Computed tomography scan of the abdomen showing bulky pancreas with dilated main pancreatic duct, intraparenchymal calcification and intraductal calculi (arrow). 

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... remains uncommon and pancreatic disease with PHPT extremely rare. Much later publications dealing with parathyroid disease are hesitant to attribute a direct causal linkage between the two and underplay the association. After the 1980s various studies from developed countries have shown the association of pancreatitis with PHPT to range from 3.2 to 5.6%. 7–9 Data from other developing countries show this association in approximately 2.5% of patients. 10,11 One centre from the northern India has reported that in 6.8% of patients with PHPT, the disease was initially suspected because of unexplained pancreatic disease. 12 As pancreatic disease remains an important initial clinical presentation in the present setting, we attempt to characterize it in patients with PHPT in terms of their clinical presentation, biochemistry and imaging parameters. This study is a retrospective review of the medical records of 13 patients of a total of 101 PHPT patients who presented with pancreatic disease at Christian Medical College, Vellore between 1 May 2000 and 30 May 2005. The medical records were reviewed for patient characteristics and clinical details. Biochemical records of all 101 patients with PHPT were retrieved from the computerized hospital information processing system. The patients were divided into group 1 having PHPT with pancreatic disease and group 2 having PHPT without pancreatic disease. The diagnosis of pancreatitis was confirmed by detection of an increased serum amylase (>3 times the normal) and/or increased lipase levels in the presence of upper abdominal pain. The diagnosis was confirmed by the presence of abnormalities on pancreatic imaging. Other aetiologies of pancreatic disease including gall bladder disease, microliths in bile, hypertriglyceridaemia, history of alcohol intake, medications and abdominal trauma were sought. The biochemical diagnosis of PHPT was made when persistent increased calcium levels above the upper limit of normal was associated with an increased circulating immune reactive intact parathyroid hormone levels. The calcium values were corrected for the serum albumin values and the results were expressed as corrected calcium levels. Detailed radiological reports were obtained from the picture archiving and communicating system (General Electric– Picture Archiving and Communicating System) and reviewed with a radiologist. Data were analysed using the Statistical Program for Social Sciences ( SPSS version 11.0 for Windows; SPSS , Chicago, IL, USA). Descriptive statistics were used in most of the reviews as the patient number was small. Thirteen patients were identified from among a cohort of 101 ( ; 13%) patients with confirmed PHPT who had clinical or ana- tomical evidence of pancreatic disease over a period of 5 years in our hospital. During the same period, there were 1284 admissions for pancreatic disease out of 302 883 inpatient admissions. In 12 patients ( ; 12%) pancreatic disease was the presenting symptom and the initial clinical indication to make an assessment for parathyroid disease. One patient had pancreatic involvement in addition to severe bone disease as the presenting symptom. The patients ranged from 22 to 52 years in age with a median age of 37 years. The median age of patients in group 2 was 43 years. There were 9 (69%) men and 4 (31%) women among patients in group 1. Among patients in group 2 there were 38 (43%) men and 50 (57%) women. The common presentation of pancreatic disease was either recurrent episodes of upper abdominal pain seen in 6 (46%) of the 13 patients or a single episode of acute pancreatitis seen in another 6 (46%) of these patients. One of the patients mentioned had an episode of life-threatening acute pancreatitis requiring surgical intervention. One patient (8%) presented with a painless chronic pancreatitis characterized by malabsorption and secondary dia- betes. The duration of symptoms before the diagnosis of PHPT was made ranged from a few days to 22 years. The median period before the diagnosis of PHPT was entertained was 6 months. Six (46%) of the patients had more than five episodes of pain, requiring an average of four hospital admissions for treatment of pain before surgery could be undertaken for the parathyroid adenoma. Significant weight loss was seen in five (38%) of the patients. However, malabsorption was documented in only one patient (8%). Other causes of pancreatitis were sought in all patients. Nine patients (69%) had a normal gall bladder on ultrasound imaging, whereas three (23%) had echogenic sludge in the gall bladder and in one (8%) patient the gall bladder could not be observed because of prior cholecystectomy. One patient (8%) had history of chronic alcohol dependence. Symptomatic nephrolithiasis was seen in 6 (46%) patients in group 1. Of the six patients with renal stones, one (8%) patient had bilateral stone disease, one (8%) had unilateral stone disease and four (30.8%) had nephrocalcinosis. Two patients (15%) had a history of bone pains whereas three (23.1%) had proximal muscle weakness. Two (15%) patients had a history of pathological fractures and one (8%) patient had a palpable mass in the neck. Among patients in group 2, bone disease was present in 60% of patients with 28% having severe bone pains, 31% had proximal muscle weakness, 37% had pathological fractures, 26% had radiological osteitis fibrosa cystica (OFC), 13% had palpable OFC and 3% had spinal deformities at the time of presentation. Symptomatic renal stones were seen in 36% patients, including 16% with the presence of renal parenchymal calcification. A palpable neck nodule was felt in 11% of patients. The median duration of symptoms in group 2 patients before the diagnosis of PHPT was 24 months. Details of the biochemical profiles of groups 1 and 2 are shown in Table 1. The pancreatic anatomy of group 1 patients was characterized with either ultrasound or computed tomography (Fig. 1). The details are provided in Table 2. Of the eight patients who underwent ultrasound of the neck, four (50%) had detectable lesions on the scan. A 99 technetium sesta- mibi scan was carried out on all patients. Eleven of them had unequivocal uptake that was suggestive of a single adenoma and two had a doubtful uptake. Surgical details are shown in Table 2. No postoperative complications were observed except for transient hypocalcaemia in two of the patients operated on. The association of primary hyperthyroidism with pancreatic disease has been controversial because of the rarity of the association in contemporary published work in developed ...

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... pancreatic anatomy of group 1 patients was characterized with either ultrasound or computed tomography (Fig. 1). The details are provided in Table ...