1. Laboratory Work-Up

2. 8.16.11Reference Direct Bilirubin223.73.4-13.0 Indirect Bilirubin95.70-18 Total Bilirubin319.48.5-23.6 SGPT/ALT201.900-45 SGOT/AST220.200-35 ALP507.4830-120

4. 8.16.11Reference SGPT/ALT201.900-45 SGOT/AST220.200-35 ALP507.4830-120

5. Tumor Markers

6. CA 19-9  Patients with pancreatic carcinoma, 75-85% have elevated CA 19-9 levels. CA 19-9 value of greater than 100 U/mL is highly specific for malignancy, usually pancreatic. CEA  The reference range is less than or equal to 2.5 mg/mL.  Only 40-45% of patients with pancreatic carcinoma have elevated CEA levels.

7. Clinical Correlation

8. 8 8

9. Sign / SymptomExplanation Epigastric pain - Likely the result of tumor compression or invasion of mesenteric, celiac, or splanchnic plexuses - Due to obstruction of hollow abdominal viscera Jaundice - Tumor compression of the common bile duct results to failure of conjugated bilirubin to be excreted, causing spillage into the systemic circulation Tea-colored Urine - Since conjugated bilirubin is soluble in water, it would be filtered by the glomerulus and would cause darkening of the urine. Light Stools - Absence or lack of bilirubin in the intestine due to impaired drainage to the duodenum Weight loss - Cancer cells compete with normal cells for nutrients. Also, tumors of the pancreas often interfere with digestion which further contributes to weight loss.

10. Laboratory FindingExplanation Elevated Bilirubins - Due to impaired excretion of bilirubins, secondary to obstructed or compressed ducts Elevated SGOT, SGPT - Accumulation of hydrophobic bile acids cause increased production of free radicals leading to oxidative damage Elevated Alkaline Phosphatase - Injury to the bile ducts will cause a marked increase in the serum alkaline phosphatase since this enzyme is concentrated in the ducts Dilated intra and extrahepatic ducts - Blocking tumor at the head of the pancreas will compress on adjacent ducts and cause dilation proximal to the obstruction Dilated pancreatic ducts - As tumor grows in the back of the head of the pancreas, it causes significant obstruction to the adjacent draining ducts Anemia - Anemia of chronic disease (malignancy)

11. Imaging Studies

12. Ultrasound Findings Pancreatic head Intrahepatic duct dilatation Dilated pancreatic duct Extrahepatic duct dilatation

13. Abdominal CT Scan August 20, 2011 BDM Imaging Center Inc.

14. LIVER STOMACH AORTA LEFT KIDNEY SPLEEN INTRAHEPATIC DUCT DILATED INTRAHEPATIC DUCTS

15. EXTRAHEPATIC DUCT CELIAC ARTERY CELIAC ARTERY AND SMA ARE INTACT DILATED EXTRAHEPATIC DUCT WITH NO EVIDENCE OF OBSTRUCTION

16. LEFT KIDNEY RIGHT KIDNEY GALLBLADDER DUODENUM PANCREAS LIVER ATROPHIC PANCREAS & ENLARGED PANCREATIC HEAD HYDROPS OF THE GALLBLADDER

22. Cholangiogram September 13, 2011 UERMMH

23. Cholangiogram Plain Film Percutaneous tube in the right hemiabdomen. Tip at the right paravertebral area at the level of the L3 vertebra.

24. Cholangiogram Intrahepatic ducts Gallbladder Proximal common bile duct Common hepatic duct Upon injection of contrast...

25. With tube manipulation... Distal portion of the percutaneous tube Duodenum

26. Therapeutics

27.  a.k.a. Pancreaticoduodenectomy Whipple’s procedure

28.  In patients with localized disease (stage I or II disease), with distal metastases excluded by prior CT scan of the abdomen and pelvis, and CT of the chest or chest x-ray, is potentially curative  5-year survival = 10%, although modern series have improved on these results.

29. Chemotherapy  Deoxycytidine analogue gemcitabine  1000 mg/m 2 weekly for 7 weeks followed by 1 week rest, then weekly for 3 weeks every 4 weeks thereafter

30.  Percutaneous transhepatic biliary drainage is used preoperatively to decompress the biliary tree and prevent complications aggravated by bile spillage.  Drainage of the biliary tree by the introduction of a catheter through the liver and into the biliary tree under radiologic guidance. Also called percutaneous transhepatic cholangiodrainage. Percutaneous Biliary Drainage

31. Indication for PTBD  To relieve obstructive jaundice when the endoscopic retrograde approach has failed or is not indicated

32. Indications for PTBD  To manage infectious complications of biliary obstruction, such as cholangitis and sepsis.  To decompress the biliary tree preoperatively and to assist the surgeon during surgical dissection and reconstructions.

33. Indications for PTBD  As initial step of other bile duct interventions, such as a biopsy of the biliary ducts or peribiliary tumors.  As definitive palliation of biliary stenosis by stent placement.  To provide access for transhepatic brachytherapy for cholangiocarcinoma

34. Percutaneous Biliary Drainage September 2, 2011 St. Luke’s Medical Center

37. Needle Dilated common bile duct

38. Guide wire Cut off area

39. Catheter Gallbladder

40. Biopsy site

41. Prognosis

42.  Median survival time for all patients is 4-6 months.  Patients who survive for 5 years after successful surgery may still die of recurrent disease years after the 5-year survival point.  The occasional patient with metastatic disease or locally advanced disease who survives beyond 2-3 years die of complications

43. Thank you for your kind attention!

44. Appendix

45. CBC8/23 HGB94 HCT26 RBC WBC4.0 Neutrophils61.5 Lymphocytes34.9 Eosinophils3.5 Basophils0 Platelets249 8/23Ref. A/G1.81.1-2.2 Dir. Bilirubin 223.73.4-13.0 Globulin19.715-34 Indir. Bilirubin 95.70-18 Tot. bilirubin 319.48.5-23.6 Tot. protein 55.8560-83 Albumin36.1635-53 Urinalysis ColorDark Yellow TurbidityClear Reaction7.0 Sp. Gr.1.020 ProteinNegative SugarNegative RBC0-1/hpf WBC0-2/hpf Casts Bacteria Epithelial cellsfew 8/8Ref. Na131.80135-145 K4.713.6-5.5 Crea68.7745-104 8/16Reference SGPT201.900-45 SGOT220.200-35 ALP507.4830-120

46.  Gallbladder Pathology  No radiation to right shoulder, no fatty food intolerance, no vomiting, no post-prandial pain, (-) Murphy’s sign  Biliary Tree Pathology  No fatty food intolerance; Not entirely ruled out  Pancreatic Pathology  Non-alcoholic Jaundice