GI - Obstructive Jaundice And Pancreatic Carcinoma

Question 1

Obstructive jaundice: causes

Answer 1

• 30% stones
• 30% Ca head of pancreas
• 30% other: lymph node inflammation at porta hepatic (TB/Ca), inflammatory (PBC, PSC, chronic pancreatitis), drugs (OCP, sulfonylureas, flucloxicillin, chlorpromazine), neoplastic (cholangiocarcinoma) and Mirizzi’s syndrome

Question 2

Obstructive jaundice: clinical features

Answer 2

• Jaundice
• dark urine and pale stools
• itch (bile salts retained)

Question 3

Obstructive jaundice: Ix - urine and bloods

Answer 3

• Urine: dark (high bilirubin and low urobilinogen)
• Bloods: raised WCC (in cholangitis), U+E (hepatorenal syndrome), LFTs (raised ALP, AST/ALT), clotting (decreased Vit K = raised INR).
• Do G+S: may need ERCP
• Look for immune markers: AMA, ANCA, ANA

Question 4

Obstructive jaundice: Ix - imaging

Answer 4

• AXR: may see stones or pneumobilia (gas forming infection)
• US: look for dilated ducts (>6mm), stones and tumours
• MRCP or ERCP
• Percutaneous transhepatic cholangiography

Question 5

Obstructive jaundice: Mx - conservative

Answer 5

• Monitor LFTs: passage of stone may lead to resolution
• give vitamins ADEK
• Analgesia

Question 6

Obstructive jaundice: Mx - interventional

Answer 6

• Do if there is no resolution, worsening LFTs or cholangitis
• ERCP with sphincterotomy and stone extraction (or surgery options)

Question 7

Obstructive jaundice: Mx - surgical

Answer 7

• Open/lap stone removal with T tube placement

- Delayed (6-12 was) cholecystectomy to prevent recurrence

Question 8

Ascending cholangitis: triad, pentad and mx

Answer 8

• Charcot’s triad: fevers/rigours, RUQ pain and jaundice
• Reynold’s pentad: charcot’s triad + shock and confusion
• Rx: ABX (Kettering = co-amoxiclav and metro) + ERCP (first line) or open/lap stone removal with T tube drain (second line)

Question 9

Pancreatic carcinoma: risk factors

Answer 9

• Smoking
• inflammation: chronic pancreatitis
• Nutrition: high fat diet
• EtOH
• DM

Question 10

Pancreatic carcinoma: pathophysiology

Answer 10

• 90% Duct always adenocarcinomas
• Present late, metastasise early with direct extension to local structures, lymphatic and haematogenous spread (liver and lungs)
• 60% head, 25% body, 15% tail

Question 11

Pancreatic carcinoma: presentation

Answer 11

• typically male
• Courvoisier’s law: painless enlarged GB, non tender and accompanied by mild painless jaundice = cause unlikely to be gallstones.
• Epigastric pain: radiates to back, relieved by sitting forward
• Anorexia, wt loss and malabsorption
• Acute pancreatitis
• Sudden onset DM in elderly

Question 12

Pancreatic carcinoma: signs

Answer 12

• palpable gallbladder
• jaundice
• epigastric mass
• thrombophlebitis (Trousseau’s sign)
• Splenomegaly (portal vein thrombosis —> portal hypertension)
• Ascites

Question 13

Pancreatic carcinoma: Ix

Answer 13

• Bloods: cholestatic LFTs, raised Ca 19-9 (very sensitive), raised calcium
• Imaging: US (pancreatic mass, dilated ducts, hepatic mets, guide biopsy), CT, EUS (better than ct/mri for staging), CXR (mets), laparoscopy (mets/staging)
• ERCP: allows stenting or biopsy of peri-ampullary lesions

Question 14

Pancreatic carcinoma: Mx -surgery

Answer 14

• If pt fit, no mets and tumour is <3cm
• Whipple’s pancreaticoduodenectomy
• Distal pancreatectomy
• 5 year survival is poor (5-14%)

Question 15

Pancreatic carcinoma: Mx - palliation

Answer 15

• Endoscopic/percutaneous stenting of CBD
• Palliative bypass surgery: cholecystectojejunostomy +gastrojejunostomy
• Pain relief: may need coeliac plexus block

Question 16

Pancreatic carcinoma: prognosis

Answer 16

• Mean survival is <6 months

- 5 year survival = < 2%