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Patient Details

Refined clinic letter (272 days ago 09:10)

Refined clinic letter Tue 08 July 2025 09:10

Last Modified: 272 days ago

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Diagnosis:
Pancreatic exocrine insufficiency - likely secondary to autoimmune pancreatitis in association with psoriatic arthritis

Other Medical Diagnoses:
• Psoriatic arthritis - on adalimumab and leflunomide
• Chronic fatigue syndrome
• Long-standing functional GI disorder
• Pre-diabetes (December 2023)
• Gastro-oesophageal reflux disease
• Irritable bowel syndrome
• Multiple joint osteoarthritis
• Hypermobility syndrome
• Depression
• Chronic rhinitis
• Hypercholesterolaemia
• Raynaud's disease

Current Medications:
• Creon 25000 gastro-resistant capsules 2-3 capsules with main meals, 1 with snacks - STOPPED 4 weeks ago
• Creon 10000 gastro-resistant capsules 1 capsule with snacks as directed

Investigations:
• Blood tests (May 2025): CRP <1, creatinine 55 (stable kidney function), LFTs normal, HbA1c 37, FBC normal
• Colonoscopy (November 2023): Normal to caecum, histology showed unremarkable large intestinal mucosa
• OGD (September 2023): Normal - performed for dyspepsia and abdominal pain
• CT abdomen (August 2023): Normal appearance of pancreas, liver, gallbladder, spleen, adrenals, kidneys
• Ultrasound abdomen (August 2023): Mildly dilated common bile duct 8mm with smooth tapering towards ampulla, main pancreatic duct normal calibre 3mm in body, no pancreatic head mass, pancreas heterogenous echotexture without collection suggesting early/mild pancreatitis
• Lipase: Consistently normal, peak level July 2023

Management Plan:
1. Ultrasound of upper abdomen
2. Blood tests including fat soluble vitamins
3. Faecal elastase testing
4. If weight dropping, restart Creon
5. Follow-up appointment in 6 months

I had the pleasure of speaking on the telephone to Ms Conway on behalf of Professor Lewis in gastroenterology clinic.

I was sorry to hear about the symptoms she experienced over the last month where she had episodes of sharp upper abdominal pain which she found different to her previous pancreatitis pain, associated with loose stools and bloating. She didn't find the pain responded to analgesia and so stopped her Creon in an attempt to improve it 4 weeks ago. Subsequent to this, she experienced 2 to 3 weeks of very loose stools but then her diarrhoea has now settled down. Over this time her weight has been stable and her most recent weight is 11 stone 3 pounds.

Over this time she has also noticed some irregularities in her blood sugars. She has been using a Libre sensor that her friend has lent her and she has been experiencing blood sugars at 3.4 to 14 over the course of a day. She is asymptomatic when the blood sugars are low and high.

I explained that it may well be that her erratic blood sugars are due to stopping her Creon and malabsorbing due to this. I'm not sure that the abdominal pain was associated with her Creon use and it may well be that she had another episode of pancreatitis or indeed another cause of upper abdominal pain.

I have explained that it would be sensible to investigate this with blood tests including kidney function, liver function and fat soluble vitamins, repeat faecal elastase measurement and an ultrasound of her abdominal organs.

With these tests I hope to be able to determine the underlying cause of her episode of abdominal pain as well as determine whether there is any biochemical evidence of malabsorption or continued pancreatic insufficiency.

If her weight is dropping then I would suggest restarting the Creon but she is understandably reluctant to do this at the moment because of her association with this with her abdominal pain.

I will book her appointment to see us again in 6 months time but we will write with the results when they come through.

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Refined clinic letter Tue 08 July 2025 09:10

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