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

3. 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

4. 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

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

6. Laboratory Data

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

8. US

9. CT Scan

10. MRCP

11. Pancreatic Mass

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

15. Tumor Markers
Ca U/ml (0-34)
CEA 3.5 ng/ml (0-3)

16. Pancreatic cancer

17. 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

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

21. 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

22. 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

23. Richard Feynman

24. MEDICINE IS SCIENCE OF UNCERTAINTY AND ART OF PROBABILITY

25. 11/27/2017

27. THANK YOU!