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From question on page 161

Computed tomography (CT) scan shows a marked decreased in pancreatic volume compared with the scan performed before bone marrow transplantation (BMT), the pancreas appearing as a thin band of tissue. Pancreatic enzymes were administered and allowed normalisation of intestinal transit and an increase in body weight. Even if the contribution of intestinal graft versus host disease (GVHD) cannot be ruled out in our patient, the most plausible explanation for her diarrhoea was that is was pancreatic in origin. The rapid development of pancreatic atrophy in the context of GVHD strongly suggests that this disease contributed to pancreatic destruction as well as to the fact that pancreatic insufficiency developed after the decrease in immunosuppression.

Exocrine pancreatic insufficiency after BMT has been reported previously,1–5 and in an autopsy study of 15 children who died after a BMT,6 a case of pancreatic atrophy was found, with extensive interstitial fibrosis and mild inflammation. Another case of exocrine pancreatic insufficiency with pancreatic atrophy on CT scan was also reported after BMT and the patient improved with pancreatic enzyme supplements.6 We hypothesise that pancreatic atrophy is a late consequence of chronic GVHD. This diagnosis must be known as chronic diarrhoea is usually interpreted in such patients as a consequence of intestinal GVHD, leading to intensification of immunosuppression. If pancreatic atrophy is demonstrated, treatment with pancreatic enzymes can be of significant benefit.


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