Age: 4.0
Sex: M
Vaccine: MMR
Symptoms: Constipation, Diarrhoea, Duodenitis, Laboratory test abnormal, Lipase increased
Clinical narrative: Initial and follow up info has been received from a licensed practical nurse and physicians concerning a 4 year old male pt who was a term C-section with no complications at delivery and with no known drug allergies, a dust mite allergy with asthma diagnosed at 3 years of age, which had required treatment with prednisone and had required hospitalization. It was reported that there was a family history of obesity on maternal and paternal sides and a cousin with asthma, but no history of diabetes, heart disease, pancreatitis, liver problems, lipid problems or gastrointestinal disorders. On 4/18/02, the pt was vaccinated SC with a second dose of MMR II (641459/0057M). The pt developed symptoms of intermittent epigastric pain in November 2002 felt to be due to constipation. Treatment included unspecified medication for the constipation as well as enemas (enema dates not specified). The pain did not improve. The primary care physician began working the pt up for other causes of the abdominal pain (also reported as epigastric pain and periumbilical pain). Amulase and lipase levels were elevated and these remained elevated for 5 1/2 months. It was reported that on 11/19/02 the pt developed acute pancreatitis with recurrent abdominal pain. In December 2002 the pt had mild peripheral eosinophilia. Also, in December 2002 the pt went to the emergency room with his typical abdominal pain and a KUB at that time suggested constipation. The pt was also treated for asthma exacerbation. On 1/27/03 laboratory evaluation revealed a lipase of 637. On 1/28/03 the pt continued with intermittent epigastric pain and it was noted that amylase and lipase levels were persistently elevated. Therefore the pt was seen in the gastroenterology clinic for follow up. It was noted on this visit of 1/28/03 that an ultrasound of his abdomen was normal and a sweat chloride test was normal. It was also noted that the pt had a positive Helicobacter pylori IgG titer, which had been done on 1/20/03. The pt had been eating foods without any restrictions, but the mother reported  no correlation between the food that the pt ate and symptoms. Treatment was non-fat to minimal fat diet and Prevacid. Lab evaluation on 2/3/03 revealed an amylase of 109 (30-110) and lipase 805 (23 to 300). On 2/4/03. at gastroenterology visit, it was reported the pt was experiencing some abdominal pain (5 out of 10) but had been free for the 2 previous days. The pain was in the periumbilical region and generally it occurred in the morning but more likely at night. The pt reportedly had some flare up of his asthma symptoms with the last episode being the night before the visit. The medications that the pt was taking at the time of this visit were Prevacid, Pulmicort inhalers as needed. It was noted that the mother felt that the budesonidde alleviated the abdominal pain. The pt had non-probmematic daily stools but there had been no relief of the pain associated with defecation. The pt had only one episode of vomiting associated with his acute pancreatitis. The pt had occasional nausea in association with the periumbilical pain. Exam at this visit noted slightly coarse breath sounds and some increase stool in the lower quadrant of his abdomen. The clinical impression noted at this visit was acute pancreatitis, with lab values showing normalized amylase and elevated lipase. It was felt that the continued abdominal pain, which appeared to be periumbilical, could be associated with the pt's tendency toward constipation. Treatment prescribed was polyethylene glycol 3350 (MiraLax). On 2/17/03 lab evaluation revealed an amylase of 116 and a lipase of 697. On 2/18/03 the pt was seen for follow up and he continued with abdominal pain that had become more severe over the last few days. It had awakened him three times the previous night. The pain was above the waistline and tended to occur in the morning on awakening or in evening after dinner and before bedtime. The pt had also experienced some exacerbation of his asthma and had required budesonide and albuteral the night prior to the visit. Current medications reported at this visit were lansoprazole, Tums, polyethylene glycol 3350 and Triaminic for the upper respiratory symptoms. Per the pt's mother, the pt had a three-day period without abdominal pain after lansoprazole had been started but the pain recurred. The calcium carbonate was being given for the pain at night, but without any abatement of the pain. Exam at this visit noted increased stool in the lower quadrant of his abdomen, particularly the right lower quadrant. The physician was concerned about the continued abdominal pain despite lansoprazole and a near three-month time interval since the pancreatitis had been diagnosed. Treatment was continuing polyethylene glycol 3350 and increasing the dose of lansoprazole, as well as being more rigid about a non-fat diet. The mother had asked to use acidophilus and then herbal teat and approval was given. On 2/25/03 lab evaluation revealed amylase of 112 and lipase of 615. On 3/4/03 the pt was seen for follow up and still complained of abdominal pain, which occurred more often in the evening and it was reported that it 'had been considered at some point to be an attention-seeking behavior." The clinical impression at this visit was that the pt continued to have evidence of mild pancreatitis, but was improving. The plan was to continue lansoprazole, polyethylene glycol 3350 and a minimal fat diet. It was noted at the visit that the pt had recently been seen in the ER for his asthma and had been prescribed prednisone and amoxicillin. The mother had not administered the prescribed medications. It was reported that "In retrospect, it appears that his pancreatitis occurred shortly after a course of corticosteroid therapy for an exacerbation of his asthma." On 3/7/03 a CT scan of the abdomen with contrast was negative. On 3/19/03 an endoscopy with biopsy revealed chronic inflammation of duodenum, chronic inactive inflammation in the gastric antrum, with mild eosinophilic infiltrates in the gastric body in the esophagus. The operative report noted that the esophagus appeared normal, the body of stomach appeared grossly normal, the antrum had slight erythematous appearance particularly at pyloric junction and the duodenum had slight erythema and mildly edematous appearance. No ulceration or bleeding was appreciated. The impression was mild duoldenitis. Multiple biopsies were taken which revealed: 4 duodenal mucosal biopsies showed no pathologic diagnosis, two deodenal mucosal biopsies revealed chronic active inflammation, mild; two gastric antrum mucosal biopsies showed chronic inactive inflammation, mild; gastric mucosal biopsy showed eosinophilic inflammation, mild. On 4/1/03 lab evaluation revealed an amylase of 87 and lipase 288 (normal). It was reported that the pt had been hospitalized on 4/1/03 and had diarrhea on the morning of the admission. However there is an outpatient clinic later dated 4/1/03 that reports that the pt was seen and continued to have abdominal pain that was usually periumbilical and occurred just before going to bed and sometimes on awakening in the morning. It was noted that the pt has been treated for the past 3 months with polyethylene glycol 3350 with perhaps some slight improvement in symptoms. This clinic noted reported that the pt had been admitted to the hospital the week prior to the visit because of abdominal pain and KUB was performed-results unknown. The impression noted at this visit was that the pain was most likely due to mild constipation. It was reported that the pancreatitis appeared to have resolved. The pt had evidence of Helicobacter pylori infection on serology, however his gastric and antral biopsies only showed mild inactive inflammation. It was noted that this could have been because the pt had been treated with lansoprazole prior to the endoscopy. The pt also had eosinophilic infiltrate in the gastric antrum inside the gastric body and in the esophagus, suggesting possibly even an eosinophilic gastrnenteropathy. Treatment was helicobacter triple therapy including metronidazole, clarithromycin and omeprazole. The pt was also continued on polyethylene glycol 3350. On 4/8/03 lab evaluation revealed an amylase of 125 and a lipase of 521 and on an office visit report it was noted that on 4/9/03 the pancreatic enzymes were again increased with lipase levels in the 500's. The pt was admitted to the hospital on 4/11/03 for the abdominal pain and the history and physical noted that the mother felt that throughout different treatments the pain had remained the same and continued to be mostly at night. The pt continued to awaken at night with pain, but calmed and fell back to sleep with Tylenol, Mylanta or having his stomach rubbed. The pt had occasional nausea with the stomach pain. Mild persistent asthma was also reported which continued to be treated with albuterol and budesonide as needed. The assessment reported on the history and physical of 4/11/03 was that the pt had a 4 month history of recurrent abdominal pain and questionable diagnosis of chronic pancreatitis and Helicobacter pylori gastritis. Therefore, the plan was to admit the pt to the hospital to determine the cause of the abdominal pain. It was reported that the pt was admitted to the hospital on 4/11/03 for five days for observation of the pain. An upper GI, which was done on an unspecified date in April 2003, was negative. On 4/29/03 lab evaluation revealed amylase 89 and lipase 421. On 5/13/03 the pt was seen at the gastroenterology clinic and the physician noted in summary that the pt had acute pancreatitis that had persisted over 4 months. The pt had also been found on serology to be Helicobacter pylori positive and had also had problems with constipation with some response to treatment with polyethyleneglycol 3350. The physician noted that the pt had been on a low fat diet and his symptoms of abdominal pain were significantly improved. The pt did not appear to have any nocturnal pain. The physician's impression was that the pt had persistent acute pancreatitis but appeared to be making a significant improvement, albeit rather slowly on a low fat diet. It was recommended that the pt continued on polyethylene glycol 3350 and Prilosec. It was reported that on 6/1/03 the pt had recovered from the acute pancreatitis with recurrent abdominal pain and evaluated lipase and amylase. Follow up info received on 7/15/03 contained the following adverse experiences: BMI substantially greater than 97% (2/4/03); allergic shiners (2/4/03); ehrythematous nasal  turbinates (2/4/03); postnasal drip (2/4/03); group A strep (March 2003); upper respiratory infection (March 2003). It was reported that acute pancreatitis and abdominal pain were other important medical events (OMIC). No further info is expected.