Intermittent abdominal pain, nausea, and diarrhea

The patient is a 45 year old man who reports 15 months of episodes of acute onset diffuse
abdominal pain, nausea, and watery diarrhea occurring initially 1-2 times per month but
increasing in frequency to approximately weekly. The abdominal pain, which was mild to
moderate, would come on without warning and would be followed soon thereafter with nausea,
malaise, and watery diarrhea. Vomiting or bowel movement would not affect the pain. During
the episodes, the stools were typically watery and profuse (3-4 stools/hour). He reported his
stools to be of normal color and consistency otherwise. The episodes would terminate
spontaneously in 30 minutes to 3 hours without a clear response to antacids, H2 blockers, or,
anticholinergics. He was placed on a proton pump inhibitor 1 year ago. The patient could not
identify any precipitating events, stress, foods, or exposures that would predict the episodes.
They had no relation with meals and could occur at night during sleep although were less frequent
than during the day. He also reported about 10-20 pound weight loss over the last 6 months due to
anorexia.

An ultrasound showed gallstones and one year ago, a laparoscopic cholecystectomy was
performed. The patients symptoms recurred soon after discharge from the hospital and did not
decrease in frequency.

He has a 10 year history of hypertension and dyslipidemia controlled with oral medications. Over
the past year, he has developed progressive glucose intolerance and non-insulin dependent
diabetes. He has no history of pancreatitis.

He had an appendectomy at age 33 where a cholecystectomy was also performed. He has no
history of cholecystitis or hepatitis.

His evaluation at an outside hospital was negative for any infectious causes of diarrhea or
hepatitis. He had an EGD and colonoscopy that revealed no abnormality.

After attempts at symptomatic therapy including medications, biofeedback, macrobiotics, and
changes in diet he had an abdominal CT scan that showed a 1.3 cm mass in the head of
the pancreas. The patient was referred to Johns Hopkins Hospital for further therapy.

Appendectomy
Cholecystectomy

His parents are alive and relatively well. His mother has diet controlled diabetes and his father
has hypertension and COPD. He has 2 brothers and a sister who are well. There is no history of
premature cardiac, renal, pulmonary, or endocrinologic disease in the family. Uncle Billy Bob
has a mild case of antisocial disorder that is most notable during the Georgia- Florida football
weekend. He and his wife have 2 children (18 yo and 14 yo) who are well other than narcissistic
behavior.

The patient lives in Georgia in a suburban setting. His hobbies include tennis and water skiing.
He drinks alcohol only socially and consumes less than 3 drinks/week. He does not go camping,
has no significant travel history outside of SEC cities for football games. He is an office worker
and is very active.

He has had no fever, chills, sweats, jaundice, skin changes, joint problems, urinary difficulty,
flushing episodes, wheezing, shortness of breath, chest pain, or headache.

Metformin
Protonix
Losartan
HCTZ
Lovastatin
Fish oil supplements

NKDA

• Weight 214 pounds; Height 5 feet 11 inches; T 97.8 F, BP 147/90, P 80 and regular, RR
  12 and unlabored.
• General: Healthy-appearing Caucasian male in no apparent distress. No temporal
  wasting.
• HEENT: Sclera anicteric. Extraocular movements intact. No cervical or supraclavicular
  lymphadenopathy
• CV: Regular rate and rhythm with no murmurs appreciated.
• Lungs: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
• Abdomen: Soft, non-tender, and non-distended with evidence of a previous laparoscopic
  cholecystectomy and right lower quadrant appendectomy scar. No palpable masses
  noted.
• Extremities: No cyanosis, clubbing, or edema. No musculoskeletal or neurologic deficits.
• Skin: no rashes or lesions

• Na 138; K 3.8; Cl 102; BUN 13; Cr 0.9; Glucose 105; Calcium 9.6; Total protein 7.1;
  Albumin 4.5; Total bilirubin 0.6; ALT 84; AST 45; ALK 85
• WBC 6170; Hemoglobin 14.9; Hct 43.4; MCV 90.6; Platelets 306

Image 1: Axial contrast enhanced CT in arterial phase shows a small slightly
hypervascular mass in the neck of the pancreas (arrows)

Image 2: Axial contrast enhanced CT in venous phase phase shows the mass enhances
more avidly in this phase (arrows)

Image 3: Sagittal reconstruction, venous phase confirms the finding (arrows)

Image 4: Coronal reconstruction, venous phase confirms the finding (arrows)

The patient was admitted to Johns Hopkins Hospital and taken to the operating room to have open
excision of the pancreatic head mass. The surgery was performed without complications. Post-
operatively, the patient developed a pancreatic leak. He was sent for an ERCP and a biliary stent
was successfully placed during the procedure. The leak gradually resolved. He was placed back
to a regular diet. His vital signs were stable and he was afebrile. He was discharged to home in
good condition. At telephone follow-up one month after discharge the patient reported no
episodes of abdominal pain, nausea, vomiting, or diarrhea.

Prior to surgery, what additional tests would help determine the cause of the patient's symptoms?