Obstructive jaundice + pancreatic cancer Flashcards
Causes of obstructive jaundice
Gall stones
Ca head of the pancreas
Lymphadenopathy @ porta hepatis: TB, Ca
Inflammatory: PBC, PSC
Neoplastic:
- Cholangiocarcinoma
- Mirizzi’s syndrome
Presentation of obstructive jaundice
- Jaundice
- Dark urine, pale, floating stools
- Pruritis (bile salts)
Investigations for obstructive jaundice
• Bloods
- FBC: ↑ WCC in cholangitis
- U+E: hepatorenal syndrome
- LFT: ↑bilirubin, ↑↑ ALP, ↑AST/ALT
- Clotting: ↓ vit K → ↑ INR
- G+S: may need ERCP
- Immune: AMA, ANCA, ANA
- CA 19 - 9
• Urine
- Dark
- ↑ bilirubin
- ↓ urobilinogen
• Imaging AXR - may visualise stone - Pneumobilia - gas forming infection
USS
- Dilated ducts >6mm
- Stones (95% accurate)
- Tumour
MRCP or ERCP
Percutaneous Transhepatic Cholangiography
Risk factors for pancreatic cancer (SINED)
- Smoking
- Inflammation: chronic pancreatitis
- Nutrition: ↑fat diet
- EtOH
- DM
Pathology of pancreatic CA
- 90% ductal adenocarcinomas
* Present late, metastasise early
Presentation of pancreatic CA
• Male >60yrs
• Painless obstructive jaundice: dark urine, pale stools
• Epigastric pain: radiates to back, relieved sitting
forward
• Anorexia, wt. loss and malabsorption
• Acute pancreatitis
• Sudden onset DM in the elderly
Signs of pancreatic CA
- Palpable gallbladder
- Jaundice
- Epigastric mass
- Thrombophlebitis migrans (Trousseau sign)
- Splenomegaly and ascites
Courvoisier’s Law
In the presence of painless obstructive jaundice, a
palpable gallbladder is unlikely to be due to stones.
Investigations for pancreatic CA
Bloods:
- LFTs
- ↑Ca19-9 (90% sens)
- ↑Ca
- Amylase
Imaging
- USS: pancreatic mass, dilated ducts, hepatic mets, guided biopsy
- chest-abdomen-pelvis CT scan - staging
- CXR: mets
- Laparoscopy: mets, staging
ERCP use
Shows anatomy
Allows stenting
Biopsy of peri-ampullary lesions
Tx of pancreatic CA
• Surgery
- Whipple’s procedure- pancreaticoduodenectomy
- Distal pancreatectomy
- Post-op chemo delays progression
When to do surgery
Fit
No mets
Tumour ≤3cm
Palliation for pancreatic CA
Endoscopic / percutaneous stenting of CBD
Palliative bypass surgery:
cholecystojejunostomy +
gastrojejunostomy
Pain relief – may need coeliac plexus block
Cholangiocarcinoma pathology
• Rare bile duct tumour - adenocarcinoma
• Typically @ confluence of right and left hepatic
ducts: called “Klatskin” tumours
Risk factors for cholangiocarcinomas
- PSC
- Ulcerative colitis
- Choledocholithiasis
- Hep B/C
- Choledochal cysts
- Alcohol
- DM
- Toxins - rubber
Presentation of cholangiocarcinoma
• Progressive painless obstructive jaundice - Gallbladder not palpable • Steatorrhoea • Wt. loss • Pruritis due to bilirubin
Cholangiocarcinoma investigations and mx
- Bloods: FBC, LFTs, CA 19-9
- USS
- MRCP
- CT staging
Tx
• Poor prognosis: not curative as many cant undergo complete surgical resection
• Palliative stenting by ERCP
RUQ pain and blood tests showing a post-hepatic jaundice, the patient otherwise well and stable. What is the most appropriate initial investigation?
USS abdomen
Common site for cholangiocarcinoma
bifurcation of the right and left hepatic ducts - Klatskin tumour
Behaviour of cholangiocarcinoma
Adenocarcinomas
Slow growing and invade locally
Metastasise to lymph nodes
Spread to peritoneal cavity, lung, and liver
Complications of cholangiocarcinoma
Biliary tract sepsis
Secondary biliary cirrhosis
Behaviour of pancreatic cancer
Direct invasion of local structures:
- spleen
- transverse colon
- and adrenal glands
Lymphatic metastasis:
- regional lymph nodes
- liver - commonly
- lungs
- peritoneum
Absolute contraindications for surgery
Peritoneal, liver and distant metastases
Whipple’s procedure
Removal of the head of the pancreas, the antrum of the stomach, the 1st and 2nd parts of the duodenum, the common bile duct, and the gallbladder.
