following abdominal irradiation . Pancreatic insufficiency

Case history A 47-year-old man presented in February 1977 with weight loss and lymphadenopathy. Investigations including a staging laparotomy showed that he had stage IV nodular sclerosing Hodgkin's disease involving cervical, mediastinal and abdominal nodes, spleen and bone marrow. He was treated with combination chemotherapy (chlorambucil, vinblastine, prednisone, procarbazine; and adriamycin, bleomycin, vinblastine, dacarbazine) with only partial response. In June 1978, because of persistent intrathoracic and abdominal disease, he was treated with mantle and inverted Y radiotherapy in 21 fractions over 43 days. The upper abdominal nodes received 3700 rad mid-plane dose. During the course of the radiotherapy he developed diarrhoea with 3-4 pale frothy stools daily. In January 1979 he was investigated for steatorrhoea. His symptoms had not changed in the intervening 6 months. Physical examination revealed no abnormalities other than anaemia. Blood count showed Hb, 8g/dl; MCV, 120/fl; WBC, 4-2 x 109/1; platelets, 100 x 109/l; and reticulocytes, 4%. Bone marrow biopsy and haematological findings were consistent with marrow hypoplasia secondary to chemotherapy and radiotherapy. Blood urea and electrolytes were normal but liver function was abnormal with SGOT, 42 i.u.; alkaline phosphatase, 750 i.u. (n < 100) (liver isoenzyme); and albumin, 25 g/l. After injection of sulphobromophthalein there was 130% retention at 45 min. Liver biopsy showed mild non-specific sinusoidal dilatation. Steatorrhoea (38 mmol =13 g/day) was confirmed and he was investigated for radiation enteritis. However, all tests performed proved normal including barium studies of the upper and lower gut; jejunal biopsy; Schilling test; 14C breath test; xylose tolerance test; and 51Cr Cl3 protein-losing enteropathy test. There was no evidence of malabsorption as judged by normal values for folate, iron, B12, prothrombin time and glucose tolerance test. Pancreatic insufficiency was considered and confirmed by a 2-hr Lundh test which showed only one unit of tryptic activity in the first 30 min and no activity at all in the subsequent 3 30-min samples (normal, >8 u./sample). The pH varied from 6-08-0 with a mean value of 7-0 An endoscopic retrograde cholangiopancreatogram showed no structural abnormality of the biliary or pancreatic ducts. He was treated with a low fat diet and oral pancreatic supplements which clinically abolished the steatorrhoea. He was last seen in December 1979 on the same regime. He was free of clinical steatorrhoea but had evidence of recurrent intra-thoracic Hodgkin's disease.