1. 50 Years بثينه عناد ديالى

2. o Classic history of obstructive jaundice for 2 months duration. o Occasional episodes of fever, rigor and abdominal pain. o Wt loss and ↓appetite.

3. TestResult TSB3.2mg/dl DMg/dl DGOT136u/l SGPT198u/l S. ALP977u/l RBSmg/dl TSPg/l Albuming/l B. Urea28mg/dl S. creatinine0.7mg/dl Biochemical tests:

4. Ultrasonography: A known case of CA head pancreas seen as hypoechoic mass seen at pancreatic head measures 55 x 37 x 28 mm with few localized metastatic LND largest 24 mm Bilateral IHBT dilatation with convoluted tubules-like cystic structures at gallbladder fossa measures 54 x 27 mm mostly GB. Attenuated extra hepatic CBD that couldn’t be traced. MRCP is better to evaluate CBD. Target lesion seen at segment 3 measures 3 cm mostly secondaries. Rim of ascites.

5. CT scan: Evidence of enhancing soft tissue mass in the head of pancreas. Irregularity of wall of adjacent duodenum with dilated CBD and mild dilatation of the pancreatic duct with evidence of multiple regional and para aortic LN enlargement with enhancing hypodense mass about 1.5 cm in inferior part of right lobe of liver. Image finding suggestive of CA head of pancreas with lymphatic and hepatic secondaries.

6. MRI: Enlarged liver size showing marked dilatation of the intrahepatic BT. Multiple metastatic lesion seen as a target sign in segment 6 and 7. No intra ductal mass or stone but abrupt obstruction of the narrowed CHD. No ascites seen. Gallbladder was distended, no obvious stone or mud or solid mass lesion but septations seen with tortuous dilated cystic ducts behind the Hartman’s pouch. Pancreas irregular ill-defined hypo intense T1 and T2 enhancing solid mass arising from lower aspect of head of pancreas and shows obvious invasion of lower CBD infiltrating upward along the portal region causing abrupt high level obstruction of CBD.

7. Multiple LNs seen in retro pancreatic region and around the celiac axis. The pancreatic duct is seen only at it’s pre-ampullary aspect and seems to be partially duplicated on tracing the rest of the pancreas. Invasion of the posterior gastric wall and first and second parts of narrowed duodenum. Mild enlargement of the spleen. Conclusion: CA pancreas with CBD and cystic duct obstruction with liver metastasis.

9. EUS: Scanning of pancreas revealed hypo-echoic heterogeneous mass at the head of pancreas with multiple celiac, para aortic peri pancreatic LNs with multiple mediastinal LN. EUS FNA from celiac LN was done. Conclusion: pancreatic tumor T3 N1

10. Cyto-pathology report: Smears are infiltrated with inflammatory cells and few groups of malignant epithelial cells in background of blood and cellular debris. The picture is consistent with metastatic carcinoma to the LN. pancreas could be the primary site.

11. ERCP After successful deep biliary cannulation by burdick procedure, cholangiogram showed dilated right intra hepatic biliary system with non- visualized Lt systm. CBD not dilated. Plastic stent 10 cm x 8.5 fr inserted