In the reader’s question, “Pain in a person with hepatitis C and a fatty pancreas” (Advisor Forum item 192-3, October 2014; available here, accessed on November 15, 2014), the expert’s answer was given as possibly caused by pancreatitis or cirrhosis.

However, being that the patient’s liver function tests and lipase levels were normal, this is highly unlikely. Neither fatty liver, fatty pancreas, nor cirrhosis in and of themselves cause abdominal pain regardless of etiology, and pancreatitis is by definition inflammatory — evidenced by elevated lipase. 

With any type of chronic abdominal pain, think broadly. No other history or associated symptoms were given, but in this diabetic patient, one must consider gastroparesis, chronic gastritis (e.g., Helicobacter pylori), peptic ulcer disease, biliary dysfunction, and ischemia. The expert suggested endoscopic ultrasound, but this would be no more revealing as to the cause of pain than simple abdominal ultrasound (looking for gallstones, mass lesion, thrombosis). 

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If the cause isn’t better defined by a more complete history (timing, provocative factors, associated symptoms, social/diet history, review of symptoms), I would give this patient a strict anti-reflux diet (good for any gastrointestinal symptoms), put him on a daily proton pump inhibitor (which, with varices, he should be taking anyway), add sucralfate 3 times a day (making sure to precaution for constipation, which can trigger encephalopathy), check a stool antigen for H. pylori, and order a HIDA scan looking for biliary dyskinesia (extremely common in end-stage liver disease).

If results are all normal, I’d proceed with a gastric-emptying study, looking for gastroparesis. — Anne Walsh, PA-C, MMSc, Los Angeles (194-2)

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