Date post: | 01-Apr-2015 |
Category: |
Documents |
Upload: | alexis-daffin |
View: | 220 times |
Download: | 4 times |
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