Transcription - 20250708T 09-50.mp3

Next letter is for sarah conway foxtrot 783870 pancreatic ex pancreatic exocrine insufficiency background and previous long standing functional gi disorder psoriatic arthritis on adalimumab and leflunomide chronic fatigue syndrome investigations blood test may 2025 crp less than 1 kidney function's stable creatinine 55 lft is normal hp on c 37 full blood count normal gonoscopy november 2023 normal colonoscopy to the cecum histology from the: unremarkable large intestinal mucosa ogd september 2023 for dyspepsia and abdominal pain normal ct august 2023 normal appearance of the pancreas liver gallbladder spleen adrenals kidneys ultrasound abdomen august 2023 mildly dilated common bile duct 8 mm smooth tapering towards the ampulla main pancreatic duct normal in caliber 3 mm in the body no pancreatic head mass pancreas heterogenous echotexture without collection early / mild pancreatitis at that time lipase consistently normal lipase peak july 3126 and the diagnosis pancreatic exocrine insufficiency likely secondary to autoimmune pancreatitis in association with psoriatic arthritis hello is that sarah conway hi my name is doctor robert and I'm 1 of the gastroenterology registrars here at darafit have I caught you at a reasonable time good glad how are you alright tell me oh I'm sorry okay so tell me about what the problems you've been having loser mhmm okay okay alright and when did you stop the crion a month ago 5 so you had 2 to 3 weeks of things being worse but now over the last sort of 1 to 2 weeks things have been okay okay 5 okay good and in terms of the tummy pain that you were getting a month ago tell me about that what else of course okay okay yeah of course yeah fine I'm sorry things have sort of gone a bit better by themselves yeah fine okay so in the plan number 1 ultrasound of the upper abdomen number 2 blood tests including fat soluble vitamins number 3 fecal elastase testing number 4 if weight dropping to restart creon number 5 follow-up in 6 months' time dear gp I had the pleasure of speaking on the telephone to ms conway on behalf of professor lewis in gastroenterology clinic full stop <\n\n> 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 loo stools and bloating full stop she didn't find the pain responded to analgesia and so stopped her crion in an attempt to improve it 4 weeks ago full stop subsequent to this, she experienced 2 to 3 weeks of very loose stools but then her diarrhea has now settled down full stop over this time her weight's been stable and her most recent weight is 11 stone 3 pounds full stop <\n\n> Over this time she's also noticed some irregularities in her blood sugars full stop she's been using a libre sensor that her friend has lent her and she's been experiencing blood sugars at 3.4 to 14 over the course of a day full stop she's asymptomatic when the blood sugars are low and high full stop <\n\n> I explained that it may well be that her erratic blood sugars are due to stopping her crion and malabsorbing due to this full stop I'm not sure that the abdominal pain was associated with her crion use and it may well be that she had another episode of pancreatitis or indeed another cause of upper abdominal pain full stop <\n\n> I've explained that it be sensible to investigate this with blood tests including kidney function liver function and fat soluble vitamins, repeat fecal elastase measurement and an ultrasound of her abdominal organs full stop <\n\n> With these tests we hope I hope to be able to at least state the underlying cause of her episode of abdominal pain as well as determine whether there's any biochemical evidence of malabsorption or continued pancreatic insufficiency full stop <\n\n> If her weight is dropping then I'd suggest restarting the creon but she's understandably reluctant to do this at the moment because of her association with this with her abdominal pain full stop <\n\n> I'll book her appointment to see us again talk to us again in 6 months time but we'll write with the results when they come through to me yours cecilia

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.

Summary

Investigations

Plans