Case 1

Data:

40 Female Married Marikina

Chief complaint

Abdominal Pain

HPI

27 days PTC Right upper quadrant pain Body malaise Decreased appetite Sought consult at Amang Rodriguez ER

UTZ was requested, revealed a stone in the common bile duct.

Advised to have ERCP but refused to seek 2nd opinion

25 days PTC Consulted at a private clinic Was given medications w/ gave

temporary relief Patient was compliant w/ meds but

remittent pain persisted until 18 days PTC

Patient experienced yellowish discoloration of the eyes and skin

No consult done

14 days PTC Patient followed up at a private clinic, and was

referred to UERM to undergo ERCP Due to the exacerbation of pain patient was

admitted

Upon admission, HBT pancreatic UTZ was doneshows: gallbladder hydrops w/ lithiases, bile sludge

on the cystic duct and proximal common bile duct w/ sludge ball at the terminal end causing extra- and intrahepatic biliary and pancreatic duct dilation. Normal pancreas

ERCP w/ biliary stenting was done Initial read was: bulging ampula, t/c

ampullary mass, distal common bile duct stricture, s/p biliary stent. Cholangitis.

CT scan w/ triphasic contrast of upper abdomen was done Initial read was: pancreatic head

prominent at 3.92cm . No enlarged lymph nodes. Dilated common bile duct just above site of stent

Patient was advised for operation but opted to be discharged due to financial constraint

Patient was asymptomatic until 2days PTC

Recurrence of RUQ pain lead patient to sought consult at our institution

PMHx

Hypertension Losartan 50mg OD

PE

General: ambulatory, not in distress

VS: BP:130/80mmHg CR: 98bpm RR: 19cpm T: 36.5C W:

Skin: Generalized jaundice

HEENT: Icteric sclera

Abdomen: Soft flabby, normoactive bowel sounds,

no tenderness, no mass palpated

diagnostics

CT scan: (11/2/14) Ampullary/periampullary mass

infiltrating the pancreatic head and duodenum w/ encasement of the portal vein causing biliary tree dilation. Consider malignancy

No regional lymph nodes cholelithiasis

Solid mass w/ irrregular margins and central hypodensities centered in the ampullary/periampullary region extending to the pancreatic head area. It measures approximately 52.4 x 30.7mm in its widest antero-posterior and transverse diameters.

The mass appears to encase more than 180 degrees of the entire diameter of the portal vein at at the junction of the splenic and superior mesenteric vein.

there is a suggestive low density lesion within the portal vein which may be secondary to a thrombus. The medial wall of the 2nd portion of the duodenum exhibits nodularities with flattening of its mucosa. Finding may indicate tumor infiltration of the duodenum.

The splenic artery, superior mesenteric and celiac arteries are unremarkable. No regional lymphnode is noted

Liver is normal in size with smooth marginal contour. No demonstrable parenchymal abnormality is seen. The enhancing solid mass lesion is noted. gallbladder lithiasis is noted.

The intrahepatic, extrahepatic ducts and pancreatic ducts are dilated. A biliary stent is visualized. There is an irregular soft tissue density in the distal end of common bile duct corresponding to the above mentioned mass. The body and tail of the pancreas are normal.

Both kidneys are normal in size, configuration and parenchymal thickness. The perirenal and pararenal spaces are unremarkable. The visualized pelvocalyces and proximal ureters appear normal.

Visualized lung fields are clear

ERCP (10/29/14)

Normal looking mucosa of the esophagus, stomach and duodenum

Bulging papilla but with normal looking mucosa

Cholangiogram: Initial injection of contrast showed markedly

dilated middle common bile duct, common hepatic duct and intrahepatic ducts. The distal 2cm of CBD did not opacify. A 7cm french 10 biliary stent was inserted with its tip seen in the mid CBD and with drainage of whitish purulent bile

Post procedure film showed almost complete drainage of the contrast media from the common bile duct into the duodenum

ERCP (10/29/14)

Diagnosis: Bulging ampula, t/c ampullary mass Distal CBD stricture s/p biliary stent

insertion cholangitis

CBC: (11/18/14)

Hgb 100 Hct 0.30 WBC: 4.2 Neu: 0.45 Plt: 366

Clin chem: (11/15) Na: 130 K: 3.9 BUN: 3.5 Cr: 70.4 Alk phos: 554 AST: 245 FBS: 4.7 Lipase: 3070 Amylase: 306

CHON: 68 Alb: 27.74 Glo: 4.3 A/G: 0.7 Bilirubin profile

Total: 106.1 Direct: 77.6 Indirect: 28.5

Coagulation PT: 11.6 %: 136 INR: 0.84 aPTT: 26.7

CA 19-9: 21.9 Normal

CEA: 9.81 increased

AMPULLARY CARCINOMAImpression:

WHIPPLES PROCEDUREPlan:

Case 2

Data

D.D 68 Male Married Pasig

Chief complaint

Yellowish discoloration of skin

HPI

1 month PTC Patient noticed yellowish discoloration of

skin associated w/ loss of appetite No meds, no consult done

2 weeks PTC Patient developed abdominal pain located

on RUQ associated w/ black tarry stools, vomiting of previously ingested food

Persistence of yellowish discoloration of skin opted patient to sought consult

PMHx

Alcoholic beverage drinker for 3o yrs

PE

Concious coherent, weak looking BP: 90/50mmHgCR: 90bpm RR: 20cpm T: 36.7C

Icteric sclerae Flabby, soft, nontender abdomen, no

palpable mass

Diagnostics

CT scan Focal narrowing of the descending and transverse portion

of the duodenum. Rule out underlying mass. Ill defined hypodense mass w/ irregular rim and central enhancement in the anteroinferior subsegment of the right liver lobe.

Rule out new growth, intrahepatic cholangiocarcinoma or metastasis. Suggest histopathologic correlation. Top normal sized gallbladder w/ moderate intrahepatic biliary and common bile duct ectasia.

Bilateral renal cortical cyst Prostatomegaly w/ tiny concretions Minimal ascites, right anterior perihepatic, left posterior

subphrenic and pelvic regions. Disc bulge L3-L4,L4-L5 and L5-S1 levels

Moderate distention of the stomach down to the duodenal bulb w/ no evident intraluminal mass. The rest of the descending and transverse portion of the duodenum are markedly narrowed.

Liver is w/in normal size. There is an ill defined hypodense mass w/ irregular rim and central enhancement in the anteroinferior subsegment of the right lobe. Measures approximately 5.1 x 6.5 x 5.7cm. Minimal fluid is seen in adjacent anterior perihepatic area. It also displaces the gallbladder inferiorly.

The adjacent intrahepatic biliary as well as common bile duct down to its suprapancreatic portion are moderately dilated. The displaces gallbladdre is top-normal sized. Measuring 3.7cm in transverse diameter w/ no evident lithiasis or wall thickening

Pancreas, spleen, and both adrenal glands are unremarkable

Both kidneys are normal in size and configuration w/ good nephrogram enhancement. Low density focus is noted in the lower pole of the right kidney measuring 0.6 x 0.7 x 0.8cm. Two subcentimeter low density foci are also noted in the left kidney. The pelvocalyces of both kidneys and both ureters are not dilated. No lithiasis seen

Prostate is enlarged w/ tiny concretions Minimal fluid is noted in left posterior subphrenic

space and pelvic peritoneal region Disc bulge is noted in L3-L4,L4-L5, and L5-S1

levels. No lytic or blastic changes are noted

AST 133 increased ALT 94 increased Alkaline phosphatase 474

increased

Total Bilirubin 320.1 increased Direct bilirubin 261

increased Indirect bilirubin 59.1

increased

EGD Gastroscope was inserted only upto the

C-loop, there is a complete obstruction w/ a friable mucosa at the area of the C-loop. Biopsy not done due to difficulty of angulation. Able to aspirate blackish fluid about 2L at the gastric lumen. Esophaus and stomach appears normal

DUODENAL MASSImpression:

Plan: