Severe pancreatic exocrine insufficiency presenting with hypoalbuminemia, anasarca, and pulmonary edema in a patient with prior gastrectomy and suspected immunoglobulin G4-related pancreatobiliary disease.
Naoya Fujita, Kenichi Hashimoto, Akinori Sekizawa et al.
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Case in brief
A 55-year-old man with prior subtotal gastrectomy presented with generalized edema, substantial weight gain, dyspnea, and frequent watery, pale stools. Testing showed profound hypoalbuminemia, markedly reduced pancreatic enzyme levels, and evidence of fat malabsorption; imaging demonstrated pancreatic atrophy alongside pleural effusions, pulmonary edema, ascites, and diffuse soft-tissue edema. Cardiac, renal, and hepatic disorders did not sufficiently explain the findings, and pancreatic exocrine insufficiency was diagnosed. Elevated serum IgG4 and prior pancreatobiliary imaging abnormalities made IgG4-related disease a possible cause, with gastrectomy a potential modifying factor. Albumin, diuretics, and pancrelipase were followed by rapid clinical improvement.
What made this case unusual
The exocrine insufficiency presented with severe hypoalbuminemia and extensive third-space fluid accumulation, including pulmonary edema and compartment syndrome-like findings, rather than only gastrointestinal symptoms.
Diagnostic / clinical pearl
When edema and hypoalbuminemia coexist with pale watery stools and pancreatic atrophy, assess for pancreatic exocrine insufficiency even if cardiac, renal, or hepatic disease is considered; the cause may be multifactorial.