The Curious Case of John Dick

The Curious Case of John DickGroup 3 Clinical Clerk Batch 2012SY 2011-2012

Objectives To discuss an intriguing case of an elderly

woman with abdominal pain To elaborate on the approach to jaundice To discuss the diagnostic approaches to

jaundice To present the management of

obstructive jaundice and review therapeutic options

Identifying Data L.S. 64-year-old Widow Vegetable vendor Tondo, Manila

Chief ComplaintGeneralized jaundice of 1 month duration

6 mos PTA

4 wks PTA

2 wks PTA

4 days PTA

1 wk PTA Admission

Colicky Abdominal Pain

Temporal Profile

Weight loss

Jaundice

Tea-colored urine

Loss of appetite

Past Medical History: Osteoarthritis, right ankle – took unrecalled

medication for 1 month Exposure to Tuberculosis G4P4 (4004) via NSD without complications No history of cancer No history of heart failure or valvular defects No history of Hepatitis B or C No hemolytic disorders No dyslipidemia No history of blood transfusion No history of needle prick injury No history of prolonged or high-dose intake of drugs

(e.g. Quinacrine, Rifampicin, etc) No previous hospitalization, surgery, dental surgery

Family History Tuberculosis – Mother No history of Cancer No history of hemolytic disorders

Social History: Non-smoker, non-alcoholic beverage drinker No IV illicit drug use

Review of Systems Weight loss (~50 kg ~36 kg in 1 month) No weakness No persistent cough, night sweats, hemoptysis,

fever No edema, difficulty of breathing, orthopnea No breast lump, pain or discharge No abnormal vaginal bleeding No history of abdominal trauma, changes in bowel

movement, nausea and vomiting, fatty food intolerance

Physical ExaminationGeneral Awake, conscious, coherent, not in pain,

appears ill-looking

Vital Signs BP 90/50 mmHg HR 64 bpm Ht 154 cmRR 18 cpm T 36.4 0C Wt 36 kg BMI 15.1 kg/m2

HEENT Icteric sclerae, yellowish palpebral conjunctivae, yellowish oral mucosa, no tonsillopharyngeal congestion, no cervical lymphadenopathies

Chest Equal chest expansion, no retractions, clear breath sounds, No spider angioma

CVS Adynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs, concordant apex beat and PMI at 5th ICS LMCL

Physical ExaminationAbdomen Globular, No caput medusae, No bulging

flanks,Abdominal girth = 29 inchesNormoactive bowel sounds, Tympanitic, Soft, Positive direct tenderness over epigastric area, No palpable masses, Liver span = 9cm, Spleen not palpable,No fluid wave, No shifting dullness, Negative Murphy’s sign

Physical ExaminationExtremities Full and equal pulses, no edema, no cyanosis,

Generalized jaundice

Mental Status Exam

Oriented to person, place and time. Remote, recent past, immediate memory not impaired.

Cranial Nerves Intact

Motor, Sensory,Cerebellar

Intact

Pertinent FindingsPositive NegativeWeight loss Drug or alcohol useAbdominal enlargement Blood transfusion or donationJaundice Tattoos or IV illicit drugsTea-colored urine History of HepatitisAnorexia Family history of Hemolytic

disordesChanges in bowel movementNausea and vomitingFeverFatty food intoleranceHistory of abdominal trauma

Pertinent FindingsPositive NegativeIcteric sclerae Fluid wave, shifting dullness,

bulging flanksJaundice Spider angioma, caput

medusaeGlobular abdomen, soft Hepatomegaly

SplenomegalyMurphy’s sign

Assessment Primary Impression

Obstructive Jaundice secondary to Pancreatic Head Mass

Differential Diagnoses: TB Lymphadenitis Peribiliary cancer Choledocholithiasis

JAUNDICE

CAROTENEMIA

DRUG INTAKE OF

PROBENECID/RIFAMPICIN

HYPERBILIRUBINEMIA

EXCESSIVE PRODUCTIO

N (Hemolytic

Anemia)

IMPAIRED CLEARANCE

UPTAKE/CONJUGATION EXCRETION

HEPATIC POST-HEPATIC

Jaundice

CarotenemiaDRUG INTAKE


HYPERBILIRUBINEMIA

Excessive intake of carotene containing food such as carrots, leafy vegetables, squash, peaches, and oranges

Yellowish discoloration concentrated on palms, soles, forehead & nasolabial folds

Jaundice



HYPERBILIRUBINEMIA

Excessive intake of carotene containing food such as carrots, leafy vegetables, squash, peaches, and oranges

Yellowish discoloration concentrated on palms, soles, forehead & nasolabial folds

Jaundice



HYPERBILIRUBINEMIA

Uniformly distributed in skin and icteric sclera

Intake of quinacrine or rifampicin

Jaundice



HYPERBILIRUBINEMIA

Uniformly distributed in skin and icteric sclera

Intake of quinacrine or rifampicin

Jaundice



HYPERBILIRUBINEMIA

Jaundice



HYPERBILIRUBINEMIA

(+) Jaundice (+) Tea-colored urine (+) yellow discoloration of the skin (+) Icteric sclerae

(-) Murphy’s sign(-) fluid wave, bulging flanks and shifting dullness(-) spider angioma and caput medusae(-) Hepatomegaly (liver span = 9 cm)(-) splenomegaly

HYPERBILIRUBINEMIA

EXCESSIVE PRODUCTION (Hemolytic

Anemia)

IMPAIRED CLEARANCE

Ssx of anemia (pallor, fatigue, weakness, dizziness, confusion,

shortness of breath, and potential for heart failure)

Usually normal colored urine and stool

If inherited symptoms should have been present at an earlier age

jaundice, splenomegaly, hepatomegaly, tachycardia, murmur

HYPERBILIRUBINEMIA

EXCESSIVE PRODUCTION (Hemolytic

Anemia)IMPAIRED

CLEARANCE

IMPAIRED CLEARAN

CE

UPTAKE/CONJUGATION

EXCRETION


IMPAIRED CLEARAN

CE

UPTAKE/CONJUGATIO

NEXCRETIO

N


(-) spider angioma and caput medusae

(-) fluid wave, bulging flanks and shifting dullness

(-) Hepatomegaly (liver span = 9 cm)

(-) splenomegaly

IMPAIRED CLEARAN

CE

UPTAKE/CONJUGATIO

NEXCRETIO

N


POST-HEPATIC

Gallbladder Biliary Tree Pancreas Intestine

Primary ImpressionObstructive jaundice secondary to Pancreatic head mass r/o pancreatic ductal adenocarcinoma

• Incidence rate 37,700 cases in the US, leading to 34,300 deaths.• No predilection between genders• Incidence is more common within the elderly

population• No established early warning symptoms• Overall 5-year survival rate, <5%

Pancreatic Adenocarcinoma

•Causes are still unknown although it is considered that environmental causes play a role:

• Cigarette smoking

• Obesity

• Chronic pancreatitis

• History of diabetes mellitus

• Diet (increased intake of red meat or dairy products)


• Said to arise from a series of gene mutations• Early on its onset, the mass would originate

within the area of the ductal epithelium and would gradually spread to adjacent areas.• Pancreatic intraepithelial neoplasia

invasive carcinoma• Activation of the KRAS2 oncogene and

inactivation of the tumour suppressor genes CDKN2A and TP53


•Presentation of the symptoms would greatly depend on the area where the tumour is located.

•In 80% of cases, the tumour would be located within the area of the pancreatic head and this would have a great likelihood to cause obstructive cholestasis.

•Abdominal pain or discomfort as well as nausea are common clinical presentations.

Diagnosis and staging

• Systemic signs would include weakness, weight loss as well as anorexia.• Physical examination:

• Signs of jaundice• Wasting • Hepatomegaly• Ascites

• Routine laboratory tests might reveal anemia, abnormal liver function tests and hyperglycemia.


Pancreatic Adenocarcinoma•Common complaints would include

abdominal pain with the possibility of radiating to the back.

•Weight loss•Splenomegaly, varices in the stomach

and esophagus, GI bleeding•DM symptoms, glucose intolerance

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The Curious Case of John Dick