Case Report 2 – Gastroenterohepatology

Elevated NT Pro BNP in 72 Y.O

Patient With Acute Necrotizing
Pancreatitis
Hambiah Hari Oki
2021

Moderator:
d r. S i n g g i h P u d j o W a h o n o , S p . P K
 Background
• Pancreatitis is an inflammation process on pancreatic tissue and
surrounding tissue  commonly caused by bile stone and alcohol
• Diagnosis established if 2 of 3 criteria are met: pancreatic abdominal
pain, elevated of amylase and or lipase more than 3 times UNL,
radiology finding suggesting pancreatic problems
• Acute necrotizing pancreatitis is type of pancreatitis with tissue
necrosis  usually has worse prognosis, laboratory tests used to
evaluating treatment and prognosis

Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, et al. Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention. RadioGraphics. 2014 Sep;34(5):1218–39.
McGuigan A, Kelly P, Turkington RC, Jones C, Coleman HG, McCain RS. Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018 2
Mizrahi JD, Surana R, Valle JW, Shroff RT. Pancreatic cancer. The Lancet. 2020 Jun;395(10242):2008–20.
 Background
• Cardiac dysfunction may occur as early complication of acute
pancreatitis  may need biochemical markers such as NT Pro BNP
• Pancreatic malignancy might manifest as mild acute pancreatitis 
further evaluation needed, which risk factor identification is one of it
• Chronic pancreatitis is one of the known risk factor of pancreatic
malignancy development
• Evaluation of symptom/disease like new onset DM in patient with
pancreatitis might help patient management in the future

3
Mizrahi JD, Surana R, Valle JW, Shroff RT. Pancreatic cancer. The Lancet. 2020 Jun;395(10242):2008–20.
Base Data
72 y.o male admitted to RSSA in 13th April 2021
Chief complaint: Abdominal pain
History of Present Illness
• Patient admitted with abdominal pain since 3 weeks prior
• Pain was felt at epigastric and LUQ, radiating to back
• He experienced decreased of appetite, nausea vomiting, with tea-
colored urine and black colored stool also
• In the last 1 month, he loss 10 kg of his body weight

4
Base Data
• No activity limitation complained by patient
• Chest pain/discomfort, cough was denied

5
Base Data
History of Past Illness
History of Treatment and Medication

• Has been consuming anticoagulant since ± 20 years ago after

undergone coronary artery bypass surgery

• Had been treated with bile stone ± 1 month before current

admission
6
Base Data
• HT (+), DM (-), CVD in 2015, NAFLD (+), BPH (+)

• History of disease with same symptom (-)

History of Past Illness
Social History

• Alcohol consumption (-)

• Smoking (+) for ± 30 years, ½ pack a day. Ceased 10 years ago

7
 Physical Examination
General Status Moderately ill, GCS : 4-5-6
Weight: 65 kg, Height: 160 cm BMI 25.4 (overweight)
Vital Signs BP: 187/118, RR: 24, HR: 106 tpm, T: 36.3°C,
SpO2: 97 % NK 3 Lpm
Head & Neck Light reflex +/+ , anemic conjungtivae +/+, icteric sclerae +/+,
NGT (+) coffee ground color
Thoraks P : simetrical, vesicular +/+, Rh - /- , Wh -/-
C : cardiomegali +, S1/S2 regular, murmur -, gallop -
Abdomen Convex, bowel sound(n), epigastric & LUQ tenderness,
organomegaly (-), shifting dullness (-)
Extremities Warm +/+, oedema -/-
Skin Within normal limit
Genitalia Within normal limit

8
Laboratory Result

9
Hematology Result Result Result Reference
(13/04) (19/04) (22/04)
Hemoglobin 10.8 7 PRC
12.6 13.4 – 17.7 g/dL
RBC 3.88 2.57 4.63 4 – 5.5 x 106/µL
Hematocrit 30.5 21.7 36.8 40 - 47%
MCV 78.6 84.4 79.5 80 – 93 fL
MCH 27.8 27.2 27.2 27 – 31 pg
MCHC 35.4 32.3 34.2 32 – 36 g/dL
RDW 16.7 15.8 15.9 11.5 – 14.5%
Leukocyte 13.5 7.23 9.1 4.3 – 10.3 x103 /µL
Diff. Count -/-/86/7/7 -/-/87/9/4 2/-/73/18/7 0-4/0-1/51-67/25-
33/2-5
Trombocyte 561 338 539 142 – 424 x 103/µL

10
 Clinical Result Result Result Result Reference
Chemistry (13/04) (14/04) (17/04) (19/04)
SGOT 48 - - - 0 – 40 U/L
SGPT 30 - - - 0 – 41 U/L
Total Bil. 2.16 - - 0.68 < 1 mg/dL
Direct Bil. 2.03 - - 0.47 < 0.25 mg/dL
Indirect Bil. 0.13 - - 0.21 < 0.75 mg/dL
Albumin 2.63 - - - 3.5 – 5.5 g/dL
Amilase - 137 108 - 13 – 53 U/L
Lipase - 119 89 - 13 – 60 U/L
ALP - 189 - - 66 – 220 U/L
Gamma GT - 162 - - 8 – 61 U/L
CRP 27.56 - - - < 0.3 mg/dL

11
 HPLC Result Reference
(14/04)
HbA1c 7 < 5.7%
Equal to average RBS 154.2

Clinical Result Result Reference

Chemistry (13/04) (19/04)
Ureum 32.8 7.4 16. 6 – 48.5 mg/dL
Creatinine 1.13 0.53 < 1.2 mg/dL
eGFR 64.6 105 > 90 mL/min per 1.73 m2
GDS - 199 < 200 mg/dL

12
 Immunoserology Result (13/04) Reference

Total Ab SARS-CoV-2 0.121 COI <1: Non-Reactive

Procalcitonin 0.2 <0.5 ng/ml
CEA 2.14 < 5 ng/mL
CA 19-9 13.81 <27 U/mL

Serum Result Result Reference

Electrolyte (13/04) (22/04)
Natrium 134 131 136 – 145 mmol/L
Kalium 5.03 4.54 3.5 – 5 mmol/L
Chloride 102 98 98 – 106 mmol/L
Calcium 8.3 - 7.6 – 11 mmol/L
Phosphor 4.1 - 2.7 – 4.5 mmol/L
13
 Cardiac Biomarkers Result (14/04) Result (16/04) Reference
Troponin I 0.5 - < 1 µg/L
CK MB 23 - 7 – 25 U/L
NT ProBNP - 6058 < 376 pg/mL

BGA (13/04) (14/04) Reference Lipid Profile Result Reference

pH 7.44 7.43 7.35 – 7.45 (16/04)
pCO2 29 35.1 35 - 45 Total Cholesterol 136 < 200 mg/dL
pO2 69.3 172.5 80-100 Triglyceride 229 < 150 mg/dL
HCO3 20.2 23.7 21-28 HDL Cholesterol 16 > 50 mg/dL
BE -4.1 -0.8 (-3)-(+3) LDL Cholesterol 56 < 100 mg/dL
SatO2 89 99.8 >95 %

14
09/04
Cardiomegaly (+) 13/04 OMI anteroseptal
10/04
USG: Pancreas deformity, fatty liver
Suggestion: Abdominal CT Scan
19/04 CT Scan: Acute necrotizing
pancreatitis, peripancreatic process dd/
malignancy, hydrops gall bladder 15
Other Workup
Echocardiography
• Consentric LVH with diastolic
dysfunction, mild MR
• EF 67%

16
Therapeutical
• Lansoprazole 1 x 30 mg (IV) • Paracetamol 3 x 500 mg (PO)
• Metoclopramide 3 x 10 mg (IV) • Atorvastatin 1 x 40 mg (PO)
• Lactulose syrup 3 x 15 cc (PO)
• Furosemide 2 x 20 mg (IV)
• Captopril 3 x 25 mg (PO)
• Amlodipine 1 x 5 mg (PO)
• Clopidogrel 1 x 75 mg (PO)
• ISDN 3 x 5 mg (PO PRN)
• MST 2 x 10 mg (PO)
17
Data Interpretation
Findings and Workups
Anemia NN, leukocytosis, ↑CRP, ↑amilase, ↑lipase, hyperbilirubinemia
direct, hypoalbuminemia, ↑gamma GT, ↑NT Pro BNP, HbA1c 7%
post hospitalization with bile stone, weight loss, history of DM (-), HT (+),
NAFLD (+), epigastric and LUQ pain, coffee ground colored NGT, black colored
stool, tea colored urination, anticoagulant consumption
CT scan: acute necrotizing pancreatitis, peripancreatic processes, susp.
malignancy, hydrops gall bladder, bile stone (-); CXR: cardiomegali; ECG: OMI
anteroseptal, echocardiography: EF 67%

18
Data Interpretation
Diagnosis
72 y.o male with acute necrotizing pancreatitis with cholestasis, upper
GIT bleeding e.c peripancreatic process, susp. stress ulcer, Preserved
EF congestive heart failure NYHA I, susp. Pancreatogenic DM dd/DMT2
Suggestion
LDH, CECT, endoscopy, UL, SPE, pancreas biopsy, anti GAD-65, GDP,
GD2PP,FL, insulin, fecal pancreatic elastase-1, 25-OH Vit D
Monitoring
CBC, amylase, lipase, BGA, ureum, creatinine, calcium serum, RBG,
ALP, gamma GT, SGOT, SGPT, bilirubin T/D/I, vital signs, ECG, NT Pro
BNP, HbA1c
19
Perjalanan Pasien

March 2021 Early April 2021 Late April 2021

• Undergone • Epigastric and LUQ • Condition getting

hospitalization d.t bile pain, radiating to back better
stone • Weight loss 10 kg in 1
• Anticoagulant month
consumption (+) • Tea colored urine,
• History of DM (-) black colored stool
20
 Establishment
of Diagnosis
Suspected
Malignancy

21
Establishment of Diagnosis
Pancreatitis
Cholestasis
1
GIT Bleeding
Heart Failure

22
 Pancreatitis
• Inflammation of pancreas and its surrounding tissue
• Bile stone and alcohol are the most common causes
• Diagnosis can be established if 2 of 3 criteria are met:
• Upper abdominal pain, sometimes radiating to back
• Increased amylase and or lipase more than 3 times UNL
• Evidence of pancreatic or peripancreatic inflammation in imaging
• Atlanta criteria defines imaging in pancreatitis more further
• Usually CT/MRI used if there is any atypical clinical presentation
and laboratory result
Alves JR, Ferrazza GH, Nunes Junior IN, Teive MB. THE ACCEPTANCE OF CHANGES IN THE MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS AFTER THE REVISED ATLANTA
CLASSIFICATION. Arq Gastroenterol. 2021 23
Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, et al. Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention. RadioGraphics. 2014 Sep;34(5):1218–39.
• Pancreatitis might presents as acute and chronic episode:
• Acute episode divided to mild, moderate, and severe based on evidence of
organ failure and its persistency in 48 hours  Ranson Criteria
• Organ dysfunction scoring using modified marshall scoring system

Foster BR, Jensen KK, Bakis G, Shaaban AM, Coakley FV. Revised Atlanta Classification for Acute Pancreatitis: A Pictorial Essay. RadioGraphics. 2016
Bugdaci MS, Oztekin E, Kara E, Koker I, Tufan A. Prognostic value of increased B type natriuretic peptide in cases with acute pancreatitis. European Journal of Internal Medicine. 24
2012 Jun;23(4):e97–100.
 Acute Necrotizing Pancreatitis
• Pancreatitis divided to two types based on its morphological
difference: interstitial edematous dan acute necrotizing
• Imaging-based criteria allow a definitive distinction between
• Acute necrotizing pancreatitis occurs in 20 – 30% patient with
pancreatitis and related with higher morbidity and mortality
• High mortality, especially in 2 weeks after disease onset related to
severe systemic inflammation
• Laboratory and clinical parameters are used as diagnostic tools for
risk stratification

Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, et al. Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention. RadioGraphics. 2014
Brand M, Götz A, Zeman F, Behrens G, Leitzmann M, Brünnler T, et al. Acute Necrotizing Pancreatitis: Laboratory, Clinical, and Imaging Findings as Predictors of Patient Outcome. American 25
Journal of Roentgenology. 2014 Jun;202(6):1215–31.
 Acute Necrotizing Pancreatitis
• Necrosis of tissue serves as potential nidus for infection
• Organ failure and mortality rates rise up to 50% in case with infected
necrosis
• Imaging criteria using MRI/ CECT used to predicting risk of infection
based on distribution of pancreatic necrosis and presence of acute
necrotic collection  Balthazar grade, CT severity index, PAN grade,
ANC grade

Brand M, Götz A, Zeman F, Behrens G, Leitzmann M, Brünnler T, et al. Acute Necrotizing Pancreatitis: Laboratory, Clinical, and Imaging Findings as Predictors of Patient Outcome. American 26
Journal of Roentgenology. 2014 Jun;202(6):1215–31.
 Cholestasis
• Stagnation of bile product secretion that might be caused by
abnormality of hepatocyte and biliary tract obstruction
• Pancreas enlargement, exposure to pancreatic proteolytic enzymes
might cause biliary obstruction  extrahepatic cholestasis
• Prolonged biliary tract obstruction might cause hydrops
gallbladder
• Direct hyperbilirubinemia, ALP >3x UNL might indicate cholestasis
• ERCP can be used to giving clearer biliary tract image

Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, et al. Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention. RadioGraphics. 2014 27
Shah R, John S. Cholestatic Jaundice [Internet]. StatPearls [Internet]. StatPearls Publishing; 2021 [cited 2021 Nov 10]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482279/
 Cholestasis
• ALP and Gamma GT are marker that commonly use to diagnose biliary
tract obstruction
• Elevated level of ALP can also be found such as primary
osteoblastic activity as well as secondary such in malignancy
• Gamma GT might be increased up to 5 -30 X UNL in cholestasis
• Acute and chronic pancreatitis might results in elevated level of
gamma GT
• Obstructive cholestasis usually doesn’t cause liver dysfunction such as
decreased albumin production

Vroon DH, Israili Z. Alkaline Phosphatase and Gamma Glutamyltransferase [Internet]. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Butterworths; 28
1990 [cited 2021 Nov 10]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK203/
 GIT Bleeding
• GIT bleeding classified to overt and occult bleeding
• Bleeding is clearly seen and manifested as hematemesis, melena
or both in overt
• Stress ulcers are often be the cause of gastrointestinal bleeding
• Often be found as complication of acute necrotizing pancreatitis
• May occur in 1–5% of cases of acute necrotizing pancreatitis with a
mortality of 34–52%.
• A CT scan can provide an overview  bleeding can occur in the
pancreatic parenchyma, peripancreatic to the gastrointestinal tract

Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, et al. Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention. RadioGraphics. 2014 29
Harrison T. Harrison’s Principles of Internal Medicine. 19th ed. Kasper D, Hauser S, Jameson J, Faucy A, Longo D, Localzo J, editors. Mc.Graw Hill Edu.; 2015.
NAFLD
History of bile Anticoagulant
stone consumption A few days after
treatment
Clinical pancreatitis GIT Bleeding Clinical & laboratory
Cholestasis improvement
Acute necrotizing pancreatitis, Total Bil. 2.16 0.68
peripancreatic process , hydrops
Direct Bil. 2.03 0.47
gall bladder, bile stone (-)
Indirect Bil. 0.13 0.21
ALP 189
Gamma GT 162

30
 Case
Findings and Workups
Epigastric & LUQ pain, coffee-ground NGT residue, black colored stool, tea colored
urine, anticoagulant consumption, post hospitalized d.t bile stone, NAFLD (+),
↑amylase, ↑lipase, ↑CRP, anemia NN, leukocytosis, direct hyperbilirubinemia,
hypoalbuminemia, ↑Gamma GT; CT scan: acute necrotizing pancreatitis,
peripancreatic process, hydrops gall bladder, bile stone(-)
Acute necrotizing pancreatitis with cholestasis
GIT bleeding e.c peripancreatic process, susp. stress ulcer e.c anticoagulant
Suggestion
LDH, CECT, endoscopy, urinalysis, SPE, HBsAg, anti-HCV
Monitoring
CBC, amylase, lipase, BGA, ureum, creatinine, calcium serum, RBG, ALP, gamma
GT, SGOT, SGPT, bilirubin T/D/I 31
 Heart Failure
• Complex clinical syndrome due to structural/functional changes in
ventricular filling or blood ejection
• Classified into preserved EF and reduced EF
• Assessment of EF is considered important because it determines
therapy and prognosis
• The Framingham criteria are used for the diagnosis of heart failure
based on clinical findings
• NT Pro BNP is used in initial diagnosis as well as monitoring
• The NYHA classification is used to assess the severity and progression
of the disease
32
Anderson J L et al. ACCF/AHA Guideline for the Management of Heart Failure. Journal of American College of Cardiology. Elsevier Inc. 2013
 NT Pro BNP in Heart Failure
• Nearly 1/3 patient with preserved HF had NT Pro BNP levels below
100 pg/mL
• Older patient tends to have higher levels of NT Pro BNP (900 pg/mL
and 1800 pg/mL for >50 y.o and >75 y.o, respectively)
• Patient with acute heart failure, severe renal impairment, sepsis and
critical illness may have elevated NT Pro BNP level

Tanase DM, Radu S, Al Shurbaji S, Baroi GL, Florida Costea C, Turliuc MD, et al. Natriuretic Peptides in Heart Failure with Preserved Left Ventricular Ejection Fraction: From Molecular 33
Evidences to Clinical Implications. Int J Mol Sci. 2019 May 28;20(11):2629.
 FRAMINGHAM
CRITERIA
2 major
or
1 major & 2 minor

Mahmood, S. S., & Wang, T. J. (2013). The epidemiology of congestive heart failure: the Framingham Heart Study perspective. Global 34
heart, 8(1), 77–82.
Anderson J L et al. ACCF/AHA Guideline for the Management of Heart Failure. Journal of American College of Cardiology. Elsevier
35
Inc. 2013
 Elevated NT Pro BNP in Pancreatitis
• Cardiac injury often found in pancreatitis but the relationship still
haven’t been well established  increase of cardiac biomarkers such
as NT-Pro BNP
• NT-Pro BNP level found to be related to severity of pancreatitis in
some study
• Patient with acute necrotizing pancreatitis tend to have higher levels
of NT-Pro BNP than interstitial one
• Normal/ decreased level of NT Pro BNP comes after resolution of
acute pancreatitis
Zhao B, Sun S, Wang Y, Zhu H, Ni T, Qi X, et al. Cardiac indicator CK-MB might be a predictive marker for severity and organ failure development of acute pancreatitis. Ann Transl Med. 2021
Mar;9(5):368–368.
Bugdaci MS, Oztekin E, Kara E, Koker I, Tufan A. Prognostic value of increased B type natriuretic peptide in cases with acute pancreatitis. European Journal of Internal Medicine. 2012 36
Jun;23(4):e97–100.
Case
Findings and Workups
HT (+), ↑NT Pro BNP, CXR: cardiomegaly, ECG: OMI anteroseptal,
echocardiography: LVH, diastolic disfunction, EF 67%

Preserved EF congestive heart failure NYHA I with

increased NT Pro BNP d.t acute necrotizing pancreatitis

Monitoring
Vital sign, ECG, NT Pro BNP, ureum, kreatinin

37
Suspected Malignancy 2
38
 Suspected Malignancy
• Pancreatic malignancy is difficult to diagnose  CA 19.9, CEA, CT scan is
not sensitive enough
• Often presents with pancreatitis clinically
• Acute pancreatitis might progress to chronic pancreatitis and pose as risk
factor of malignancy
• Acute pancreatitis is generally caused by biliary tract disease and alcohol
 In chronic pancreatitis the etiology is sometimes unclear
• Exocrine insufficiency is found in chronic, necrotic processes 
reserves of large pancreatic function, damage >90% only causes clinical
manifestations of insufficiency
• Chronic pancreatitis is difficult to evaluate, often presents with acute
clinical presentation and amylase, lipase is within normal limit
Harrison T. Harrison’s Principles of Internal Medicine. 19th ed. Kasper D, Hauser S, Jameson J, Faucy A, Longo D, Localzo J, editors. Mc.Graw Hill Edu.; 2015.
Using faecal elastase-1 to screen for chronic pancreatitis in patients admitted with acute pancreatitis | Elsevier Enhanced Reader [Internet]. [cited 2021 Nov 7]. Available from:
39
https://reader.elsevier.com/reader/sd/pii/S1365182X15309527?token=EC9C28C97F229BCFAAF434038BBEE7761D6977CF1810C5ED750417B5DCCE3F81064CC7A0A00D2F5949BF85A228937840&originRegion=eu-west-1&originCreation=20211107060324
 Pancreatic Cancer
• Cancer with a poor prognosis
• 90% are adenocarcinomas, most of which originate in the head of
the pancreas
• The majority occurs in the 7/8 decade, especially in males
• Clinical manifestations vary depending on the location of the tumor
• Most cause biliary obstruction due to location in the head 
painless jaundice
• ERCP is a commonly used non-invasive modality gold standard
remains histopathology

McGuigan A, Kelly P, Turkington RC, Jones C, Coleman HG, McCain RS. Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018 40
Mizrahi JD, Surana R, Valle JW, Shroff RT. Pancreatic cancer. The Lancet. 2020 Jun;395(10242):2008–20.
 41
Mizrahi JD, Surana R, Valle JW, Shroff RT. Pancreatic cancer. The Lancet. 2020 Jun;395(10242):2008–20.
 CA 19-9 in Ca Pancreas
• CA 19-9 has low NPV  cannot be used for screening
• Serial examinations can be used to monitor therapy and the
possibility of recurrence
• Increases only in 70% of patients with pancreatic Ca
• Has prognostic value in established diagnosis
• Cut off of 37 IU/ml has sensitivity 77% and 87% in differentiating
benign and malignant lesion
• CEA is a non-specific marker that has been found to be elevated in
some patients with pancreatic cancer

McGuigan A, Kelly P, Turkington RC, Jones C, Coleman HG, McCain RS. Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018 42
Harrison T. Harrison’s Principles of Internal Medicine. 19th ed. Kasper D, Hauser S, Jameson J, Faucy A, Longo D, Localzo J, editors. Mc.Graw Hill Edu.; 2015.
 DM and Pancreatitis
• The pancreas has an important role in the regulation of blood sugar
• The inflammatory process in acute necrotizing pancreatitis can cause
permanent islet cell damage  decreased insulin production
• Pancreatic malignancies can cause pancreatogenic DM in addition to
chronic and recurrent pancreatitis
• New-onset diabetes (<2 years) has been extensively studied in
relation to pancreatic malignancies

Banks PA, Conwell DL, Toskes PP. The Management of Acute and Chronic Pancreatitis. Gastroenterol Hepatol (N Y). 2010
43
Andersen DK, Korc M, Petersen GM, Eibl G, Li D, Rickels MR, et al. Diabetes, Pancreatogenic Diabetes, and Pancreatic Cancer. Diabetes. 2017 May;66(5):1103–10.
 Pancreatogenic DM
• It is a form of DM due to impaired pancreatic exocrine function that
causes pancreatic endocrine dysfunction
• Classified as type 3c DM by the ADA and WHO
• Can be caused by acute, recurrent, chronic pancreatitis and
pancreatic cancer
• Can be caused by acute, recurrent, chronic pancreatitis and
pancreatic cancer
• Insulin resistance is generally not found in this type of DM

Pancreatogenic (Type 3c) Diabetes [Internet]. The University of Michigan Library; [cited 2021 Nov 7]. Available from: http://pancreapedia.org/?q=node/9050 44
Andersen DK, Korc M, Petersen GM, Eibl G, Li D, Rickels MR, et al. Diabetes, Pancreatogenic Diabetes, and Pancreatic Cancer. Diabetes. 2017 May;66(5):1103–10.
• Homeostasis Model Assessment (HOMA)  estimation of insulin resistance
(HOMA-IR) and pancreatic -cell function (HOMA-B)
• Calculations using fasting blood glucose and insulin
• HOMA-IR > 2 indicates an insulin resistance and HOMA-B < 48.9% indicates a
decrease in pancreatic cell function
Pancreatogenic (Type 3c) Diabetes [Internet]. The University of Michigan Library; [cited 2021 Nov 7]. Available from: http://pancreapedia.org/?q=node/9050
Bautista FP, Jr GJ, Dampil OA. Insulin Resistance and β-Cell Function of Lean versus Overweight or Obese Filipino Patients with Newly Diagnosed Type 2 Diabetes Mellitus. Journal of the ASEAN 45
Federation of Endocrine Societies. 2019 Nov 26;34(2):164–70.
 Pancreatic Elastase 1
• Specific proteases produced by pancreatic acinar cells
• Very stable, not influenced by other pancreatic enzymes
• One of the non-invasive tests that can be used to assess the exocrine
function of the pancreas
• A result below 200 µg /g indicates an exocrine pancreatic insufficiency

Dominici R, Franzini C. Fecal Elastase-1 as a Test for Pancreatic Function: a Review. Clinical Chemistry and Laboratory Medicine [Internet]. 2002 Jan 24 [cited 2021 Nov 9];40(4). Available
from: https://www.degruyter.com/document/doi/10.1515/CCLM.2002.051/html
46
Clinical Pancreatitis
Bile Stone History of Pancreatitis ?
↓ Weight 10 kg
Age > 70 th
New onset DM
Acute necrotizing pancreatitis,
peripancreatic process dd/ Pancreatogenic DM
?
malignancy Exocrine insuff.

Suspected
Pancreatic
Malignancy
47
 Case
Findings and Workups
Weight loss, on treatment for acute pancreatitis, history of DM (-), CT: acute
necrotizing pancreatitis, susp. malignancy, HbA1c 7%

Susp. Ca pankreas

Susp. Pancreatogenic DM dd/ DMT2

Suggestion
Pancreas biopsy, anti GAD-65, GDP, GD2PP, FL, insulin, fecal pancreatic elastase-
1, 25-OH Vit D
Monitoring
RBG, HbA1c, amylase, lipase 48
Summary
• It has been discussed 72 y.o male with acute necrotizing
pancreatitis with cholestasis, upper GIT bleeding e.c
peripancreatic process, susp. stress ulcer, Preserved EF
congestive heart failure NYHA I, susp. Pancreatogenic DM
dd/DMT2
• Patients with ANP findings should be monitored for possible
infection, it can be with CRP, WBC, signs of sepsis, and clinical
conditions
• CECT/MRI can be considered in patients with suspected
pancreatitis because it can provide disease stratification and
predict the possibility of infection
49
Summary
• Increased level of NT Pro BNP in this patient might influenced
also by CHF but serial test might be helpful in prognostication of
acute pancreatitis
• The suspicion of pancreatic malignancy in this patient is based on
several risk factors including age, weight loss, new-onset DM, and
the possibility of chronic pancreatitis in this patient
• It is hoped that the evaluation of pancreatic exocrine
insufficiency and the possibility of pancreatogenic DM in these
patients will help in future management of these patients

50
Summary
Suggestion
LDH, CECT, endoscopy, UL, SPE, pancreas biopsy, anti GAD-
65, GDP, GD2PP,FL, insulin, fecal pancreatic elastase-1, 25-
OH Vit D
Monitoring
CBC, amylase, lipase, BGA, ureum, creatinine, calcium
serum, RBG, ALP, gamma GT, SGOT, SGPT, bilirubin T/D/I,
vital signs, ECG, NT Pro BNP, HbA1c

51
T h a n k Yo u F o r Yo u r K i n d A tt e n ti o n

52