Abstract

Bilal Bin Abdullah, Nida Nausheen, Md Zoheb, Nivesh Seehra and Syed Mustafa

We report the case of a 57 year old lady, known to be diabetic for last 4 years getting treated with oral hypoglycemic agents. She reported to the medical outpatient department (OPD) of a tertiary medical care hospital with the history of pain abdomen, nausea, and loss of appetite since 3 months. On examination, she was conscious and well oriented, afebrile, with pulse rate of 86 min -1 , blood pressure of 130/84 mmHg, respiratory rate of 16 min -1 , mild pallor, no icterus, right hypochondriac tenderness was present. Routine investigations revealed Hb of 9.6 g%, fasting blood glucose of 214 mg/dl and HbA1c of 10.6%; normal serum amylase and lipase levels, urine for ketones was negative; all other investigations were within normal limits except for elevated serum alkaline phosphates. Abdominal ultrasound showed multiple gall bladder stones. She underwent an endoscopic ultrasound which revealed a distended gall bladder containing multiple small calculi and a single large calculus; pancreas appeared bulky, parenchyma was hypoechoic with multiple hyperechoic areas with evidence of calcification, the impression was chronic pancreatitis, cholelithiasis. We further proceeded with endoscopic retrograde cholangiopancreatography (ERCP). ERCP showed common bile duct (CBD) stones with left intra hepatic biliary dilatation with chronic calcific pancreatitis. For this, she underwent endoscopic sphincterotomy and internal biliary stenting and was discharged with pancreatin tablet, H2 blockers and human mixtard injection of 30 units per day and she was asked to attend the OPD after a fortnight. After 1 week, she presented with symptoms of gastritis, insomnia, and mood disturbances. Upper gastrointestinal (GI) endoscopy showed Grade 1 distal oesophagitis, severe antral gastritis and duodenitis of D1 and D2, serum electrolytes and serum calcium were within normal range and she was managed conservatively and treated by psychiatrist for symptoms of depression with antidepressants tablet (fluoxetine) 20 mg once daily (OD). Despite this, there was no improvement. Owing to her age and symptoms, we evaluated her parathyroid status.