Clinical Topics Conference:Chapter 15, Pancreas and Diabetes

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  1. 4 month old female with recurrent pneumonia
  2. Acute abdominal pain in an alcoholic
  3. Abdominal pain and biliary obstruction in an elderly man
  4. A 47 year-old female with recurrent hypoglycemia
  5. A 12 year-old female with polydipsia
  6. A 47 year-old female with chronic fatigue

Clinical vignette 1

A four month old Caucasian female was admitted to the hospital for the second time with pneumonia and respiratory distress. Two weeks prior to this admission, she had been seen in the ER for wheezing and on chest X-ray she was found to have pneumonia. She was hospitalized for 48 hrs and was sent home with oral antibiotics. A week after discharge she again presented with respiratory distress, prompting the current admission.

On admission she was pale and in moderate distress. The rerespiratory rate was 35/min and heart rate was 100/min. Bilateral wheezes were noted. Her body weight was 5 kg, 1 kg over birth weight (failure to thrive).

Laboratory examination

WBC9.1 thousand/ul
RBC2.45 million /ul
Reticulocyte count 2.2 %
ElectrolytesWNL
Liver function testsWNL
Total protein6.1 g/dl
Albumin3.2 g/dl
RSV serologynegative
Chlamydia culturenegative
Gram stain, sputum4+ Gram negative rods, 4+ PMNs
Sputum culture 4+ Pseudomonas aeruginosa

During hospitalization, the nurses reported the patient's bowel movements were poorly formed and greasy, which led to the clinical suspicion of CF. A sweat chloride test was performed.

A repeat sweat test was performed on the next day.

Discussion topics

  1. Describe a definitive diagnostic test for CF.

  2. Prescribe treatment for this patient.

  3. Describe a screening test for CF in the newborn.

  4. Describe the treatment for older and end-stage patients.

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    Clinical vignette 2

    A 45 year old man presented one morning with a 10 hr history of acute abdominal pain that followed an all-day alcoholic binge. He had no history of hepatobiliary disease, but did admit to many years of alcoholic over-indulgence. On admission, he was sitting on the stretcher with his trunk flexed and his knees drawn up, since this position diminished the intensity of the pain. He described his abdominal pain as the worst he had experienced, located in epigastrium and radiating to his back. A stat CT scan showed edematous enlargement of pancreas, with no evidence of neoplasm.

    Laboratory examination

    WBC19.2 thousand/ul
    Hct49%
    Serum glucose200 mg/dl
    bilirubin0.6 mg/dl
    ALT34
    AST32
    Ca7.5 mg/dl(normal 8.5-10.2)
    Amylase, total
    p-type    		950 U/L( normal 220)
    890 U/l( normal 115), 94% of the total
    Lipase1800 U/L(normal 200)

    Discussion topics

    1. List your differential diagnoses.

    2. Describe the treatment.

    3. List the possible complications.

    4. List unfavorable prognostic factors.

    5. List signs of progressing into acute hemorrhagic pancreatitis.

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    Clinical vignette 3

    A 70 year old man was well until five months prior to death when he developed abdominal pain, bulky stool and dark urine. He had lost 20 kg in the previous three months.

    Laboratory examination

    WBC12,000/ul
    RBC4.5 million/ul
    Hb12.8 mg/dl
    bilirubin2.5 mg/dl, direct:2.0
    alkaline phosphatase450 IU/L


    CT scan of abdomen revealed a 5 cm tumor at the head of pancreas, periphery of which was atrophic. Exploratory laparotomy was performed. An initial biopsy of pancreatic tumor was read as chronic pancreatitis with diffuse fibrosis. The surgeon, suspecting carcinoma, then took a deeper biopsy, which on frozen section showed a mucin-producing adenocarcinoma. Upon further exploration, there were a few small metastatic nodules in the liver, biopsy of which showed the same histology as the pancreatic carcinoma. There was diffuse fibrosis around the biliary tract.

    Discussion topics

    1. Describe the probable reason why the initial biopsy was read as chronic pancreatitis.

    2. Describe post-surgical treatment.

    3. Describe prognosis in this patient.

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    Clinical vignette 4

    A 47 year old female complained of intermittent preprandial episodes of confusion, light headedness, incoherent speech, sweetening and amnesia in the last one year. As the symptoms were relieved by drinking orange juice and frequent eating, she gained 20 kg of body weight in the last 6 months. She visited the ER as she almost blacked out while driving a car. The serum glucose was 50 mg/dl. On admission, oral glucose tolerance test(75 gm glucose) was performed:

    Time0 1hr 1/2hr2 hr3 hr6 hr
    glucose53130 120 907045 mg/dl
    insulin40 120 18027016035 IU/ml


    At 0 time, 90% of insulin was proinsulin. A CT scan and celiac angiography at venous phase both revealed a 1 cm tumor at the tail of pancreas. At laparotomy, enucleation of the tumor was performed.

    Discussion topics

    1. Describe an immunohistological method to establish the diagnosis.

    2. Describe the adequacy of the surgical procedure.

    3. Further evaluation revealed that the patient also had hypercalcemia and hyper-prolactinemia. Describe the best diagnosis and treatment of this patient, and evaluation of her family members.

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    Clinical vignette 5

    A 12 year old Caucasian girl was brought to the ER by her parents who were alarmed by her complaints of abdominal pain, polyphagia and polydipsia. She had been in good health, energetic and active in sports until 8 weeks prior to presentation when she developed fever, cough and nasal congestion that her family physician attributed to a viral URI. The symptoms of URI resolved but she then developed polydipsia and polyuria accompanied by nausea, fatigue and right upper quadrant pain. On admission, her height was145 cm, weight-27 kg, 2.5 kg less than six months ago. Her skin was thin and dry.

    Laboratory Examination

    WBC16 thousand/ul
    Hb14 mg/dl
    Na139 mmol/L
    K5.1 mmol/L
    C0214 mmol/L
    Blood urea nitrogen (BUN)18 mg/dl
    glucose290 mg/dl
    pH 7.32
    pC0232 mm Hg (normal 35-48)
    p02108 (normal 35-108)
    Urinalysisketone bodies 2+
    albumin negative

    Discussion topics

    1. List diagnostic criteria of type 1 diabetes.

    2. Describe serum pH conditions.

    3. Describe the method to find her endogenous insulin secretory reserve.

    4. Describe her condition in surface islet antibody and HLA type.

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    Clinical vignette 6

    A 45 year old housewife and mother of three presents to your primary care clinic. Her chief complaint is chronic fatigue. Her height-165 cm, weight-75 kg. Eye grounds are normal. BP 150/95. Her past history revealed no major illness, except her last two deliveries were difficult because the babies weighed more than 5 Kg each.

    Laboratory Examination

    Serum glucose240 mg/dl
    total cholesterol255 mg/dl
    Triglyceride400 mg/dl
    serum insulin 25 mU/ml
    Urinalysis1+ glucosuria


    An oral glucose tolerance test was also performed:

    Time01 hr1 1/2 hr2 hr
    glucose135190150 145 mg/dl
    insulin27 150120 100 mU/ml

    Discussion topics

    1. Is she a type 2 diabetic?

    2. Which of the following treatment would be initially appropriate?

      • anti-hypertensive drug.
      • lipid-lowering drug.
      • oral hypoglycemic drug.
      • insulin injection
      • diet, weight loss and exercise.

    3. After 3 months on 1,500 calorie diet, she weighs 65 Kg. She feels much better. Her fasting glucose is 115 mg/dl and blood lipids were decreased to near normal levels. BP 130/86. For the next three years, her condition is readily controlled by diet and exercise. However, she recently reported increased urinary frequency and trace 1+ post-prandial glucose on urinalysis. She has lost 10 Kg weight, feels hungry all the time, and is having increasing difficulty in maintaining her diet. Her lab values are: Fasting glucose-180 mg/dl, cholesterol-235 mg/dl, triglyceride-375 mg/dl. What should do you do now?

    4. Do you consider she is now type 1 diabetic?

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