47-year-old man with epigastric pain and weight loss
A 47-year-old man is admitted with severe epigastric pain radiating to the back and vomiting for 18 hours after a binge-drinking weekend. He has had 3 similar hospitalizations in the past 2 years. Temperature is 37.1 C, blood pressure is 118/74 mm Hg, and pulse is 102/min. He has epigastric tenderness without guarding. Lipase is 640 U/L. CT abdomen shows pancreatic calcifications and a 7-mm dilated pancreatic duct without necrosis or fluid collection. Stool elastase is low. Despite pancreatic enzyme therapy, he reports steatorrhea and 15-lb weight loss over 6 months. Which of the following is the most appropriate next step in management?
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D
Explanation
Clinical Pearl:
In chronic pancreatitis with a dilated obstructed pancreatic duct and persistent pain or malabsorption despite medical therapy, ductal decompression by endoscopic or surgical intervention is the next step. Pancreatic enzymes help exocrine insufficiency but do not correct fixed ductal obstruction.
Explanation:
This patient has chronic pancreatitis from alcohol use, supported by pancreatic calcifications, low stool elastase, recurrent attacks, steatorrhea, and weight loss. The dilated pancreatic duct points to obstructive large-duct disease, and persistent symptoms despite enzyme replacement make ductal decompression the guideline-based next step, either endoscopically or surgically depending on anatomy and expertise. A proton pump inhibitor can sometimes be added as an adjunct to improve enzyme efficacy, but it does not address the mechanical problem driving his ongoing pain and malabsorption. Glucocorticoids are used for autoimmune pancreatitis, which is not suggested here by the history or imaging. Cholecystectomy is appropriate for gallstone pancreatitis, but this vignette instead supports alcohol-related chronic disease. Prophylactic antibiotics are not indicated in uncomplicated pancreatitis without infected necrosis or another documented infection.
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