A 54-year-old man comes to the office with abdominal pain, chronic diarrhea, and recent weight loss. He has had episodic abdominal pain in the past, but lately it has become persistent and worsens after eating. The patient does not use tobacco or illicit drugs but does consume alcohol regularly. An upright abdominal x-ray reveals calcifications in the epigastric area. Which of the following is the most likely cause of his diarrhea?
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This patient's epigastric calcifications and history of alcohol use make chronic pancreatitis the most likely diagnosis. It is thought that alcohol-related chronic pancreatitis develops in part due to alcohol-induced secretion of protein-rich fluid. These proteinaceous secretions can precipitate within the pancreatic ducts, forming ductal plugs that may calcify and be detectable on abdominal imaging.
Ductal obstruction by such concretions may cause exocrine insufficiency due to atrophy of the pancreatic acinar cells and pancreatic fibrosis. Pancreatic exocrine insufficiency (eg, failure to secrete adequate amylases, proteases, and lipases) leads to malabsorption with consequent diarrhea/steatorrhea. Weight loss and bulky, frothy stools are typical clinical findings. This patient's abdominal pain is most likely due to the pancreatitis itself.
(Choice A) Bile salt malabsorption typically occurs with conditions affecting the terminal ileum (eg, ileal resection, Crohn ileitis). Patients may have diarrhea as a result of excessive bile salt accumulation in the colon (cholerheic enteropathy).
(Choice C) Portal hypertension (eg, due to liver cirrhosis) causes varices at sites of portocaval anastomoses, leading to anorectal varices, caput medusae over the abdomen, and esophageal varices. Bleeding esophageal varices can cause hematemesis and melena. Ascites is another sign of portal hypertension.
(Choice D) Gastrinomas (duodenal/pancreatic gastrin-secreting neuroendocrine tumors) cause hydrochloric acid hypersecretion, which can result in multiple and/or refractory peptic ulcers. Patients may also have diarrhea/malabsorption as digestive enzymes become deactivated by high gastric acid output.
(Choice E) Celiac disease classically presents with malabsorption due to immune-mediated enteropathy involving the proximal small intestine. This condition is triggered by the ingestion of foods containing gluten (eg, wheat).
(Choice F) Chronic alcohol use may result in the interference of nutrient/vitamin absorption due to intestinal mucosal injury. However, this patient's abdominal pain and epigastric calcifications suggest that his diarrhea is most likely a consequence of chronic pancreatitis.
Educational objective:
Diarrhea, weight loss, and epigastric calcifications in a patient with chronic alcohol use suggest chronic pancreatitis with resulting pancreatic exocrine insufficiency and malabsorption.