Woman undergoes treatment for rare pancreatic disorder

Mariecar Jara-Puyod, Senior Reporter

Neither delay nor be embarrassed in seeking medical help.

This is the lesson all must bear in mind as a 49-year-old lady in Abu Dhabi “has resumed normal daily activities,” albeit medically determined, to require long-term anti-blood clotting treatment “with regular re-assessment and vascular follow-up.”

From the most recent books of Burjeel Hospital, Abu Dhabi, comes once more the reminder for healthy living, particularly on the care of the “major digestive organ,” the pancreas.

According to Internal Medicine specialist Dr Niyas Khalid, the patient who “had been experiencing intermittent abdominal pain and constipation for several months and had received multiple treatments for this condition” eventually “developed new, persistent abdominal pain for approximately three to four days, which became progressively severe.”

“When the pain became intense and persistent, she presented herself to the Emergency Department. By then, she was in significant distress, with severe predominantly upper abdominal pain radiating to the back,” continued Khalid on Wednesday.

“My stomach became swollen, making me look like pregnant. I could not pass stool properly although I constantly had the urge to use the toilet,” said the lady, who requested anonymity.

Diagnosis was the rare or “under-recognised” Venus Ischaemic Pancreatitis.

Khalid, with 17 years of experience, explained that Pancreatitis is “acute or chronic inflammation or injury of the pancreas” with the “common causes” attributed to “gallstones, alcohol, very high triglycerides (fats), certain medications, and metabolic abnormalities.”

Consequent “extensive etiological investigation,” to uncover the real cause, led to the “exclusion” of “gallstone disease, hypertriglyceridemia (high triglycerides level) hypercalcaemia (high calcium level), pancreatic malignancy, autoimmune pancreatitis, major inherited thrombophilias (abnormal formation of blood clots), antiphospholipid syndrome (an autoimmune disorder whereby the immune system forms abnormal antibodies that attack normal proteins and fats), and myeloproliferative disorders (rare blood cancers).

“That was one reason the vascular findings became so important,” said Khalid.

The medical team was surprised to note, that as imaging tests had demonstrated, that the patient’s pancreas was injured with its veins “distended and filled with acute thrombus (immobile blood clot),” among other findings, the levels of her pancreatic enzymes, instead of being “elevated,” as in the normal cases of Venus Ischaemic Pancreatitis, were “rather reduced.”

The patient’s “amylase was only 22 units per litre (U/L) and lipase, 18 U/L; serial measurements remained low despite the radiological pancreatic injury.”

“That was the key question for us. Why are her pancreatic enzymes low when, with the degree of her pancreatic injury, I would expect them to be high?” added Khalid.

At this point, the Internal Medicine specialist was asked about pancreatic enzymes: “The pancreas is a major digestive organ. It produces enzymes. The lipase digests fats. The amylase digests carbohydrates. The proteases digest proteins.”

“These enzymes normally travel from the pancreas into the intestine and help us absorb nutrients from food. They are important throughout life. If pancreatic enzyme production becomes severely impaired, a person can develop poor digestion, bloating, and nutritional deficiencies, and weight loss,” explained Khalid.

He also said: “In Acute Pancreatitis, amylase and particularly lipase are also useful blood markers because damaged pancreatic cells commonly release these enzymes into the circulation.”

On the possibility that the patient’s previous bariatric surgeries led to her rare medical condition, which the medical team had classified as “life threatening,” Khalid replied: “We cannot say it was the sole cause. But it was a clinically relevant potential contributor.”

Khalid went on to say: “She had undergone two previous bariatric procedures. Bariatric surgery is a potential risk factor for Portomesentric Venous Thrombosis because it can be associated with changes in the blood flow, dehydration, rapid weight changes, abdominal pressure, and prothombotic (blood clot increase) environment.”

Portomesentric Venous Thrombosis is a blood clot in the portal and mesenteric veins. It impedes the blood flow to the intestines, spleen and liver, leading to the death of the bowel tissue.

The patient’s initial treatments were the “low-molecular-weight heparin, followed by an oral anti-coagulant.”

Khalid described the heparin as a “powerful anti-coagulant used to stop a blood clot from growing and to prevent further clot formation.”