BILIARY-ENTERIC OBSTRUCTION FROM RECURRENT CANCER Resident(s): Osama Abdul-Rahim

Attending(s): Jeffrey Weinstein

Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA

Originally Posted: January 15, 2015

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation Abdominal pain

History of Present Illness 57 y/o male with pancreatic adenocarcinoma s/p Whipple 8 months

prior presents with abdominal pain

RELEVANT HISTORY

Past Medical History Spinal stenosis Hypertension GERD Arthritis Anxiety

Past Surgical History “Jaw“ surgery, Whipple

Family & Social History 1 pack/day x 40 years, no EtOH or drug use

DIAGNOSTIC WORKUP

Physical Exam Mild right upper quadrant tenderness to palpation

Laboratory Data Total Bilirubin: 7 mg / dL

DIAGNOSTIC WORKUP - IMAGING

Pancreatic adenocarcinoma prior to Whipple

1 month s/p Whipple - No local or distant disease recurrence

DIAGNOSTIC WORKUP - IMAGING

8 months post Whipple there is a mass in right perinephric space (green arrow) causing afferent limb (yellow arrow) and biliary ductal dilatation (red arrow)

DIAGNOSIS

Metastatic pancreatic adenocarcinoma

CT abdomen and pelvis shows recurrent tumor in the right perinephric space

Resultant mass effect is obstructing the afferent jejunal limb causing secondary biliary obstruction, indicated by the intrahepatic bile duct dilatation and elevated bilirubin

INTERVENTION

Left hepatic internal/external percutaneous biliary drain was placed

3 days later, ductal dilatation improved but afferent jejunal limb remains dilated

INTERVENTION

Transhepatic enterography shows persistent afferent limb obstruction due to extrinsic compression

Guidewire was advanced across the obstruction

INTERVENTION

Initially, an 18 x 60 mm Wallstent was placed. Due to foreshortening, it was thought to be too short

A 14 x 100 mm Nitinol stent was deployed within the Wallstent. Contrast flowed freely through the stent

CLINICAL FOLLOW UP

Follow up CT showed improvement in both biliary ductal and afferent jejunal limb dilatation after intervention

QUESTION 1

1) Why was endoscopic guided therapy less feasible in this scenario?

A: Endoscopy is not indicated for biliary obstruction.

B: Endoscopy can never be performed following a Whipple procedure.

C: Endoscopy is technically challenging following a Whipple procedure.

D: What’s endoscopy?

SORRY, THAT’S INCORRECT.

1) Why was endoscopic guided therapy less feasible in this scenario?

A: Endoscopy is not indicated for biliary obstruction. (Endoscopy is often a good option for evaluation and treatment of biliary obstruction)

B: Endoscopy can never be performed following a Whipple procedure. (Endoscopy is sometimes possible following a Whipple and requires a double-balloon technique. It is very difficult however and often unsuccessful.)

C: Endoscopy is technically challenging following a Whipple procedure. (Due to the anatomic alterations resulting from a Whipple complicating the endoscopic approach, transhepatic approach to a dilated biliary system was a good choice for intervention in this patient.)

D: What’s endoscopy? (Small, flexible camera that enters the mouth or anus and can travel through the proximal small bowel or colon, respectively, allowing direct visualization and possible therapeutic intervention.)

CONTINUE WITH CASE

CORRECT!

1) Why was endoscopic guided therapy less feasible in this scenario?

A: Endoscopy is not indicated for biliary obstruction.

B: Endoscopy can never be performed following a Whipple procedure.

C: Endoscopy is technically challenging following a Whipple procedure. Although endoscopy is often a good option for evaluation and treatment of biliary obstruction, due to the anatomic alterations resulting from a Whipple, although endoscopy is sometimes possible using a double-balloon technique, it is very difficult and often unsuccessful.

D: What’s endoscopy?

CONTINUE WITH CASE

QUESTION 2

What are some of the more common uses of stents in the GI tract?

A: Esophagus

B: Stomach

C: Common Bile Duct

D: Colon

E: All of the above

CORRECT!

What are some of the more common uses of stents in the GI tract?

A: Esophagus (Can be used for palliation of dysphagia from esophageal or gastric cardia cancer, tracheoesophageal fistula, esophageal rupture)

B: Stomach (Gastric outlet obstruction, pseudocyst drainage)

C: Common Bile Duct (Relieve obstruction or leak)

D: Colon (Relieve obstruction either as a bridge to surgery or for palliation)

E: All of the above

CONTINUE WITH CASE

SORRY, THAT’S INCORRECT.

What are some of the more common uses of stents in the GI tract?

A: Esophagus (Can be used for palliation of dysphagia from esophageal or gastric cardia cancer, tracheoesophageal fistula, esophageal rupture)

B: Stomach (Gastric outlet obstruction, pseudocyst drainage)

C: Common Bile Duct (Relieve obstruction or leak)

D: Colon (Relieve obstruction either as a bridge to surgery or for palliation)

E: All of the above

CONTINUE WITH CASE

SUMMARY & TEACHING POINTS

57 y/o male with recurrent metastatic pancreatic adenocarcinoma s/p Whipple causing afferent jejunal limb and biliary obstruction

Biliary obstruction was initially relieved with internal/external percutaneous transhepatic biliary drain placement

Persistent afferent jejunal limb obstruction was subsequently successfully relieved by placing an enteric stent transhepatically

REFERENCES

Lee JM, Han YM, Lee SY, Kim CS, Yang DH, Lee SO. Palliation of postoperative gastrointestinal anastomotic malignant strictures with flexible covered metallic stents: preliminary results. Cardiovasc Intervent Radiol 2001;24:25-30.

Yim HB, Jacobson BC, Saltzman JR, Johannes RS, Bounds BC, Lee JH, et al. Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc 2001;53:329-32.

Feretis C, Benakis P, Dimopoulos C, Manouras A, Tsimbloulis B, Apostolidis N. Duodenal obstruction caused by pancreatic head carcinoma: palliation with self-expandable endoprostheses. Gastrointest Endosc 1997;46:161-5