Diagnosis and Management Pearls PANCREATIC LESIONS Diagnosis and Management Pearls Presented by: Vivek Batra MD April 19, 2017

Case Presentation 55 year old female CC: abdominal pain 6 months of dull pain, constipation, anorexia, halitosis, dark urine Saw PCP and GI, with “negative” workup Occasional ethanol, no smoking or drugs

HPI Used ginger pills for symptoms relief No weight loss, jaundice, melena, hematochezia, hematemesis or fevers No risk factors for liver disease or HIV No blood transfusion No recent travel 2 weeks ago, had viral illness, resolved

Pertinent History PMHx: Remote shoulder/elbow surgery Medications: Naproxen Family History: No history of malignancy Exam: mild epigastric pain, mild jaundice

Laboratory Data

Investigation - Hepatitis serologies - HIV Tylenol level <15 - Ceruloplasmin, - AMA,- CK,-Anti-Smooth muscle +aldolase, +ANA

US

CT Scan

MRCP

Pancreatic Mass

EUS Role of EUS Diagnosis, FNA Staging Tumor localization, celiac plexus neuro-lysis, EUS drainage and ablation

Tumor Markers Ca19-9 626 U/ml (0-34) CEA 3.5 ng/ml (0-3)

Pancreatic cancer

Clinical Course EUS Pathology: Pancreatic adenocarcinoma Borderline resectable ERCP with CBD stent for jaundice ERCP induced pancreatitis Neoadjuvant: FOLFIRINOX vs gemcitabine, and Abraxane.  Port, fever, chemotherapy Plan for Whipple

Whipple Surgery 1960: 25% mortality, 5% 5-year survival 1% mortality Minimally invasive 1 week post-op Morbidity Diagnosis 20% turn benign

Role of hospitalist or PCP Diagnosis Age and functional status Co-morbidities Appropriate referral Pancreatic cyst = majority are benign Pancreatic cyst = Asymptomatic bacteruria vs UTI. Infiltrate vs. true pneumonia Incidentaloma vs Real (in physics, blackbox) Around 20%, turn benign even after Whipple

Black-box A device, system, or object which can be viewed in terms of its inputs and outputs, without any knowledge of its internal workings

Richard Feynman

MEDICINE IS SCIENCE OF UNCERTAINTY AND ART OF PROBABILITY

11/27/2017

THANK YOU!