BY : MATHURA NANTHAGOPAL

64 yo /m/male admitted to 4A on 8th June 2013K/C/O DM, HPT, CVA with residual right hemiparesis

Presenting withEpigastric pain 2/52Yellow discoloration of the eyes 2/52Vomitting x 1/52, post prandialLOA x 1/52

Gradual onset of dull epigastric & right hypochondriac pain radiating to the back, aggravated by eating food relieved by analgesics.Generalized body itching with no rash.Unremitting yellow discoloration of the eyes.Pale stoolTea coloured urine.On and off low grade fevers

Loss of weight+, unsure of amountNon productive cough on and off x 2/52No NauseaNo h/o blood transfusion or contact with anyone with yellow eyes .No SOB, chest painNo UTI symptoms

PMH : DM, HPT, CVA with residual right hemiparesis

PSH : patient claims OGDS and colonoscopy done 2 years ago, unsure of results : h/o surgery done 4 years ago, claims growth at RIF

SH : Married, with children : chronic smoker since 9 yo , 1 pack per day : chronic alcoholic recently stopped

FH : no family history of DM, HPT or Malignancy

Old medicationsT. Amloidipine 10mg odT. Metformin 500mg bdT. Cardipine 100mg od

O/EAlert consciousafebrile, deep jaundice, scratch marks.BP 140/80 , PR 89bts/min, T : 37.0Lungs : clear , a/e equalP/A soft, non tender. Mass palpable in the right hypochondrium. A firm globular mass 3cm in the widest diameter (gall bladder) liver palpable.No ascites.Operative scar + PR : pale yellow stool, no mass palpable

INVESTIGATIONS TRENDS

19/48/610/611/611/613/615/616/6

FBCHGBWBCPLT9.57.15548.07.084237.66.6141711.87.6345RPUREANAKCLCREAT6.71393.9104123151394.110432514.51333.510335914.51333.41.236513.61303.310132114.41393.410633812.41343.610333510.61363.1105321LFTT. PROTA/GT. BILIALTALP6928/41250.3897555824/35260.3607165924/35250.7567125923/56300.1486266024/3633844633

OTHER INVESTIGATIONS :Ca 19-9 : 628.1U/mL(0 -27.0)AFP : 1.1IU/mlCEA : 9.5Ug/LTotal PSA : 3.60ug/L

PROVISIONAL DIAGNOSISObstructive jaundice 2 to ? Cholelithiasis / ? Cholangiocarcinoma / ? Ca pancreasPLAN1. Allow orally2. Keep NBM Sunday 12MN3. IVD 5 pints 3 NS, 2 D5% once NBM4. USG HBS urgent TRO ? Cholelithiasis, ? Cholangiocarcinoma on Monday5. DXT QID6. For RT if persistent vomitting 7. IV Pantoprazole 40MG stat and bd8. IV Maxalon 10mg stat

U/S HBS proceed to CT Plain Liver 10 June 2013Heterogenous hypoechoic infiltrative lesion with necrotic center arising from head of pancreas measuring aprx 3.6x4.0x4.6 cm causing biliary obstruction involving the proximal CBD and both intrahepatic ducts. Its also compressed and causing narrowing of the portal confluence.GB distended with mobile echogenicity. Appear hyperdense on CT.

Imp Infiltrative pancreatic head tumor causing biliary obstruction.GB slugde / bile stasis

14 / 6 / 2013S/B Mr. AnnalImp / Ca of head of pancreas

Plan / To optimize patient for ERCP 17/6/2013.To tx 2 pints of PC in view of low HgbKIV for stenting on 17/6/2013. Cont other management.

17/6/2013ERCP was attempted but failed at cannulation as patient did not tolerate well.Imp / Malignant stricture in keeping with uncinate tumor of pancreas.

Plan from Mr. Annal (post ERCP)

Hourly obsvervationNPOFor urgent CECT to assess operability cm.To optimize patient for bypass surgery.

CT THORAX and ABDOMEN (PANCREATIC PROTOCOL) done on 18/6/2013

Imp / 1. Ca head of pancreas with :Local infiltration and engulfment of main vessel, with probable portal vein thrombus.Severe biliary tract obstruction2. Bilateral cortical renal cysts.3. Focal cystics bronchiectasis and fibrous in the left lower lobe, most likely d/t prev infection.

19 June 2013S/B Mr. Annal / Mr. Chong / Dr. KhooFor ECHO and Lung Function TestIncentive spirometry for pre op optimizationTo d/w family regarding capability to afford metallic stent KIV for op if patient is fitFor ERCP and stenting on Monday (24/06/2013)

The bile ducts of the liver consist of the:Right and left hepatic ducts, Common hepatic duct (4cm), Gallbladder: concentrates bile; stores bile; selectively absorbs bile salts, keeping the bile acid; excretes cholesterol; and secretes mucus,Cystic duct & Common Bile Duct (8cm).

DISCUSSION:OBSTRUCTIVE JAUNDICEDefinitionJaundice or icterus is the yellow pigmentation of tissues especially skin or sclera due to deposition of bile pigments associated with increased circulating bilirubin (hyperbilirubinemia)

Total bilirubin level 0.3 1.0 mg/dLDirect bilirubin 0.0 0.4 mg/dLIndirect bilirubin 0.1 1.0 mg/dL

Obstructive jaundice occurs as a result of obstruction of the biliary tree, due to either intrahepatic or extrahepatic obstruction. Extrahepatic obstruction is also called surgical jaundice.

EtiologyCommon CholedocholithiasisCarcinoma of the head of pancreas Malignant lymph nodes at the porta hepatis

UncommonCarcinoma of the Ampulla of Vater Chronic Pancreatitis Liver cysts and abscesses

Rare Benign strictures : 95% iatrogenic, rarely trauma Recurrent cholangitis Mirrizi's syndrome Primary sclerosing cholangitis CholangiocarcinomaBiliary atresia (neonates)Infestations

Clinical featuresJaundice : Onset- Sudden- Gall-stone obstruction Gradual- Carcinoma

Pain : Present - Gall stone : Usually colicky Ca : Moderate midepigastric, deep seated, radiating to back Absent - Ca Bile duct, Ca Ampulla of Vater, Ca Head Pancreas (Early) Fever & Chills: Cholangitis due to obstruction usually due to calculus

Pruritis: All forms of cholestatic jaundice

Weight Loss: Progressive loss in Ca Head pancreas

Stool : Pale, clay-coloured due to excess fat and absence of stercobilin

Urine: Dark due to excess bilirubinHemorrhage: Failure of absorption of Vit. K with impaired coagulation Supraclavicular node: Virchows node indicates malignancyGall Bladder : May be palpable with Ca Head of pancreas Non palpable with gall-stone obstruction (Courvoisiers Law)Hepatomegaly: Hard, nodular in metastases and hepatomaAbdominal Mass : Suggests malignancy and may be associated with ascitesDiabetes: Sometimes precedes jaundice

Investigation of obstructive jaundice1. LFTs Conjugated hyperbilirubinemia > 50% of total bilirubinIncrease in ALP / GGT >> Enzymes AST / ALT Prolonged PT and PTT 2. Urinalysis Bilirubin in urine; urobilinogen absent in total obstruction.3. StoolPale, clay colored, absence of stercobilin 4. Ultrasound ScanInitial and most useful investigationDemonstrates dilated ducts (Normal CBD

6. Radionuclide scanning99 technetium iminodiacetic acid (HIDA) Taken up by hepatocytes and actively excreted into bile Allows imaging of biliary tree Failure to fill gallbladder = acute cholecytitis Delay or absence of flow into duodenum = biliary obstruction 7. (ERCP)Visualization of papilla, biliary and pancreatic ductsAllows biopsy or brush cytology Stone extraction or stentingComplications include hemorrhage, pancreatitis ,sepsis

8. Percutaneous transhepatic cholangiogram (PTC)90% successful in patients with dilated ductsPerformed with 22G Skinny/Chiba Needle Contraindicated with coagulopathy (>PT) , ascitis, sepsis

Consequences of obstructive jaundiceAscending cholangitis Charcot's triad is classical clinical picture Intermittent pain, jaundice and fever Cholangitis can lead to hepatic abscesses Need parenteral antibiotics and biliary decompression Operative mortality in elderly is up to 20%

Clotting disorders (Prolonged PT) Vitamin K required for gamma-carboxylation of Factors II, VII, IX, X Vitamin K is fat soluble and not absorbed. Needs to be given parenterally (Vit K 10 mg IM/IV x 3days)Urgent correction will need Fresh Frozen Plasma (FFP)Also endotoxin activation of complement system

MANAGEMENTCarcinoma of Head of Pancreas1. Curative:

Resectional surgery only possible in 20% of patientsPancreaticoduodenectomy (Whipples procedure) Traditional surgery Overall mortality in experienced hands is 5%Common complication is pancreatic fistula in 5-20%Pylorus-preserving pancreaticoduodenectomy (Modified Whipples)Total pancreatectomyNo advantage over Whipples but higher mortality and brittle diabetes

2. Palliative: Cholecystojejunostomy Choledochojejunostomy Duodenal obstruction managed by gastrojejunostomy Resectional palliation Endoscopic prosthesis/ stent Percutaneous transhepatic drainage Adjuvant radiation and chemotherapy

Common Bile Duct Stones

Accurate prediction of common bile duct stones can be difficultIf elevated bilirubin and ALP & CBD > 12 mm risk of CBD stones 90%If normal bilirubin, ALP & CBD diameter, risk of CBD stones 0.2% ERCP and endoscopic sphincterotomy is investigation of choice Stones extracted at endoscopy (ERCP) with balloon or Dormia basket90% successful Complication rate 8%

Alternatives include: Open cholecystectomy & exploration of CBD + T- tube drainage Choledochoduodenostomy- markedly dialated CBD, impacted stoneLaparoscopic exploration of CBD

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