Chronic calcific pancreatitis due to primary hyperparathyriodism

1. 60yr old female with
abdominal pain & vomiting
Dr. Prodipta Chowdhury
Phase-B Resident
Dept. of Endocrinology

2. Particulars of the patient
• Mrs. X
• Age: 60yr
• Address: Jheniydah
• Occupation: Homemaker
• Date of admission: 25 April 23

3. Chief Complaints
• Abdominal pain for 04 months
• Vomiting for same duration

4. Background History
Abdominal pain
• Sudden
• Severe
• Upper abdomen
• Radiates to back
• Persisted throughout day and night for 03 days
• Aggravated after taking food
• Relieved with parenteral analgesics
• Associated with vomiting

5. Vomiting
• Occurs at the height of pain
• After taking food
• Non-projectile
• Initially contains undigested food material
• Later bilious
• No h/o hematemesis
• Associated with constipation & distension

6. Admitted in KuMCH
• Diagnosed as Subacute Intestinal Obstruction
• Treated conservatively with NG suction, I/V antibiotic, opioid analgesics
• Improved to some extent & discharged
Consulted Internist
• Dx: Nephrolithiasis
• Symptoms not improved

7. Consulted Gastroenterologist
• Dx: Gastric Ulcer (by endoscopy)
• H. Pylori eradication therapy
• Undergone: CT scan of W/A
• Dx: Acute Pancreatitis with Pancreatic Pseudocyst
Referred to SRGIH
• Treated conservatively : 2 weeks
• Calcium & PTH levels found to be elevated
Referred to BSMMU

8. History Of Present Illness
Abdominal pain
• Mild to moderate
• Localized
• Upper abdomen
• Continuous
• Dull aching
• Aggravated after taking meal
Vomiting
• Occasional
• After taking food
• Non-projectile, not bile stained
• Undigested food material

9. On query
• Weight loss about 17kg in 4 months
Difficulty in walking
• For last 1 year
• Fall from bed
• No fracture
• Walking stick or with help of others

10. No history of
• Pheo-spell, headache, blurring of vision
• Hyperpigmentation or postural dizziness
• Polyuria, polydypsia, anuria, oedema
• Previous psychiatric illness or treatment
• Myalgia, easy bruising
• Cough, SOB
• Back pain
• Constipation, itching
• Neck or breast lump
• Vitamin supplement intake

11. H/O past illness:
• H/O TAH 20 yrs ago
• 01 unit of BT
Personal history:
• Non-alcoholic
• 02 sons, 01 daughter
• No such type disease in her family history

12. Vaccination history:
• Available vaccine
• COVID vaccine

13. General Examination
• Ill-looking
• Mildly Anaemic
• Pulse: 70 b/m, regular
• BP: 90/70 without postural drop
• Temp: 98’f
• R/R: 14 b/m
• Dehydration: Absent
• Oedema: Absent
• BMI: 22.95 kg/m2
• No thyromegaly or lymphadenopathy
• Cannula in situ in left hand

14. Alimentary System
Mouth cavity: Normal
Abdomen:
• Inspection: Normal, Umbillicus: central & inverted, Flanks: not full, moves
with respiration, no visible vein
• Palpation: No organomegaly, No lump
• Percussion: Tympanitic
• Auscultation: Bowel sound: Present

15. Nervous System
Higher psychic function: Depressed
Cranial nerves: Intact
Motor system:
• MB, MT, MP, Jerks : Normal
• Planter: Flexor
• Co-ordination: Intact
• Gait: Antalgic, Limping the left leg (Restricted movement @ Lt. hip joint)
Sensory system: Intact
Cerebellum: Intact

16. Case summery
• Mrs. X normotensive, non-diabetic 60yr old homemaker admitted in
our hospital with abdominal pain & vomiting for 04 months
• Previously, she was admitted in KuMCH with sudden severe epigastric
pain for 03 days with vomiting & conservatively treated as subacute
intestinal obstruction
• Later, consulted an Internist & treated as nephrolithiasis
• Then, consulted a gastroenterologist & treated as GU
• Subsequently undergone CT scan, dx as acute pancreatitis with
pseudocyst

17. • Referred to SRGIH, during aetiological evaluation Ca & PTH found
elevated
• Referred to our center
• Now complaining of mild to moderate intensity dull aching localized
abdominal pain, which usually aggravated after meal and associated
with vomiting
• Also gives H/O, 17kg weight loss in 04 months & difficulty in walking
for last 01 year after fall from bed

18. • No history of pheo-spell, headache, visual disturbance, urinary
complain, cough, SOB, backpain, previous psychiatric illness, fatigue,
myalgia, easy bruising, constipation, itching, neck or breast lump,
vitamin intake
• She had H/O TAH 20 years ago & no such of family history
• O/G/E: Ill-looking, mildly anaemic, vitals:normal, cannula in left hand,
no dehydration, thyromegaly or lymphadenopathy
• P/A/E: Normal findings
• N/S/E: Depressed mood, Antalgic gait with limping of left leg

19. Provisional Diagnosis
Primary Hyperparathyroidism with complications:
• Acute pancreatitis
• Nephrolithiasis
• Peptic ulcer disease
• Bone disease

20. Differential Diagnosis
• Chronic pancreatitis

21. Investigations

22. Investigations
Complete blood count
Date 27 Jan 23 10 Mar 23 05 Apr 23 09 Apr 23 07 May 23
Hemoglobin (g/dl) 9.6 10.3 10.2 10.4 9.0
ESR (mm in 1st hour) 25 06 13 19 08
Total count (/cmm) 7,000 6,000 5,130 5,710 4,000
Neutrophil (%) 63 55 60 58 51
Lymhocyte (%) 27 35 29 34 40
Monocyte (%) 08 08 07 06 07
Eosinophil (%) 02 02 04 02 02
Basophil (%) 00 00 00 00 00
Platelet (/cmm) 4,50,000 3,10,000 2,20,000 1,69,000 2,05,000

23. Blood film:
• RBCs: Normocytic normochromic
• WBCs: Mature with normal count & distribution
• Platelets: Normal
• Comment: Normocytic normochromic anaemia
Name Result Normal value
Serum Vit B12 681 239-931 pg/mL
Ferritin 1677 10-120 ng/mL
Serum Iron 46 70-180 ug/dL
TIBC 79 155-300 ug/dL
Tsat 58.22%

24. Date 03 Jan 23 27 Jan 23 10 Mar 23 05 Apr 23 09 Apr 23
Name
S. Amylase (U/L) 52
S. Lipase (U/L) 58 21
Urinary Amylase 151 (21-447)
CRP (<10 mg/L) 15.1
ALP (U/L) 145
SGPT (U/L) 13 22
Bilirubin (mg/dl) 0.6 0.4

25. CA 19-9 (<37 u/ml) 32.7 (10Feb) 61 (12Apr)
HBsAg Negative
Anti HCV Negative
Blood C/S No Growth
S. TSH ( uIU/ml) 3.09
Date 10 Mar 23 09 Apr 23
Urine R/M/E
pH 6.5 7.5
Specific gravity 1.020 1.006
Albumin Trace Nil
Epithelial Cells 15-20 1-2
Pus Cells 12-16 2-4

26. Date 30 Dec 22 04 Jan 22 27 Jan 23 10 Mar 23 09 Apr 23 16 Apr 23 26 Apr 23
Name
S. Creatinine (mg/dl) 1.13 0.70 0.79 0.60 0.75 0.70
S. Electrolytes
Na 125 139 134
K 3.75 3.63 3.00
Cl 86 100 99
HCo3 25 25 20
RBS (mmol/L) 5.58 5.23

27. Date 09 Apr 23 13 Apr 23 17 Apr 23 26 Apr 23 03 May 23
Name
S. Calcium (8.4-10.2
mg/dl)
12
(c: 13.2)
11.5
(c: 12.6)
11.6
(c: 12.7)
In Phosphate (2.5-
4.5 mg/dl)
1.82 2.2
S. Albumin (g/L) 2.5 2.6
iPTH ( 9-80 pg/ml) 642.8 942
24 hours Urinary
Calcium
(100-300mg/d)
UV: 3500ml UV: 2600ml
Uca: 283.5 mg Uca: 262 mg
25 OH Vit D (<10
ng/ml: deficient)
4.93

28. Calcium/Creatinine clearance ratio
• S. Creatinine: 0.7 mg/dl
• S. Calcium: 12.9 mg/dl
• Urine Creatinine: 257 mg/day
• Urine Calcium: 262 mg/day
• Calcium/creatinine clearance ratio: 0.055

29. • Lipid Profile:
Date 10 Apr 23 Normal values
Name
Triglycerides 91 <150 mg/dl
Total Cholesterol 133 <200 mg/dl
HDL Cholesterol 40 >40 mg/dl
LDL Cholesterol 74 <100mg/dl

30. Plain X-ray Abdomen
Comment:
Intestinal obstruction
Bilateral mild pleural
effusion

31. USG of W/A
Date Findings
03 Jan 23
(Admitted in
KuMCH)
1. A bit enlarged Pancreas with fat stranding & mild peritoneal
fluid collection
(Advice: Please correlate with S.lipase)
2. Lt renal small calculus (8.4mm)
3. A bit distended bowel loops
13 Jan 23 1. Left renal stone (10mm)
2. Cystitis
31 Mar 23 Stomach wall is thickened and swollen with
Inhomogeneous Pancreas (2.6 cm at body) suggestive of
pancreatitis
with mild fatty liver and bilateral renal small calculus

32. Date Findings
05 Apr 23 1. Swollen pancreas
2. Left renal calculus (5.1mm)
13 Apr 23 1. Pancreas is swollen and hypoechoic. MPD is not dilated.
Peripancreatic collection is noted: Suggestive of acute
pancreatitis.
2. Bilateral pleural effusion
30 Apr 23 1. Pancreas is swollen & heterogeneous. MPD is dilated (about
1.49 cm). Multiple bright echogenic structures casting distal
acoustic shadows are seen in MPD, body & tail region of
pancreas. Calcifications are also noted within the pancreatic
parenchyma. Suggestive: Calcific panreatitis.
2. Fatty change in liver (grade - 1).

34. CT scan Of W/A
• Severe acute pancreatitis & pseudo-pancreatic cyst especially right side
that infiltrating C loops of duodenum & adjoining grater curvature of
stomach resulting thickened duodenal & stomach wall
• Bilateral renal calculi
• Mild fatty liver

36. X-ray Both Hands
• Comment: Osteopenia

37. X-ray Pelvis A/P view
• Comment : Osteopenia

38. Xray Left Knee Joint B/V
Comment:
• Osteoarthritic change in
left knee joint
(Osteophytes are noted
around articular margin)
• Osteopenia

39. BMD
Site T-Score
Lumbar 1st to 4th vertebrae (AP) -5.8
Right femoral neck -4.5
Left femoral neck -4.6
Osteoporosis in lumbar vertebrae and both the femoral neck.

40. ECG:
Echo:
• No regional wall motion abnormality at rest.
• Good LV systolic function. LVEF: 64 % .
• Normal chamber dimensions
• Normal valves morphology.

41. USG of Neck
• Mild thyromegaly ( Right lobe: 13mm, Left lobe: 13mm in AP
diameter)
• No definite enlarged parathyroid gland could be seen.

42. Pending Investigation
• Parathyroid scan @ 10th May 23

43. Diagnostic workup

45. Confirmed diagnosis
• Chronic calcific pancreatitis due to Primary Hyperparathyroidism

46. Ongoing treatment
• Fluid: 03 L water + 01 L green coconut water
• Inf. Normal saline 1000ml/day @ 30d/min
• Inj. Zoledronic acid 5mg with NS over 30 min stat
• Tab. Cholecalciferol 2000IU/day
• Tab. Ondansetron 8mg/tds
• Cap. Esomeprazole 20mg/bd
• Syp. Avolac
• Supp. Tramadol 100mg SOS

47. Referral to Gastroenterology

48. Problem list
• Further evaluation
• Preparation for definitive treatment

49. Thank You

50. Differential diagnosis of primary
hyperthyroidism