Clinico-pathological Conference A 20-year-old man with recurrent abdominal pain and vomiting since the age of 5 years SIR GANGA RAM HOSPITAL, NEW DELHI

THE CASE A 20-year-old man presented to Sir Ganga Ram Hospital (SGRH) with complaints of recurrent abdominal pain and vomiting since the age of 5 years. The pain was in the epigastrium and radiated to the back. Investigations at the time of onset of symptoms did not reveal any abnormality, and he was given analgesics. In 1998, when he was 11 years old, he underwent an endoscopic retrograde cholangiopancreatogram (ERCP), which revealed changes consistent with chronic pancreatitis. He was started on proton-pump inhibitors and pancreatic enzyme supplements. Two years later, he underwent stenting of the pancreatic duct with three changes of stents in the subsequent year. A year later, in 2001, when he was 14 years old, he developed diabetes and was treated with insulin. Since 2002, he had been followed up at SGRH and his pancreatic duct stent had been changed many times. In February 2006, the pancreatic stent was removed and he had complete relief from pain. However, 4 months later, he presented with episodes of weakness and sweating. Investigations at this time showed the following: