Foresee Your Next Patient
Acute Pancreatitis Secondary to Neuroendocrine Tumor
By ERICH G. HANEL, MD, ALI A. SOVARI, MD, and LALITHA YEKKIRALLA, MD
University of Illinois College of Medicine at Urbana-Champaign |
March 1, 2009
Right upper quadrant pain of 24 hours’ duration prompted a 20-year-old man with a history of gastritis to seek medical attention. The pain was sharp and nonradiating, with no alleviating or aggravating factors. The patient occasionally consumed alcohol(Drug information on alcohol) and regularly smoked cigarettes (tobacco and marijuana). He denied nausea, vomiting, diarrhea, and diaphoresis.
Right upper quadrant pain of 24 hours’ duration prompted a 20-year-old man with a history of gastritis to seek medical attention. The pain was sharp and nonradiating, with no alleviating or aggravating factors. The patient occasionally consumed alcohol and regularly smoked cigarettes (tobacco and marijuana). He denied nausea, vomiting, diarrhea, and diaphoresis.
A CT scan of the abdomen (shown) revealed massive hepatomegaly with several solid lesions in the liver and a large mass in the pancreas. All abdominal organs, including the stomach, spleen, and kidneys, were compressed by the enlarged liver.
Serum tumor markers α1 1-fetoprotein and CA 19-9 were elevated (82.7 ng/mL and 41.4 U/mL, respectively). A CT-guided biopsy specimen from one of the liver lesions showed malignant cells suggestive of metastatic grade 2 (of 3) neuroendocrine carcinoma, consistent with pancreatic islet cell tumor. The patient was referred to a tertiary care center for further treatment. Acute pancreatitis occurs in about 3% of patients with pancreatic carcinoma.1 Pancreatic tumors arise from either the exocrine pancreas or the endocrine pancreas; the latter is rarer (up to 2% of cases).2 Neuroendocrine tumors are often found as “incidentalomas.” For the most part, imaging (increasingly with positron emission tomography) plays a key role in diagnosis and staging.3 In metastatic disease, the organs most frequently involved are the liver (70%) followed by bone and mediastinum.4
The most common neuroendocrine tumors of the pancreas are gastrinomas and insulinomas. Pancreatic islet cell tumors secrete a biologically active substance and result in a clinical syndrome in more than 80% of cases.5 In this patient, the vasoactive intestinal peptide level was 32 pg/mL; however, the gastrin level was 200 pg/mL, which might explain the previous diagnosis of gastritis. Gastrinomas account for about 20% of pancreatic islet cell tumors.5
Chemotherapy with streptozocin, 5-fluorouracil, and doxorubicin(Drug information on doxorubicin) is used in metastatic neuroendocrine tumors. Surgical resection is indicated for focal disease. Given the age of this patient, liver transplantation with lifelong follow-up for recurrence may be an option.
1. Pandol SJ, Saluja AK, Imrie CW, Banks PA. Acute pancreatitis: bench to the bedside [published correction appears in Gastroenterology. 2007;133:1056]. Gastroenterology. 2007;132:1127-1151.
2. Frankel WL. Update on pancreatic endocrine tumors. Arch Pathol Lab Med. 2006;130:963-966.
3. Becherer A, Szabó M, Karanikas G, et al. Imaging of advanced neuroendocrine tumors with (18)F-FDOPA PET. J Nucl Med. 2004;45:1161-1167.
4. Stephen AE, Hodin RA. Neuroendocrine tumors of the pancreas, excluding gastrinoma. Surg Oncol Clin N Am. 2006;15:497-510.
5. Snow ND, Liddle RA. Neuroendocrine tumors. In: Rustigi AK, ed. Gastrointestinal Cancers: Biology, Diagnosis and Therapy. Philadelphia: Lippincott-Raven; 2005:585.
BLOG FOR CONSULTANTLIVE
Send us your blogs! Contact us for more information if you are interested in writing a post or becoming a blogger.
ABOUT OUR BLOGGERS
| || |
On Health and Mental Health
Erik R. Vanderlip, MD, is a senior fellow and acting instructor in the University of Washington Department of Psychiatry. As a dually-trained family physician and psychiatrist, Dr Vanderlip is active in national health system redesign efforts with a particular interest in newer models of the medical home. He practices family medicine in a hybrid primary care clinic within a mental health center in Seattle.
| || |
The HIV-AIDS Observer
Rodger D. MacArthur, MD, is Professor of Medicine, Wayne State University, Department of Internal Medicine, Division of Infectious Diseases and Director and Site Principal Investigator, Wayne State University HIV/AIDS Clinical Research Unit.
| || |
Speaking of Pain
Steven A. King, MD, MS, is in the private practice of pain medicine in New York, and he is Clinical Professor of Psychiatry at the New York University School of Medicine, New York.
| || |
Tales Doctors Tell
David T Nash, MD, is Clinical Professor of Medicine at Upstate Medical Center in Syracuse, New York. The author of more than 250 peer-reviewed clinical articles, Dr Nash has practiced cardiology in Syracuse for over 50 years. He is a Fellow of the National Lipid Association.
| ||Primary Care Matters |
Gregory W. Rutecki, MD, is Professor of Medicine at the University of South Alabama College of Medicine in Mobile. He is section editor of the hypertension topic center on this web site.
| ||Practice Makes Perfect |
Pamela Wible, MD, pioneered the first community-designed ideal medical clinic in America. An expert in patient-centered care, Dr Wible helps citizens design cutting-edge clinics and hospitals nationwide. Her model is taught in medical schools and featured in Harvard School of Public Health's newest edition of Renegotiating Health Care. Dr. Wible is a medical reporter for the Oregonian, has been interviewed by CNN, ABC, CBS, and is a frequent guest on NPR.
FROM PHYSICIANS PRACTICE
Five Steps to Improving Patient Access Judy Capko,
May 21, 2013
Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.