1. Pancreatic Cancer: The Silent Killer By Suzanne Sica Class 2008

2. Case Demographics 55 y/o Caucasian male presents to ER 55 y/o Caucasian male presents to ER Chief c/o: Chief c/o: RUQ and epigastric pain x 5 weeks worsened with eating. RUQ and epigastric pain x 5 weeks worsened with eating. Significantly worsened sxs over last 2-3 weeks Significantly worsened sxs over last 2-3 weeks Nausea, anorexia, and unexplained weight loss of 25 lbs. Nausea, anorexia, and unexplained weight loss of 25 lbs. Proceeded to ER when: Proceeded to ER when: Jaundice, light colored stools, and darker urine x 2 days. Jaundice, light colored stools, and darker urine x 2 days. Denied fever, chills, or hematoemesis. Denied fever, chills, or hematoemesis.

3. Physical Examination Abdomen Abdomen BS x 4 quadrants Nontender and nondistended. Negative masses, hepatosplenomegaly, or lymphadenopathy. Negative Murphy’s Sign with inspiration.

4. Differential Diagnosis What typically causes RUQ pain associated with eating with an otherwise normal exam? What typically causes RUQ pain associated with eating with an otherwise normal exam? What does jaundice, light colored stools, and tea-colored urine indicate? What could cause these sxs? What does jaundice, light colored stools, and tea-colored urine indicate? What could cause these sxs? What diagnosis would we be more concerned about if a fever was present? What diagnosis would we be more concerned about if a fever was present?

5. Abdominal Ultrasound Gall bladder distention with multiple calculi. Common bile duct ~6mm in diameter (higher limits of normal) Negative wall thickening or pericholecystic fluid. No free air nor intrahepatiic bile duct dilation.

6. Lab Results Alkaline phosphatase of 273, Alkaline phosphatase of 273, AST of 143, AST of 143, ALT of 288, ALT of 288, Total Bilirubin of 3.5, Total Bilirubin of 3.5, Direct Bilirubin of 2.0, Direct Bilirubin of 2.0, Amylase of 324. Amylase of 324.

7. Diagnosis/ Treatment Biliary Colic/ Choledocholithiasis Biliary Colic/ Choledocholithiasis Cholecystectomy scheduled for next week Cholecystectomy scheduled for next week Immediate ERCP Immediate ERCP Rule out ascending cholangitis Concerned about jaundice, PMH of diabetes, and risk of sepsis prior to surgery

8. Surgery Pimp Questions What are the symptoms of ascending cholangitis? Clue: One is a triad and the other is a pentad.

9. Charcot’s Triad Fever Fever Jaundice Jaundice RUQ Pain RUQ Pain

10. Reynold’s Pentad Fever Fever Jaundice Jaundice RUQ Pain RUQ Pain Confusion (Altered Mental Status Changes) Confusion (Altered Mental Status Changes) Hypotension (Shock) Hypotension (Shock)

11. ERCP Intervention used to treat conditions of the bile and pancreatic duct, and make diagnoses. Intervention used to treat conditions of the bile and pancreatic duct, and make diagnoses.

12. ERCP Findings/ Results Performed by Gastroenterologist Performed by Gastroenterologist Common bile duct stenosis found Common bile duct stenosis found 10Fr 7cm biliary stent placed with difficulty 6cm into biliary duct 10Fr 7cm biliary stent placed with difficulty 6cm into biliary duct Suspicious for malignant pancreatic tumor Suspicious for malignant pancreatic tumor Hospital admission Hospital admission Following stent placement: Following stent placement: Jaundice, light colored stools, and dark urine resolved. Jaundice, light colored stools, and dark urine resolved.

13. Repeat Abdominal CT Scan Revealed 4.6cm x 2.8cm pancreatic head mass Revealed 4.6cm x 2.8cm pancreatic head mass No pancreatic ductal dilatation No pancreatic ductal dilatation Visualizes metastases >1cm in size. Visualizes metastases >1cm in size.

14. Explorative Laparoscopy Revealed 1mm white nodule on lower lobe of liver Revealed 1mm white nodule on lower lobe of liver Nodule biopsied and sent for frozen sample Nodule biopsied and sent for frozen sample Nodule was benign Nodule was benign Proceed with Whipple’s Procedure Proceed with Whipple’s Procedure

15. Whipple’s Procedure: A Cure?

16. Contraindications to Whipple’s Procedure If superior mesenteric artery or portal vein become involved. If superior mesenteric artery or portal vein become involved. Presence of ascites, nodal, or peritoneal metastases occur. Presence of ascites, nodal, or peritoneal metastases occur. If tumor is >4cm- debatable. If tumor is >4cm- debatable. Problem: Over 75% of patients present with metastases initially. Note: CA 19-9 levels were documented at 1515. Note: CA 19-9 levels were documented at 1515.

17. Whipple’s Procedure At the beginning of procedure, At the beginning of procedure, A 5mm white nodule was found on Glissen’s capsule. A 5mm white nodule was found on Glissen’s capsule. Nodule was biopsied and sent for frozen section. Nodule was biopsied and sent for frozen section. Metastatic cancer was confirmed. Metastatic cancer was confirmed. Whipple’s Procedure was aborted. Whipple’s Procedure was aborted. A palliative biliary bypass was performed. (Roux-en-Y cholecystojejunostomy) A palliative biliary bypass was performed. (Roux-en-Y cholecystojejunostomy)

18. Prognosis for Metastatic Pancreatic Cancer Palliative Treatments Biliary bypass and common bile duct stenting Biliary bypass and common bile duct stenting Alleviates future gastroduodenal obstruction. Alleviates future gastroduodenal obstruction. Avoids recurrent jaundice. Avoids recurrent jaundice. Chemotherapy not recommended for pancreatic adenocarcinomas Chemotherapy not recommended for pancreatic adenocarcinomas Doesn’t respond well. Doesn’t respond well. No benefit over supportive care. No benefit over supportive care. Survival Rates 3-6 months. 3-6 months. Even had resection been performed, 5 year survival rate was ~20%. Even had resection been performed, 5 year survival rate was ~20%.

20. References Carson-DeWitt, Rosalyn, MD. (2007, June). Surgical Procedures for Pancreatic Cancer. Retrieved September 1, 1007 from EBSCO Publishing. Carson-DeWitt, Rosalyn, MD. (2007, June). Surgical Procedures for Pancreatic Cancer. Retrieved September 1, 1007 from EBSCO Publishing. Castillo, C.F., MD. Jimenez, R.E., MD. (2006, June 20). Pancreatic Cancer: Palliation of Symptoms. Retrieved August 31, 2007 from UptoDate database. Castillo, C.F., MD. Jimenez, R.E., MD. (2006, June 20). Pancreatic Cancer: Palliation of Symptoms. Retrieved August 31, 2007 from UptoDate database. Erickson, R.A., MD. (2005, December 15). Pancreatic Cancer. Retrieved July 20, 2007 from Emedicine database. Erickson, R.A., MD. (2005, December 15). Pancreatic Cancer. Retrieved July 20, 2007 from Emedicine database. Merchant, N.B., MD. Conlon, K.C., MD. (1998). “Laparoscopic Evaluation in Pancreatic Cancer.” Semin. Surgical Oncology. 15:155-165. Merchant, N.B., MD. Conlon, K.C., MD. (1998). “Laparoscopic Evaluation in Pancreatic Cancer.” Semin. Surgical Oncology. 15:155-165. Parker, Stephen BSc. (2007, June 3). Pancreatic Carcinoma. Retrieved August 31, 2007 from http://www.surgicaltutor.org.uk/defaulthome.htm?system/abdomen /pancreatic_ca.htm~right Parker, Stephen BSc. (2007, June 3). Pancreatic Carcinoma. Retrieved August 31, 2007 from http://www.surgicaltutor.org.uk/defaulthome.htm?system/abdomen /pancreatic_ca.htm~right http://www.surgicaltutor.org.uk/defaulthome.htm?system/abdomen /pancreatic_ca.htm~right http://www.surgicaltutor.org.uk/defaulthome.htm?system/abdomen /pancreatic_ca.htm~right