Case Discussion

[ASHRAF]

A 61-year-old woman with a medical history of insulin-dependent diabetes mellitus for 7 years, hypertension, hyperlipidemia, and one previous episode of idiopathic pancreatitis presents with worsening abdominal pain that has lasted for the past month. The pain is intermittent and localized to the epigastric region. It is nonradiating and not associated with her diet. There is no nausea, vomiting, diarrhea, constipation, vaginal discharge or bleeding, fever, coughing, or urinary symptoms. She denies having any chest pain or shortness of breath. She is not a smoker and denies any alcohol use. She cannot identify any exacerbating or relieving factors of her pain. Her previous medical history includes a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed 30 years ago. The family history is significant for pancreatic cancer in her mother, the details of which are unknown to the patient. Her medications include insulin, lisinopril, and simvastatin. Her diabetes control has been poor, and a recent hemoglobin A1c value was 10.0%.

On presentation, she has a pulse of 77 bpm, blood pressure of 159/78 mm Hg, and temperature of 97.9° F (36.6° C). The physical examination demonstrates a comfortable-appearing woman in no acute distress. The head and neck examination is normal and no scleral icterus is noted. She does not appear dehydrated. Her lung sounds are clear bilaterally. The S1 and S2 heart sounds are normal, with no audible murmurs, rubs, or gallops. The patient has a soft abdomen, with bowel sounds heard in all 4 quadrants. There is tenderness to deep palpation of the epigastrium. The patient does not demonstrate guarding, and there is no Murphy sign or McBurney point tenderness. A rectal examination reveals brown, guaiac-negative stool. No neurologic deficits are noted.

Laboratory studies include normal findings for serum amylase, lipase, alkaline phosphatase, aspartate transaminase (AST), alanine transaminase (ALT), bilirubin, albumin, serum chemistries, and renal function tests, as well as a normal complete blood count (CBC). Radiography of the chest is performed and is unremarkable. She has a normal electrocardiogram (ECG) that does not show evidence of ischemic disease. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast is performed. Then a magnetic resonance cholangiopancreatography (MRCP) is performed which confirms the diagnosis.
WHAT IS THEYOUR DIAGNOSIS ?

[Noor Ebrahim]

Alsalam 3lykm
First thank u for this nice case
Of course the first diagnosis will rise up to your mind is ca pancreas due to her age, significant family history and clinical picture.but there is some questions:
The first question why it is type 1 diabetes in this age? May be due to her disease which lead to complete destruction to pancreatic cells.
what about her weight?is there weight loss?
Why it is idiopathic pancreatitis , she is known case of hyperlipidemia which is a recognized cause for this disease!
What is the cause of her previous TAH.
Other deferential diagnosis is chronic pancreatitis .
Thanks