Friday, August 29, 2008

He Named It, Then Died of It

A 60 year old man presents to your emergency department with epigastric pain that radiates to the back. He says that the pain is alleviated by sitting up or leaning forward. It is worse 15-30 minutes after eating. Sometimes, he also gets nausea and vomiting. He is a heavy drinker and smoker. As you ask him about other symptoms, he mentions loose, greasy, foul smelling stools. He went to a free diabetes clinic last year and was told he had diabetes. He had several episodes of hypoglycemia in which he came to this ER but after being treated, left AMA (against medical advice).

In 1865, a physician documented an odd pattern of traveling thrombosis. He described a patient who had recurrent migratory thrombosis of the superficial veins in odd sites like the arms and chest. You notice that in this patient. He looks pretty ill, and when you ask him further, he says he's lost a significant amount of weight.

Challenge: Imaging studies are necessary to confirm, but what's your top diagnosis?

Related Questions:
1. The first and second paragraphs, though related, suggest distinct diseases (ie. the first is a risk factor for the second). What are they?
2. What's the pattern of traveling thrombosis called?


Alex said...

acute pancreatitis -> pancreatic cancer

trousseau's sign

Craig said...

He Named It, Then Died of It

The abdominal pain and associated symptoms at the beginning of the case suggest chronic pancreatitis. Severe pancreatic exocrine dysfunction can result in steatorrhea, malabsorption of fat soluble vitamins (ADEK) and B12 (though clinically symptomatic vitamin deficiency is rare), and pancreatic diabetes (with a higher incidence of hypoglycemic events because alpha cells producing glucagons are also destroyed). There are many complications of chronic pancreatitis, including pancreatic cancer.

Trousseau’s syndrome is the odd finding described in the second paragraph, also called migratory superficial thrombophlebitis. It links venous thrombosis with malignancy; indeed, Trousseau himself later developed unexplained DVT and was diagnosed with gastric carcinoma. Here, the collection of symptoms suggest pancreatic cancer.

Source: UpToDate.