Extrahepatic Biliary Obstruction

DR. WILLIAM OLALIAMATIAS MAULION MEDENILLA MEDINA

A 58-year-old male with Progressive Jaundice

HISTORY Two months PTC

Vague abdominal pain and anorexia One month PTC

Progressive yellowish discoloration of the sclera

Tea-colored urine Pruritus Acholic stools 20% Weight loss

PAST PERSONAL HISTORY Heavy smoker (3 pack years) Occasional beverage drinker No history of hepatitis Known hypertensive (10 years)

Captopril Metoprolol

No history of DM

A 58-year-old male with Progressive Jaundice

PE FINDINGS Vital Signs: Normal Icteric sclerae (-) Palpable cervical or supraclavicular LN Heart & Lungs: Normal Abdomen

Globular with vague ballotable mass at RUQ Smooth, non tender and moves with

respiration (-) Fluid wave Rectal Exam: Acholic stools

A 58-year-old male with Progressive Jaundice

Diagnostic Algorithm

A 58-year-old male with Progressive Jaundice

Lab Findings

Normal Value

CBC NormalCreatinine 2 mg/dL 0.6 –

1.5mg/dLAlk. Phosphatase

500 u/L 32 – 110 u/L

Total Protein 6.5 g/dL 5 – 9 g/dLAlbumin 3.5 g/dL 3.5 – 5.0

g/dLGlobulin 2.5g/dLCA 19-9 350

units/mL< 37 units/mL

DIAGNOSTIC WORK-UP

A 58-year-old male with Progressive

JaundiceDIAGNOSTIC WORK-UP Chest X-ray: Normal Ultrasound

Distended gallbladder with no stones CBD 2.5 cm Dilated intrahepatic ducts Enlarged head of the pancreas Normal Liver

A 58-year-old male with Progressive Jaundice

ANCILLARY DIAGNOSTIC TOOLS ERCP CT Scan MRI EUS

UltraSound

Homogenous echotexture No hyperechoic structures were noted Presence of dilated intrahepatic ducts

Ultrasound

(L) Dilated gallbladder . No stones or calcifications/posterior shadowing present.

(R) Dilated CBD

Ultrasound

Hyperechoic masses: Presence of extrahepatic mass

ERCP

CT Scan

MRI

MRI

MRI

EUS

A 58-year-old male with Progressive

JaundiceSALIENT

FEATURES Progressive

jaundice Tea-colored urine Acholic stools Pruritus

Vague abdominal pain

Anorexia Weight loss

Icteric sclerae Abdomen

Globular with vague ballotable mass at RUQ

Smooth, non tender and moves with respiration

Rectal Exam: Acholic stools

Biliary Tract Obstruction secondary to Pancreatic Head Malignancy

Clinical Impression

Pancreatic Cancer

Head 80%, body 15%, tail 5%

Types Ductal adenocarcinoma, most common Intraductal papillary mucinous carcinoma Mucinous cystadenocarcinoma

Age Peak age incidence: 65-75 years old 40-45% locally advanced 40-45% metastatic 10-20% localized resectable

Pancreatic Cancer

CLINICAL PRESENTATION Jaundice (progressive), pruritus Anorexia, weight loss Back pain

an indication of advance disease because retroperitoneal nerves may have already been affected

Palpable GB (Courvoisier’s sign) Virchow’s node (left supraclavicular node),

Sister Joseph’s sign (nodules in the umbilicus) denote advanced malignancy

Pancreatic Cancer

RISK FACTORS Tobacco smoking Familial background Peutz-Jeghers syndrome HNPCC Li-Fraumeni syndromeFAP Chronic pancreatitis

PROGNOSIS Advanced disease: overall median survival <6 months;

5-year survival rate 0.4-5% 2.6-9% undergo pancreatic resection OMS 11-20 months 5-year survival rate 7-25%: relatively fatal since it

presents usually at an advance stage All patients die within 7 years of diagnosis

Differential Diagnosis

Pancreatic Cancer Management Algorithm

No

NoYes

Yes

Clinical, US, CT, ERCP, EUC, MRCP

Multidisciplinary team

SurgeonNursing staffAnesthetistsRadiologyIntensivistGastroenterologyDieticiansPathologyOncology

Biopsy

Palliative care

StentingSurgical bypassPain reliefChemotxRadiotcNew Rx

Dx of pancreatic cancer

Is patient fit for resection?

Resection

Kausch-WhippleKW-PPLeft resection

Assess respectability CECT, EUS

Adjuvant treatment

Enzyme supplementsChemotherapyNovel treatments

Treatment

Resectable?

Yes No

Good risk Good risk Poor risk Poor risk

Whipple’s

PPPD

Endoscopic drainage Bypass

Cholecystojejunostomy with Gastrojejunostomy

Hepaticojejunostomy with Gastrojejunostomy

ERCP

PrognosisStaging of Pancreatic Cancer

Primary Tumor (T)

T1 Limited to pancreas, < 2 cm

T2 Limited to pancreas, > 2 cm

T3 Extension into duodenum or bile duct

T4 Extension into portal vein, SMV, SMA, Stomach, Spleen, Colon

Regional Lymph Nodes (N)

N0 No nodal metastases

N1 Regional nodal metastases

Distant Metastases (M)

M0 No distant metastases

M1 Distant metastases (Liver, Lung)

Prognosis

Stage

T N M Description

I 1,2 0 0 Tumor confined to pancreas

II 3 0 0 Tumor invades duodenum &/or bile duct, no nodal involvement

III 1,2,3

1 0 Tumor has not spread beyond duodenum or bile duct but includes regional lymph nodes

IVA 4 Any

0 Locally advanced tumor growing into blood vessels, stomach, spleen, and colon with or without lymph node involvement

IVB Any Any

1 Distant metastases (liver, lungs) present

THANK YOU!