Transcript Case 1

Case 1
Data:
 40
 Female
 Married
 Marikina
Chief complaint
 Abdominal Pain
HPI
 27 days PTC
 Right upper quadrant pain
 Body malaise
 Decreased appetite
 Sought consult at Amang Rodriguez ER
UTZ was requested, revealed a stone in the common
bile duct.
Advised to have ERCP but refused to seek 2nd opinion
 25 days PTC
 Consulted at a private clinic
 Was given medications w/ gave temporary relief
 Patient was compliant w/ meds but remittent
pain persisted until
 18 days PTC
 Patient experienced yellowish discoloration of the
eyes and skin
 No consult done
 14 days PTC
 Patient followed up at a private clinic, and was
referred to UERM to undergo ERCP
 Due to the exacerbation of pain patient was admitted
Upon admission, HBT pancreatic UTZ was done
shows: gallbladder hydrops w/ lithiases, bile sludge on
the cystic duct and proximal common bile duct w/
sludge ball at the terminal end causing extra- and
intrahepatic biliary and pancreatic duct dilation.
Normal pancreas
 ERCP w/ biliary stenting was done
 Initial read was: bulging ampula, t/c ampullary
mass, distal common bile duct stricture, s/p biliary
stent. Cholangitis.
 CT scan w/ triphasic contrast of upper
abdomen was done
 Initial read was: pancreatic head prominent at
3.92cm . No enlarged lymph nodes. Dilated
common bile duct just above site of stent
 Patient was advised for operation but opted
to be discharged due to financial constraint
 Patient was asymptomatic until
 2days PTC
 Recurrence of RUQ pain lead patient to sought
consult at our institution
PMHx
 Hypertension
 Losartan 50mg OD
PE
 General:
 ambulatory, not in distress
 VS:
 BP:130/80mmHg
 RR: 19cpm
CR: 98bpm
T: 36.5C
W:
 Skin:
 Generalized jaundice
 HEENT:
 Icteric sclera
 Abdomen:
 Soft flabby, normoactive bowel sounds, no
tenderness, no mass palpated
diagnostics
 CT scan: (11/2/14)
 Ampullary/periampullary mass infiltrating the
pancreatic head and duodenum w/ encasement of
the portal vein causing biliary tree dilation.
Consider malignancy
 No regional lymph nodes
 cholelithiasis
 Solid mass w/ irrregular margins and central
hypodensities centered in the
ampullary/periampullary region extending to the
pancreatic head area. It measures approximately
52.4 x 30.7mm in its widest antero-posterior and
transverse diameters.
 The mass appears to encase more than 180 degrees
of the entire diameter of the portal vein at at the
junction of the splenic and superior mesenteric vein.
 there is a suggestive low density lesion within the
portal vein which may be secondary to a thrombus.
The medial wall of the 2nd portion of the duodenum
exhibits nodularities with flattening of its mucosa.
Finding may indicate tumor infiltration of the
duodenum.
 The splenic artery, superior mesenteric and celiac
arteries are unremarkable. No regional lymphnode is
noted
 Liver is normal in size with smooth marginal contour.
No demonstrable parenchymal abnormality is seen.
The enhancing solid mass lesion is noted.
gallbladder lithiasis is noted.
 The intrahepatic, extrahepatic ducts and pancreatic
ducts are dilated. A biliary stent is visualized. There is
an irregular soft tissue density in the distal end of
common bile duct corresponding to the above
mentioned mass. The body and tail of the pancreas
are normal.
 Both kidneys are normal in size, configuration and
parenchymal thickness. The perirenal and pararenal
spaces are unremarkable. The visualized
pelvocalyces and proximal ureters appear normal.
 Visualized lung fields are clear
ERCP (10/29/14)
 Normal looking mucosa of the esophagus,
stomach and duodenum
 Bulging papilla but with normal looking mucosa
 Cholangiogram:
 Initial injection of contrast showed markedly dilated
middle common bile duct, common hepatic duct and
intrahepatic ducts. The distal 2cm of CBD did not
opacify. A 7cm french 10 biliary stent was inserted with
its tip seen in the mid CBD and with drainage of
whitish purulent bile
 Post procedure film showed almost complete drainage
of the contrast media from the common bile duct into
the duodenum
ERCP (10/29/14)
 Diagnosis:
 Bulging ampula, t/c ampullary mass
 Distal CBD stricture s/p biliary stent insertion
 cholangitis
 CBC: (11/18/14)
 Clin chem: (11/15)
 Hgb 100
 Na: 130
 Hct 0.30
 K: 3.9
 WBC: 4.2
 BUN: 3.5
 Neu: 0.45
 Cr: 70.4
 Plt: 366
 Alk phos: 554
 AST: 245
 FBS: 4.7
 Lipase: 3070
 Amylase: 306
 CHON: 68
 Coagulation
 Alb: 27.74
 PT: 11.6
 Glo: 4.3
 %: 136
 A/G: 0.7
 Bilirubin profile
 Total: 106.1
 Direct: 77.6
 Indirect: 28.5
 INR: 0.84
 aPTT: 26.7
 CA 19-9:
 21.9
Normal
 CEA:
 9.81
increased
Impression:
AMPULLARY CARCINOMA
Plan:
WHIPPLES PROCEDURE
Case 2
Data
 D.D
 68
 Male
 Married
 Pasig
Chief complaint
 Yellowish discoloration of skin
HPI
 1 month PTC
 Patient noticed yellowish discoloration of skin
associated w/ loss of appetite
 No meds, no consult done
 2 weeks PTC
 Patient developed abdominal pain located on
RUQ associated w/ black tarry stools, vomiting of
previously ingested food
 Persistence of yellowish discoloration of skin
opted patient to sought consult
PMHx
 Alcoholic beverage drinker for 3o yrs
PE
 Concious coherent, weak looking
 BP: 90/50mmHg
 RR: 20cpm
CR: 90bpm
T: 36.7C
 Icteric sclerae
 Flabby, soft, nontender abdomen, no
palpable mass
Diagnostics
 CT scan
 Focal narrowing of the descending and transverse portion





of the duodenum. Rule out underlying mass. Ill defined
hypodense mass w/ irregular rim and central enhancement
in the anteroinferior subsegment of the right liver lobe.
Rule out new growth, intrahepatic cholangiocarcinoma or
metastasis. Suggest histopathologic correlation. Top
normal sized gallbladder w/ moderate intrahepatic biliary
and common bile duct ectasia.
Bilateral renal cortical cyst
Prostatomegaly w/ tiny concretions
Minimal ascites, right anterior perihepatic, left posterior
subphrenic and pelvic regions.
Disc bulge L3-L4,L4-L5 and L5-S1 levels
 Moderate distention of the stomach down to the
duodenal bulb w/ no evident intraluminal mass. The rest
of the descending and transverse portion of the
duodenum are markedly narrowed.
 Liver is w/in normal size. There is an ill defined
hypodense mass w/ irregular rim and central
enhancement in the anteroinferior subsegment of the
right lobe. Measures approximately 5.1 x 6.5 x 5.7cm.
Minimal fluid is seen in adjacent anterior perihepatic
area. It also displaces the gallbladder inferiorly.
 The adjacent intrahepatic biliary as well as common bile
duct down to its suprapancreatic portion are
moderately dilated. The displaces gallbladdre is topnormal sized. Measuring 3.7cm in transverse diameter
w/ no evident lithiasis or wall thickening
 Pancreas, spleen, and both adrenal glands are
unremarkable
 Both kidneys are normal in size and configuration
w/ good nephrogram enhancement. Low density
focus is noted in the lower pole of the right kidney
measuring 0.6 x 0.7 x 0.8cm. Two subcentimeter low
density foci are also noted in the left kidney. The
pelvocalyces of both kidneys and both ureters are
not dilated. No lithiasis seen
 Prostate is enlarged w/ tiny concretions
 Minimal fluid is noted in left posterior subphrenic
space and pelvic peritoneal region
 Disc bulge is noted in L3-L4,L4-L5, and L5-S1 levels.
No lytic or blastic changes are noted
 AST
 ALT
 Alkaline phosphatase
 Total Bilirubin
 Direct bilirubin
 Indirect bilirubin
133
94
474
increased
increased
increased
320.1 increased
261 increased
59.1 increased
 EGD
 Gastroscope was inserted only upto the C-loop,
there is a complete obstruction w/ a friable
mucosa at the area of the C-loop. Biopsy not done
due to difficulty of angulation. Able to aspirate
blackish fluid about 2L at the gastric lumen.
Esophaus and stomach appears normal
Impression:
DUODENAL MASS
Plan: