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Bondoc-Borja, J.- Borja, P.-Buenavente- Bustamante-Buti-Cabanag-Calaquian-Calayan.

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Presentation on theme: "Bondoc-Borja, J.- Borja, P.-Buenavente- Bustamante-Buti-Cabanag-Calaquian-Calayan."— Presentation transcript:

1 Bondoc-Borja, J.- Borja, P.-Buenavente- Bustamante-Buti-Cabanag-Calaquian-Calayan

2  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%

3 Past Personal HistoryPast 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

4  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

5  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

6 ERCP CT scan

7 Endoscopic ultrasound MRI

8 SubjectiveObjective 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

9 Biliary Obstruction secondary to Pancreatic Head Carcinoma

10  Cancer of the pancreas is the 5 th 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

11  Head 80%, body 15%, tail 5% Types Ductal adenocarcinoma- most common Intraductal papillary mucinous carcinoma Mucinous cystadenocarcinoma  Peak age incidence: years old

12  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

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15  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

16 CholedocholithiasisPatient  > 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

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18  Rare cause of extrahepatic biliary obstruction caused by gallstone impaction in either Hartmann's pouch of the gall bladder or the cystic duct ◦ Chronic and/or acute inflammatory changes lead to contraction of the gallbladder secondary stenosis of the CHD ◦ Large impacted stones lead to cholecystocholedochal fistula formation

19  Classification ◦ To aid in surgical management

20 MirriziPatient  elderly; any patient with cholelithiasis at risk  Male = Female  No consistent or unique clinical features that distinguish it from other more common forms of obstructive jaundice  painless jaundice or with cholangitis  with cholecystitis or pancreatitis 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

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22  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

23 CHRONIC PANCREATITISPATIENT 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

24 CHRONIC PANCREATITISPATIENT

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26 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.

27 CHOLANGIOCARCIMAPATIENT  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

28 CHOLANGIOCARCINOMA PATIENT

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30  Arises within 2 cm of the distal CBD  90% an adenocarcinoma  May invovle locoregional lymph nodes  Liver is the most frequent site for metastases

31 AMPULLARY CARCINOMAPATIENT 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

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35  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

36  Tissue for microscopic examination can be obtained by ◦ Fine needle biopsy ◦ Tissue needle cone biopsy ◦ Excisional biopsy (at the time of laparotomy)

37  Angiography ◦ useful to determine if the vessels around the pancreas are involved by the tumor

38  CAT scan  Endoscopic ultrasound (EUS)  Endoscopic retrograde cholangiopancreatography (ERCP)  PTC (percutaneous transhepatic cholangiography)

39  Histopathology ◦ “Gold Standard” ◦ 80% are adenocarcinomas of the ductal epithelium ◦ Only 2% of tumors of the exocrine pancreas are benign

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41  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.

42  Pancreaticoduodenectomy (whipple procedure)  Distal pancreatectomy  Total pancreatectomy

43  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

44 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).

45  Patients who will most likely benefit from this procedure have a tumor located in the head of the pancreas or the periampullary region

46  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

47  Tumor involves the neck of the pancreas. ◦ Either the tumor originates from the neck or is growing into the neck

48  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)

49 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

50 3 clinical problems in advanced pancreatic CA: 1.Pain 2.Jaundice 3.Duodenal obstruction ** cachexia, malabsorption

51 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

52  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

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54  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

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56  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

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58  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

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