1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Jason Rexroad Affiliation: Civilian Medical Center

2. MedPix No: 4599 - History Pt Demographics: Age = 84 y.o. Gender = woman The patient is a 83 year old white female with a one month history of weight loss and painless jaundice. Downloaded by (-1)

3. MedPix No: 4599 - EXAM & LABS Thin elderly female with jaundice and palpable firm mass at the right upper abdomen. Elevated direct bilirubin. Normal amylase and lipase.

4. Pancreatic adenocarcinoma Contrast enhanced axial CT images of the abdomen show distention of the gallbladder and dilatation of the intrahepatic bile ducts. The common duct is also dilated as is the main pancreatic duct. Multiple hypodense lesions are seen throughout the liver, with at least one of the peripheral lesions in the right lobe showing adjacent enhancement, a finding associated with hepatic metastases. A heterogeneous mass lesion is seen at the head of the pancreas, predominantly hypodense and only minimally enhancing as compared to the surrounding, more normal appearing pancreas. These findings are consistent with pancreatic head mass (metastatic adenocarcinoma is the diagnosis of exclusion) obstructing the main pancreatic duct and the extra- as well as the intra-heaptic biliary system. Downloaded by (-1)

5. Pancreatic adenocarcinoma Contrast enhanced axial CT images of the abdomen show distention of the gallbladder and dilatation of the intrahepatic bile ducts. The common duct is also dilated as is the main pancreatic duct. Multiple hypodense lesions are seen throughout the liver, with at least one of the peripheral lesions in the right lobe showing adjacent enhancement, a finding associated with hepatic metastases. A heterogeneous mass lesion is seen at the head of the pancreas, predominantly hypodense and only minimally enhancing as compared to the surrounding, more normal appearing pancreas. These findings are consistent with pancreatic head mass (metastatic adenocarcinoma is the diagnosis of exclusion) obstructing the main pancreatic duct and the extra- as well as the intra-heaptic biliary system. Downloaded by (-1)

6. Pancreatic adenocarcinoma Contrast enhanced axial CT images of the abdomen show distention of the gallbladder and dilatation of the intrahepatic bile ducts. The common duct is also dilated as is the main pancreatic duct. - - Multiple hypodense lesions are seen throughout the liver, with at least one of the peripheral lesions in the right lobe showing adjacent enhancement, a finding associated with hepatic metastases. A heterogeneous mass lesion is seen at the head of the pancreas, predominantly hypodense and only minimally enhancing as compared to the surrounding, more normal appearing pancreas. - - These findings are consistent with pancreatic head mass (metastatic adenocarcinoma is the diagnosis of exclusion) obstructing the main pancreatic duct and the extra- as well as the intra-heaptic biliary system. Downloaded by (-1)

7. Pancreatic adenocarcinoma Contrast enhanced axial CT images of the abdomen show distention of the gallbladder and dilatation of the intrahepatic bile ducts. The common duct is also dilated as is the main pancreatic duct. Multiple hypodense lesions are seen throughout the liver, with at least one of the peripheral lesions in the right lobe showing adjacent enhancement, a finding associated with hepatic metastases. A heterogeneous mass lesion is seen at the head of the pancreas, predominantly hypodense and only minimally enhancing as compared to the surrounding, more normal appearing pancreas. These findings are consistent with pancreatic head mass (metastatic adenocarcinoma is the diagnosis of exclusion) obstructing the main pancreatic duct and the extra- as well as the intra-heaptic biliary system. Downloaded by (-1)

8. FINDINGS Contrast enhanced axial CT images of the abdomen show distention of the gallbladder and dilatation of the intrahepatic bile ducts. The common duct is also dilated as is the main pancreatic duct. Multiple hypodense lesions are seen throughout the liver, with at least one of the peripheral lesions in the right lobe showing adjacent enhancement, a finding associated with hepatic metastases. A heterogeneous mass lesion is seen at the head of the pancreas, predominantly hypodense and only minimally enhancing as compared to the surrounding, more normal appearing pancreas. These findings are consistent with pancreatic head mass (metastatic adenocarcinoma is the diagnosis of exclusion) obstructing the main pancreatic duct and the extra- as well as the intra-heaptic biliary system.

9. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Pancreatic adenocarcinoma, metastatic to liver - Pancreatitis (much less likely given the presence of liver lesions and associated pancreatic and biliary ductal dilatation) -

10. Diagnosis: Pancreatic adenocarcinoma; presumed by imaging findings which suggest nonresectable disease burden. Dx Confirmed by:

11. DISCUSSION Please see factoid.