2. • A general physician has referred to you a 65 years old male patient having
yellowish discoloration of his eyes for 2 months associated with vague upper
abdominal discomfort. He has poor appetite and has lost 15 kgs in the past
one month. Patient also complains of clay coloured stools and itching for the
past 3 weeks. He is a smoker and consumes alcohol regularly for the past 20
years and has been diagnosed to have chronic pancreatitis in the past.
Differential diagnosis
3. Obstructive jaundice
In our case, presented with
chronic painless obstructive
jaundice and significant
weight loss. So I will concern
about malignant causes
4. • On physical examination, Patient looks emaciated, dehydrated and was
clinically deeply jaundiced. His Pulse rate is 88/min, Temperature is 37.3c,
Blood Pressure is 120/80 and Respiratory rate is 20/min. He had multiple
scratch marks. Chest Examination was unremarkable. Abdominal
Examination: there was a palpable mass in the right hypochondrium and the
gallbladder was palpable.
Back to our case
Mass in right
hypochondrium
5. Courvoisier’s sign
(palpable non-tender gallbladder)
Occur as chronic obstruction above the level of cystic duct insertion which usually CBD.
Possible causes include :
• Periampullary tumors :
- Tumors of pancreatic head/ uncinate process.
- Tumors of distal common bile duct.
- Ampullary tumors (of ampulla of vater)
- Periampullary duodenal tumors.
• Pancreatic or common bile duct stricture.
• Portal lymphadenopathy
• Bile duct obstruction due to ascaris.
• AIDS associated cholangiopathy.
• Mucocele.
Exception
A gallbladder containing stones is tender and likely to have been
chronically diseased and subject to repeated, although possibly
subclinical, episodes of cholesytitis. This results in extensive
fibrosis of the gallbladder wall which is then unable to distend
when obstructed.
6. Could you think about
common condition which
give similar presentation
?
7. Neoplasm of exocrine pancreas
• a highly lethal malignancy. It is the fourth leading cause of
cancer-related death in the United States and second only to
colorectal cancer as a cause of digestive cancer-related death.
Risk factors :
Environmental factors:
• Smoking
• Obesity and physical
inactivity
• Diet
• Coffee and alcohol
consumption
• Aspirin and NSAID use
• Helicobacter pylori
infection
• HBV and HCV infection.
Genetic predisposition
syndromes:
• Hereditary breast cancer
(BRCA and PALB2)
• Peutz – jeghers syndromes
• Familial atypical multiple
mole and melanoma
syndrome
• Lynch syndrome
• Ataxia – telangiectasia.
Miscellaneous factors:
• Chronic pancreatitis.
• Diabetes mellitus
• Pancreatic cysts
10. Clinical manifestation
(classify according to site of tumor )
Head of pancreas (70%)
• Biliary obstruction (most common):
- Painless Jaundice
- Pruritus
- Clay- colored stool
- Dark urine
• Pain
• Thrombophlebitis (classic trousseau’s
syndrome):
- Hypercoagulable state.
- Thromboembolic event (in advance tumor)
Body / tail of pancreas (25%)
• Pain (common) :
- Gradual epigastric pain radiate to
back.
- Worse by eating or lying supine (at
night )
- Improve by lying in fetal position
or leaning forward.
• Biliary obstruction (less common)
• Atypical diabetes mellitus
• Thrombophlebitis (more
common).
11. • Commonly affect the liver, peritoneum, lungs, and less frequently, bone.
• Signs of advanced, incurable disease include:
- An abdominal mass
- Ascites
- Left supraclavicular lymphadenopathy (Virchow's node)
- A palpable periumbilical mass (Sister Mary Joseph's node) or a palpable rectal shelf
are present in some patients with widespread disease.
Signs of metastatic
disease
Virchow’s lymph node ascites Sister Mary Joseph's
node
13. • A general physician has referred to you a 65 years old male patient having
yellowish discoloration of his eyes for 2 months associated with vague upper
abdominal discomfort. He has poor appetite and has lost 15 kgs in the past
one month. Patient also complains of clay coloured stools and itching for the
past 3 weeks. He is a smoker and consumes alcohol regularly for the past 20
years and has been diagnosed to have chronic pancreatitis in the past.
Full history and clinical examination.
Laboratory test include :
• LFT with picture of :
- High direct bilirubin and ALP with normal AST and ALT.
• Coagulation profile with high INR and prolonged PT /APTT
• Pancreatic enzyme usually normal.
• CBC to rule out infection.
• RFT as baseline.
• Serum tumor markers for carbohydrate antigen (CA19-9).
Imaging studies :
• US abdomen
14. • biliary tract dilation.
• pancreatic carcinoma
typically appears as a focal
hypoechoic hypovascular
solid mass with irregular
margins.
US abdomen
result
If negative
result
Abdomen CT scan/MRI :
• an ill-defined hypoattenuating
mass within the pancreas.
• dilatation of the pancreatic duct or
common bile duct.
• parenchymal atrophy, and contour
abnormalities.
• double duct sign as Dilation of both
the pancreatic duct and CBD which
suggest head of pancreas or
ampullary carcinomas.If positive
result
Abdomen CT scan/MRI :
• to confirm the presence of
the mass and to assess
disease extent.
• Staging system of pancreas
tumor.
Other include EUS, chest
CT, PET scanning.
Histologic biopsy :
• Not always required unless unclear previous
assessment or suspicious of other condition
or local evidence of unresectability on
staging studies and patient unfit for surgery.
• Done by :
- Percutaneous biopsy using US or CT guidance.
- EUS guided biopsy.
15. Abdomen CT show mass of head of
pancreas
MRCP show double duct sign
17. Management
Depend on multiple factors including staging system and patient factors
Inoperable carcinomaOperable carcinoma
18. Operable carcinoma
Pre-operative assessment :
• Give parenteral VitK to prevent risk of bleeding.
• Parenteral antibiotic with biliary decompression to prevent risk of ascending
cholangitis.
• Immunization in case of splenectomy.
Type of surgery depend
on site of tumor
Body/tail of pancreas :
• distal subtotal
pancreatectomy, usually
combined with splenectomy.
Head of pancreas :
• pancreaticoduodenectomy
(ie, Whipple procedure)
• Pylorus-preserving
pancreaticoduodenectomy
19. Adjuvant therapy :
• To improve the survival rate by given of 6 months of adjuvnat
chemotherapy including:
- gemcitabine alone.
- gemcitabine plus capecitabine, leucovorin-modulated fluorouracil.
Post-treatment surveillance :
• Follow up every 3-4 months and testing for serum tumor markers
(CA19-9) and abdominal CT scan at least every 3-4 months during the
first 2 yrs and then every 6 months.
22. Complication of whipple procedure:
Immediate
• Pancreatic fistula → leakage of pancreatic juices → tissue necrosis &
inflammation
• Sepsis
• Bleeding
• Gasto-paresis
• Anastomotic failure
Late
• Malabsorption
• Weight loss
23. Inoperable carcinoma
Pre-treatment assessment :
• A tissue diagnosis should be established before initiation of therapy.
• Relieve obstructive jaundice by biliary stent.
Then according to
grade and stage of
tumor
Chemotherapy :
• gemcitabine monotherapy.
• gemcitabine-based combination regimen (eg, gemcitabine plus nanoparticle albumin-
bound paclitaxel.
• combination chemotherapy with FOLFIRINOX
Consider Palliative care
