Background: 45-year-old man with a history of chronic alcoholism accompanied by chronic pancreatitis and insulin-dependent diabetes mellitus, presenting with very low dietary intake. He was admitted to hospital several times for flare-ups of his chronic pancreatitis. In 2002 he underwent surgery to remove a pancreatic pseudocyst which became complicated and ended with a cystogastrostomy which resolved favourably. In February 2003, he was admitted again for emphysematous cholecystitis with complicated perivesicular abscess and a cholecystostomy with Pezzer tube was performed to perform cholecystectomy in a second surgery. He was discharged with a cholecystostomy tube drainage of approximately 500 ml. In November 2003, she attended surgery for a qualitative examination of the stool, which showed an increase in fat and food debris, a foul odour and a pasty consistency. No treatment was prescribed.
Current illness: In February 2004, she attended the emergency department with a 3-month history of bilateral eye pain, redness, itching, photophobia and reduced visual acuity. She was admitted to the Ophthalmology Department for study and treatment. Ophthalmological examination revealed peripheral ulcerative keratitis and visual acuity of less than 10% in the right eye. In the left eye, there was a central corneal ulcer with stromal necrosis and hyphema, and she only had light perception. Imaging tests were negative. Corneal cultures were negative. ENT, digestive and rheumatology examinations were not significant. The patient was referred to the Nutrition Unit for weight loss of 16 kg in the last 6 months. The nutritional assessment revealed severe caloric and mild protein malnutrition, weight of 52 kg with a BMI of 18.2 and loss of 23% of her usual weight in the last 6 months, tricipital fold of 5, 2 mm (42% of the 50th percentile for her age and sex), arm muscle circumference of 18.3 (74% of the 50th percentile for her age and sex), hypoproteinaemia with albumin 2.42 g/dl and Retinol Transport Protein 1.5 mg/dl (Reference value: 3.5-7.5 mg/dl), severe deficit of fat-soluble vitamins, especially Vitamin A (Vitamin A: 0.24 ng/ml. Reference value: 0.4-0.8) and vitamin D (Vitamin D: 0, not detectable in blood. Reference value 15-100 ng/ml). Both vitamin B complex vitamins, vitamin C and zinc were normal. The 24-hour stool malabsorption study showed the presence of mild malabsorption (Nitrogen: 2.5 g, faecal fats 6.3 g and faecal sugars 3.8 g), however when this last stool sample was collected the patient was already on treatment with Pancrease®.
Treatment: The patient's diet was supplemented with special hyperprotein and hypercaloric formulas for diabetics (Resource diabet® 2 shakes every day), the deficient vitamins were administered orally (Natecal D® 2 tablets every day, Auxin A+E 2 tablets every/day), and pancreatic enzymes were added (Pancrease® 2-0-2).
Evolution: In April 2004 cholecystectomy was performed and cholecystostomy was closed. We evaluated the patient 3 months later and he had a BMI of 20, the anaemia had subsided and the ophthalmological problems had evolved favourably. The corneal ulcers have healed and visual acuity has almost completely recovered (right eye 100% and left eye counts fingers (table I).