Bondoc-Borja, J.- Borja, P.-Buenavente-Bustamante-Buti-Cabanag-Calaquian-Calayan

58-year old male CC: progressive jaundice

HPI: 2 months PTA:

◦ experienced vague abdominal pain and anorexia

1 month PTA: ◦ progressive yellowish discoloration of the sclera◦ tea-colored urine, pruritus, and acholic stools◦ weight loss of around 20%

Past Personal History Past Medical History

heavy smoker( 1 pack a day for the last 3 years);

occasional alcoholic beverage drinker

known hypertensive for the past 10 years;

no history of hepatitis

no history of diabetes

on captopril and metoprolol

HEENT: icteric sclerae; no palpable cervical lymph nodes

Heart/Lungs: unremarkable Abdomen: globular with a vague ballotable

mass at the RUQ, smooth, not tender and moves with respiration, (-) fluid wave.

Rectal exam: acholic stools

CBC – normal; Creatinine: 2 mg/dl Alkaline phosphatase: 500 u/L; Total

protein: 6.5 g/dl; albumin: 3.5g/dl; globulin: 2.5g/dl

Total bilirubin: 10 mg/dl; Direct bilirubin: 8 mg/dl; Indirect bilirubin: 2 mg/dl

CA 19-9: 350 units/ml Chest x-ray: normal Ultrasound: distended gallbladder with

no stones; CBD 2.5 cm; dilated intrahepatic ducts; enlarged head of the pancreas; normal liver

ERCP CT scan

Endoscopic ultrasound MRI

Subjective Objective

• 58 y/o, male• CC: progressive jaundice• Vague abdominal pain

and anorexia• Progressive yellowish

discoloration of the sclera, tea-colored urine, pruritus, and acholic stools

• Weight loss of 20%• heavy smoker (3-pack

years)occasional alcoholic beverage drinker;

• (+)HPN

• Icteric sclerae• Globular abdomen, with a

vague ballotable mass at the RUQ– smooth, not tender and moves

with respiration• Rectal exam: acholic stools

Labs:• Alkaline phosphatase: 500 u/L; • Total bilirubin: 10 mg/dl• Direct bilirubin: 8 mg/dl• CA 19-9: 350 units/ml

Imaging:• Ultrasound: distended

gallbladder with no stones; CBD 2.5 cm; dilated intrahepatic ducts; enlarged head of the pancreas; normal liver

Biliary Obstruction secondary to Pancreatic

Head Carcinoma

Cancer of the pancreas is the 5th leading cause of cancer death in the US

Risk factor consistently linked to pancreatic cancer is smoking; smoking increases the risk of developing pancreatic cancer by at least 2-fold

Other risk factors: long-standing diabetes, chronic pancreatitis, family history

Head 80%, body 15%, tail 5%•Types

•Ductal adenocarcinoma- most common•Intraductal papillary mucinous carcinoma•Mucinous cystadenocarcinoma

Peak age incidence: 65-75 years old

Signs and symptoms•Jaundice, pruritus•Anorexia, weight loss•Back pain•Late-onset diabetes•Vomiting due to duodenal obstruction•Palpable GB (Courvoisier’s sign)•Virchow’s node, Sister Joseph’s sign

found in 6 to 12% of patients with stones in the gallbladder incidence increases with age secondary common bile duct stones

◦ majority of ductal stones in Western countries are formed within the gallbladder cystic duct common bile duct

◦ usually cholesterol stones primary stones

◦ form in the bile ducts◦ usually of the brown pigment type◦ more commonly seen in Asian populations◦ associated with biliary stasis and infection ◦ causes of biliary stasis

biliary stricture papillary stenosis Tumors other (secondary) stones

Choledocholithiasis Patient

> 60 yrs. Old Female Abdominal pain

◦ Colicky, moderate in severity, located in the RUQ,

◦ intermittent, transient, and recurrent

jaundice Icteric sclerae nausea vomiting Tea-colored urine Acholic stools RUQ tenderness

• 58-year old • male• vague abdominal pain• progressive

jaundice• icteric sclerae• anorexia• tea-colored urine• pruritus• acholic stools• 20% weight loss• globular abdomen • vague ballotable mass

at RUQ– smooth, not tender and

moves with respiration

long-standing inflammation of the pancreas that results in irreversible deterioration of pancreatic structure and function.

Chronic inflammation, fibrosis, progressive destruction of both exocrine and eventually endocrine tissue

CHRONIC PANCREATITIS PATIENT

• 58-year old • male• vague abdominal pain• progressive jaundice• icteric sclerae• anorexia• tea-colored urine• pruritus• acholic stools• 20% weight loss• globular abdomen • vague ballotable mass

at RUQ– smooth, not tender and

moves with respiration

CHRONIC PANCREATITIS PATIENT

• mucin-producing adenocarcinomas that arise from the bile ducts– grouped by their anatomic site of origin as

intrahepatic, hilar (central) and peripheral (distal)• Several predisposing factors:

– primary sclerosing cholangitis– liver fluke in Asians: Opisthorchis viverrini and

Clonorchis sinensis. – chronic biliary inflammation and injury

• with alcoholic liver disease, choledocholithiasis, choledochal cysts and Caroli's disease.

CHOLANGIOCARCIMA PATIENT

Elderly: 60’s-70’s M:F ratio is 1:2.5  painless jaundice pruritus weight loss acholic stools Abdominal pain

• 58-year old • male• vague abdominal pain• progressive jaundice• icteric sclerae• anorexia• tea-colored urine• pruritus• acholic stools• 20% weight loss• globular abdomen • vague ballotable mass at

RUQ– smooth, not tender and

moves with respiration

CHOLANGIOCARCINOMA

PATIENT

Arises within 2 cm of the distal CBD 90% an adenocarcinoma May invovle locoregional lymph nodes Liver is the most frequent site for metastases

AMPULLARY CARCINOMA PATIENT

• 58-year old • male• vague abdominal pain• progressive jaundice• icteric sclerae• anorexia• tea-colored urine• pruritus• acholic stools• 20% weight loss• globular abdomen • vague ballotable mass at

RUQ– smooth, not tender and

moves with respiration

Physical exam◦ presents clinically with non-specific signs and

symptoms such as pain, jaundice (yellowing of the skin) and weight loss

Blood tests◦ CA 19-9 (carbohydrate antigen 19-9) is the

mainstay tumor marker and is ordered when pancreatic cancer is suspected

Tissue for microscopic examination can be obtained by◦ Fine needle biopsy◦ Tissue needle cone biopsy◦ Excisional biopsy (at the time of laparotomy)

Angiography◦ useful to determine if the vessels around the

pancreas are involved by the tumor

CAT scan Endoscopic ultrasound (EUS) Endoscopic retrograde

cholangiopancreatography (ERCP) PTC (percutaneous transhepatic

cholangiography)

Histopathology◦ “Gold Standard”◦ 80% are adenocarcinomas of the ductal

epithelium◦ Only 2% of tumors of the exocrine pancreas are

benign

Only potentially curative treatment for patients with pancreatic cancer

The resectability of malignant pancreatic tumors needs to be established

Pancreatic masses are characterized◦resectable, unresectable, or borderline resectable. 

Pancreaticoduodenectomy (whipple procedure)

Distal pancreatectomy Total pancreatectomy

Removal of the head and uncinate process of the pancreas, duodenum, proximal 6 in (15 cm) of jejunum, gallbladder, common bile duct, and distal stomach

With anastomosis of the common hepatic duct and the remaining pancreas and stomach to the jejunum

All share a common blood supply

The Whipple procedure. Before the procedure(A). After the procedure; note the anastomosis of the hepatic duct and the remaining pancreas and stomach to the jejunum(B).

Patients who will most likely benefit from this procedure have a tumor located in the head of the pancreas or the periampullary region

May be an effective procedure for tumors located in the body and tail of the pancreas

Isolation of the distal portion of the pancreas containing the tumor

Resection of that segment Oversewing of the distal pancreatic duct

Tumor involves the neck of the pancreas.◦ Either  the tumor originates from the neck or is

growing into the neck

Single- and multiple-agent chemotherapeutic regimens

gemcitabine vs. fluorouracil◦ first-line therapy ◦ 12-month survival advantage◦ improves or stabilizes pain, performance status,

and weight Clinical trial (gene therapy)

• External beam and intraoperative radiation therapy – ↓ local progression – neither affects survival or metastasis

• Radiation therapy alone – not effective• Combined radiation therapy and

fluorouracil-based chemotherapy vs. radiation therapy alone – 40 vs. 10% survival after 1 year, NNT = 3

3 clinical problems in advanced pancreatic CA:

1. Pain2. Jaundice3. Duodenal obstruction

** cachexia, malabsorption

• Oral narcotics – mainstay– SR preparations of morphine sulfate

• Celiac plexus neurolysis – i.e. chemical splanchnicectomy of the celiac plexus

with alcohol. – injecting 50% alcohol directly into the tissues along

the sides of the aorta just cephalad and posterior to the origin of the celiac trunk.

– intraoperatively, percutaneously, or endoscopic ultrasonography.• effective • minimal risk of the potentially serious complications

Choledochojejunostomy ◦ surgical formation of a communication between the

common bile duct and the jejunum Cholecystojejunostomy

◦ surgical formation of a communication between the gallbladder and the jejunum.

** can be performed with gastrojejunostomy

Expandable wire stents: endoscopically◦ Lower risk vs. surgery◦ not as durable as a surgical bypass◦ Complications: bleeding, infection, and

pancreatitis; recurrent obstruction & cholangitis◦ effectively manage duodenal obstruction in 81%

of patients◦ Metal stents cost less and require a shorter

hospital stay than surgical treatment

Gastrojejunostomy◦ GI surgery procedure in which the duodenum is

excised or bypassed and the stomach is end-to-end anastomosed to the jejunum

◦ relieves gastric outlet or duodenal obstruction◦ sometimes associated with delayed gastric

emptying

Pancreatic enzyme replacement◦ Exocrine pancreatic insufficiency and subsequent

malabsorption◦ 30,000 IU of pancrelipase ◦ before, during, and after a meal, with ↑ titration

as needed Appetite stimulants, high-calorie diet

or nutritional supplements