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Looking beyond Alcohol

Looking beyond Alcohol. Dr Charles Panackel MD, DNB, DM Dr Sunil K Mathai MD, DM Dept of Gastroenterology Medical Trust Hospital. Case History. 31 yr old male seen in Jan 2011 Epigastric pain and vomiting 2 days Had a binge of alcohol 3 days ago O/E: HR 84/ min PA- Epigastric guarding +

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Looking beyond Alcohol

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  1. Looking beyond Alcohol Dr Charles Panackel MD, DNB, DM Dr Sunil K Mathai MD, DM Dept of Gastroenterology Medical Trust Hospital

  2. Case History • 31 yr old male seen in Jan 2011 • Epigastric pain and vomiting 2 days • Had a binge of alcohol 3 days ago • O/E: HR 84/ min • PA- Epigastric guarding + • Investigations: • T bili 0.9 SGOT 100 SGPT 67 • Amylase 966 Lipase 2362 • USG Abdomen – bulky pancreas, No GB stones • Ca 10.2 mg/dl

  3. Course In Hospital • Diagnosis: Acute Pancreatitis (Mild)- Alcohol induced • Pain subsided in 2 days • Did not develop any organ failure/ local complications • Discharged 2 days later

  4. 1 month later- Feb 2011 • Abdominal pain and vomiting – 1 day • Had alcohol 2 days prior • Hb 14 HCT 42 TC 14900 Platelets 2.36 lacs • T bili 0.89 SGOT 28 SGPT 51 ALP 129 • Amylase 697 Lipase 2673 • USG Abdomen - edematous pancreas, minimal left pleural effusion, No GB stones

  5. Further Evaluation • Triglycerides – 9.2 mg/ dl • Calcium – 10.3 mg/dl (N : 8.5-10) • PTH – 170 pg/ml (N: 15-75)

  6. Sestamibi Parathyroid Scintigraphy

  7. MRI neck with upper chest

  8. Course • Pt underwent excision of left superior parathyroid gland under GA • ~ 1 cm enlarged parathyroid gland – firm in consistency

  9. Histopathology

  10. Post operative course • Uneventful • Calcium levels dropped • PTH reduced to 71 pg/ml • Pt discharged on 4th post op day

  11. Diagnosis • Recurrent Acute Pancreatitis due to Hypercalcemia • Hyperparathyroidism – due to parathyroid Adenoma

  12. 3 months later - May 2011 • Epigastric pain and vomiting since 1 day • PA- epigastrium guarding + • Amylase 561 Lipase 2886 • Calcium 9.5 • T bili 0.48 SGOT 33 SGPT 35 ALP 142 • USG Abdomen - pancreas appears edematous • Repeat PTH – 81 pg/ml ( N 15-75)

  13. OGD • Multiple bossy lesions in D1 and D2 – biopsies taken • ? Neuroendocrine tumour

  14. Course • Chromogranin A – 542 ng/ml ( N < 100) • IHC : • Planned for MRI Brain and surgery subsequently • Diagnosis: MEN 1

  15. Multiple Endocrine Neoplasia Type 1 • Autosomal Dominant disease; M=F; All age groups • Commonly Parathyroid (90%), Pancreas (30-80%), Pituitary in 15-90% ( need 2 of the 3 to diagnose) • Others: Adrenal Cortical tumours, Bronchial or GI Carcinoids, Lipomas, Angiofibromas

  16. Take Home Message • Alcohol is most common cause for pancreatitis • But, keep an open mind – check Calcium, Triglycerides, USG Abdomen for Gall stones • Every disease evolves over time • Multidisciplinary approach always essential for complex cases

  17. THANK YOU!

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