Painless Obstructive Jaundice Investigations Blood Results

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Jaundice by Billy Rubin PBL 4
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Overview

• Case presentation
• Differential Diagnosis
• Surgical Management
• Medical Management
• Questions

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Case Presentation

• 77 year old female
• Retired seamstress
• Lives at home with husband

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Presenting Complaint

• Jaundice

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• HxPC
• Pruritus
• Dark urine
• Pale stools
• No pain
• Heaviness in epigastrium

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• PMHx
• Bowel cancer 1985
• Hysterectomy 1985
• DHx
• No regular medication
• NKDA
• SHx
• Does not smoke or drink
• Lives at home with husband
• FHx
• None

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Examination

• Jaundice
• Epigastric tenderness
• Fullness in the epigastrium
• No palpable lymph nodes
• No organomegaly

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Differential diagnosis of jaundice?

• Prehepatic
• Sickle Cell disease
• Haemolytic anaemia
• Drug side effects
• Blood transfusion

• Hepatic
• Hepatitis
• Cirrhosis
• Ca liver

• Post hepatic
• Cholangitis
• Cholelithiasis
• Acalculus
• Ca of pancreas
• Cholangio-carcinoma

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Painless Obstructive Jaundice

• Cholangiocarcinoma
• Ca head of pancreas
• Gallstones

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Investigations

• Full blood count
• Urea and electrolytes
• Liver function tests
• Amylase
• Clotting screen
• CRP

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Blood Results

• LFT
• Bilirubin 252 (3-17micromol/L)
• ALT 352 (3-35iu/L)
• ALP 178 (25-110iu/L)
• GGT 440 (lt65iu/L)
• Clotting screen
• PT 10.9s
• aPPT 25.8s (24.6-34.9)
• INR lt1
• CRP lt 3

• FBC
• Hb 12.6 (11.5-16.5g/dL)
• WCC 3.9 (4-11x109/L)
• Platelets 276 (150-400x109/L)
• UEs
• Na 139 (135-145mmol/L)
• H 3.7
• Urea 3.6 (2.5-6.7mmol/L)
• Creatinine 44 (70-150ymol/L)
• eGFR gt90 (100-130 ml/min)

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Further investigations

• CT/ USS
• ERCP

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Summary

• 77 y/o woman
• Painless obstructive jaundice
• Ca head of pancreas
• Unresectable
• Palliative care

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Pancreatic Cancer

• In the UK lt 2 of malignancies and 5000 deaths/yr
• MaleFemale 21
• Aetiology Smoking, alcohol, industrial agents
• 95 are ductal adenocarcinomas
• 70 head of pancreas
• 5 year-survival lt5
• Median survival is 3-6 months
• Symptoms obstructive jaundice, pruritis,
  epigastric pain, weight loss
• Diabetes and malabsorption

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Management
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Surgical management of pancreatic cancer

• Pancreaticoduodenectomy
• Classic Whipples procedure
• Pylorus-preserving pancreaticoduodenectomy (PPPD)
• Indications
• Ca head of pancreas, carcinoid tumour, chronic
  pancreatitis, Klatskin tumour, traumatic injury
• Very complex procedure!

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Exposure

• Patient supine
• Upper midline incision
• Subcutaneous dissection and division of rectus
  abdominis

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Search for metastases

• Liver
• Lymph nodes
• Adjacent vessels
• Bowel
• Peritoneum

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4 cuts

• Cholecystectomy/ biliary tree
• Hemigastrectomy (classic)
• Pancreatectomy at junction between neck and body
  send sample of body for histology
• Divide jejunum distal to ligament of Treinz

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Resection specimen
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Join up!

• Pancreaticojejunostomy
• Gastrojejunostomy
• Hepaticojejunostomy

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Classic Whipples procedure with gastrojejunostomy
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Pylorus-preserving pancreaticoduodenectomy (PPPD)
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Vulnerable structures

• Close proximity to major vessels IVC and
  superior mesenteric vessels
• BEWARE ANATOMICAL ANOMALIES replaced common
  hepatic artery or replaced right hepatic artery

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Complications

• Blood loss
• Leaking from anastomoses
• Gastroparesis
• Diabetes

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Outcome of procedure

• 5 year survival - 20 with Whipples (may rise to
  40 if lymph nodes not involved) compared with 5
  on chemotherapy alone.
• Mortality lt 5

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Surgical Contraindications

• Three main concerns
• Patient not fit for surgery
• Metastatic disease
• Un-resectable tumors

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The future?

• Laparoscopic pancreaticoduodenectomy
• Many retrospective studies ongoing
• Issues with operating time and technical
  difficulty

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Palliative Care

• Pain management is of paramount importance
• Radiotherapy
• Chemotherapy
• Stenting
• Treatment of exocrine or endocrine insufficiency

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Liverpool Care Pathway

• The gold standard care pathway for patients
  diagnosed as dying by an MDT
• Patients needs are assessed on their individual
  circumstances
• Symptom management ensuring patients quality of
  life
• Anticipatory prescribing is essential

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References

• Oxford Handbook of Clinical Medicine
• Clinical Surgery, M. Henry, Johnson
• http//www.bcdecker.com/SampleOfChapter/1550092707
  .pdf

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Thank You