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Obstructive jaundice
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- 2. • A generalphysician 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 ourcase, presented with chronic painless obstructive jaundice and significant weight loss. So I will concern about malignant causes
- 4. • On physicalexamination, 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-tendergallbladder) 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 thinkabout common condition which give similar presentation ?
- 7. Neoplasm of exocrinepancreas • 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
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- 10. Clinical manifestation (classify accordingto 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 affectthe 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
- 12. Approach to patientwith pancreas tumor
- 13. • A generalphysician 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 tractdilation. • 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 showmass of head of pancreas MRCP show double duct sign
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- 17. Management Depend on multiplefactors including staging system and patient factors Inoperable carcinomaOperable carcinoma
- 18. Operable carcinoma Pre-operativeassessment : • 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.
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- 21. distal subtotal pancreatectomycombined with splenectomy.
- 22. Complication of whippleprocedure: Immediate • Pancreatic fistula → leakage of pancreatic juices → tissue necrosis & inflammation • Sepsis • Bleeding • Gasto-paresis • Anastomotic failure Late • Malabsorption • Weight loss
- 23. Inoperable carcinoma Pre-treatmentassessment : • 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
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- 25. References 1. Principle andpractice of surgery. 2. Toronto notes 2016 3. Uptodate.