review labs and discuss options.