Case Discussion for Medical Students and Brief Education on Pancreatic Carcinoma.

2. 52 year old male patient presents with progressive Jaundice, itching,
loss of weight.
• Gradually progressive jaundice
• Recurrent episodes of itching
•White stools for last 2 months
• Dark yellow urine
• Generalized weakness & fatigability- 6 months
•Weight loss in last 1 year
• Reduced appetite
• No fever

3. H/o past illness:
• No H/O DM, HT,TB, IHD
• No previous surgery(no history of cholelethiasis).
Personal History:
• Decreased appetite with pale stools
• Normal bladder habits but deep yellowish colour
• Smoker – 40 yrs
• Non-alcoholic

4. General Physical Examination:
– Pulse 88/min,BP 110/70, RR 16,Temp 98 F
– Anemia +, Jaundice ++
– No Lymphadenopathy
– Scratch marks
Per abdomen:
Normal Inspection
On palpation:
– Soft non-tender
– Gall bladder palpable
BS audible

5. • Hgb: 11.7
• Hct: 35
•WBC: 6000;
• normal differential count
• Platelet: 350,000
• Serum Crea: 1.2 mg
•Total bil: 20 mg; B1(unconj): 2 mg B2 (conj): 18 mg
• Alkaline phosphatase: 990 U/L
• CA 19-9: 350 units/ml
•Total protein: 6.5 grams

6. • USG-Abdomen:
Solid mass in distal CBD, dilated CBD, Intrahepatic Biliary distension and
distended GB.

7. CT abdomen e IV contrast:
It showed grossly dilated intra and extrahepatic biliary channelsWith distended gall
bladder And possibility of periampullary mass.

8. MR cholangiopancreatography (MRCP), which can be used to look at
the pancreatic and bile ducts, is described below in the section on
cholangiopancreatography.
a) 3D magnetic resonance cholangiopancreatography with maximum intensity projection; (b) coronal T2-
weighted image; (c) 2D magnetic resonance cholangiopancreatography: mild dilated bilobar radicles [(b),
yellow arrow] with dilated common bile duct [(a) and (c), yellow arrow] with distal short and irregular
stricture at distal common bile duct (red arrows). Final diagnosis: malignant distal common bile duct
stricture

9. Endoscopic retrograde cholangiopancreatography (ERCP):
Double Duct Sign

13. Malignant
Uncertain malignant potential

16. Head
Regional lymph nodes Liver
Lungs
Duodenum, Stomach and
Colon

18. • Demographic factors:
• Environment/lifestyle
1. Smoking
• Genetic factors and medical conditions:

19. MIDEPIGASTRIC PAIN

20. PAINLESS OBSTRUCTIVE JAUNDICE

22. Epigastric Mass
Palpable gallbladder(+clinical jaundice)
Ascites

23. CBC
• Liver FunctionTest
• Serum amylase/lipase*
• Elevated tumor markers

25. • Ultrasound
• CT scan with IV contrast

26. • Endoscopic ultrasound
• MR cholangiopancreatography (MRCP),
• MR angiography (MRA),

27. MRCP
ULTRASOUND CT SCAN

30. Treatment Approach
Resectable disease
Stages I-II
(20%)
Surgery
Adjuvant chemotherapy
Adjuvant radiation

31. Treatment Approach
Inoperable disease
Locally Advanced stage
III
(30-40^)
Chemoradiation
Chemotherapy
Metatatic Stage IV
(40-50%)
Chemotherapy
Supportive Care

33. • Operable cases

35. Whipple Procedure

36. Pylorus preserving pancreaticoduodenectomy (PPPD)

37. Stage23 Incidence Survival/5 years
I 8.5% 20%
II 23% 10%
III 14% 2.5%
IV 54% 1.6%

39. • Chemotherapy