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Pancreatic Cancer:
The Silent Killer
By Suzanne Sica
Class 2008
Case Demographics
55 y/o Caucasian male presents to ER
Chief c/o:
 RUQ and epigastric pain x 5 weeks worsened with
Significantly worsened sxs over last 2-3 weeks
 Nausea, anorexia, and unexplained weight loss of 25
Proceeded to ER when:
 Jaundice, light colored stools, and darker urine x 2
 Denied fever, chills, or hematoemesis.
Physical Examination
BS x 4 quadrants
Nontender and nondistended.
Negative masses, hepatosplenomegaly, or
Negative Murphy’s Sign with inspiration.
Differential Diagnosis
What typically causes RUQ
pain associated with eating
with an otherwise normal
What does jaundice, light
colored stools, and tea-colored
urine indicate? What could
cause these sxs?
What diagnosis would we be
more concerned about if a
fever was present?
Abdominal Ultrasound
Gall bladder distention with multiple calculi.
Common bile duct ~6mm in diameter (higher limits of normal)
Negative wall thickening or pericholecystic fluid.
No free air nor intrahepatiic bile duct dilation.
Lab Results
Alkaline phosphatase of 273,
AST of 143,
ALT of 288,
Total Bilirubin of 3.5,
Direct Bilirubin of 2.0,
Amylase of 324.
Diagnosis/ Treatment
Biliary Colic/
scheduled for next week
Immediate ERCP
Rule out ascending
Concerned about jaundice,
PMH of diabetes, and risk
of sepsis prior to surgery
Surgery Pimp Questions
What are the symptoms of
ascending cholangitis?
Clue: One is a triad and the other is a pentad.
Charcot’s Triad
 Jaundice
 RUQ Pain
Reynold’s Pentad
 Jaundice
 RUQ Pain
 Confusion (Altered Mental Status
 Hypotension (Shock)
Intervention used to treat conditions of the bile
and pancreatic duct, and make diagnoses.
ERCP Findings/ Results
Performed by Gastroenterologist
Common bile duct stenosis found
10Fr 7cm biliary stent placed with difficulty 6cm
into biliary duct
Suspicious for malignant pancreatic tumor
Hospital admission
Following stent placement:
Jaundice, light colored stools, and dark urine
Repeat Abdominal CT Scan
Revealed 4.6cm x
2.8cm pancreatic
head mass
 No pancreatic ductal
 Visualizes metastases
>1cm in size.
Explorative Laparoscopy
Revealed 1mm white
nodule on lower lobe
of liver
 Nodule biopsied and
sent for frozen
 Nodule was benign
 Proceed with
Whipple’s Procedure
Whipple’s Procedure: A Cure?
Contraindications to Whipple’s
If superior mesenteric artery or portal vein
become involved.
 Presence of ascites, nodal, or peritoneal
metastases occur.
 If tumor is >4cm- debatable.
Problem: Over 75% of patients present with
metastases initially.
 Note: CA 19-9 levels were documented at 1515.
Whipple’s Procedure
At the beginning of procedure,
5mm white nodule was found on Glissen’s
 Nodule was biopsied and sent for frozen
 Metastatic cancer was confirmed.
 Whipple’s Procedure was aborted.
 A palliative biliary bypass was performed.
(Roux-en-Y cholecystojejunostomy)
Prognosis for Metastatic
Pancreatic Cancer
Palliative Treatments
Biliary bypass and common bile duct stenting
Alleviates future gastroduodenal obstruction.
Avoids recurrent jaundice.
Chemotherapy not recommended for pancreatic
Doesn’t respond well.
No benefit over supportive care.
Survival Rates
3-6 months.
Even had resection been performed, 5 year survival
rate was ~20%.
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Castillo, C.F., MD. Jimenez, R.E., MD. (2006, June 20). Pancreatic
Cancer: Palliation of Symptoms. Retrieved August 31, 2007 from
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Erickson, R.A., MD. (2005, December 15). Pancreatic Cancer.
Retrieved July 20, 2007 from Emedicine database.
Merchant, N.B., MD. Conlon, K.C., MD. (1998). “Laparoscopic
Evaluation in Pancreatic Cancer.” Semin. Surgical Oncology. 15:155165.
Parker, Stephen BSc. (2007, June 3). Pancreatic Carcinoma.
Retrieved August 31, 2007 from