Upper Gastrointestinal
CASE 29: painleSS jaunDiCe
history
A 73-year-old man is admitted from surgical outpatients. You have been asked to clerk the patient and initiate his investigations. For the past 3 months, he has noticed a progressively deepening yellow discolouration of his skin. He has not had any abdominal pain. His appetite has reduced significantly and he has found that his clothes have become loose. He has also noticed that his urine has darkened and his stools have become pale and difficult to flush. He enjoys the occasional whisky at home in the evening and has smoked ten cigarettes a day since he was a teenager. He is not on any regular medication.
examination
The patient appears underweight and has a yellow discolouration of the skin and sclera. The heart sounds are normal with a blood pressure of 136/64 mmHg and a pulse of 86/min. He is afebrile and his chest is clear. The abdomen is soft with a smooth mass present in the right upper quadrant, which moves with respiration.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
13.0 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
12 × 109/l |
4.0–11.0 × 109/l |
platelets |
260 × 109/l |
150–400 × 109/l |
Sodium |
137 mmol/l |
135–145 mmol/l |
potassium |
4.3 mmol/l |
3.5–5.0 mmol/l |
urea |
5 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
65 μmol/l |
44–80 μmol/l |
amylase |
32 iu/l |
0–100 iu/dl |
alp |
229 iu/l |
35–110 iu/l |
aSt |
96 iu/l |
5–35 iu/l |
ggt |
63 iu/l |
11–51 iu/l |
albumin |
46 g/l |
35–50 g/l |
bilirubin |
82 mmol/l |
3–17 mmol/l |
glucose |
5 mmol/l |
3.5–5.5 mmol/l |
Questions
•Why are the stools pale?
•What is Courvoisier’s law?
•What additional investigations are required to make the diagnosis?
•How should this patient be managed?
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100 Cases in Surgery
ANSWER 29
The most likely cause in this patient is pancreatic cancer. The patient reports having pale floating stools, which is consistent with steatorrhoea caused by an inability to absorb fat from the digestive tract resulting in excess fat in the stools. Courvoisier’s law states that a palpable gallbladder in the presence of jaundice is unlikely to be secondary to gallstones. The presence of gallstones leads to a shrunken fibrotic gallbladder and is usually associated with pain. Pancreatic cancer classically presents with painless jaundice from biliary obstruction at the head of the pancreas and is associated with a distended gallbladder. Patients with pancreatic cancer can also present with epigastric pain, radiating through to the back, and vomiting due to duodenal obstruction.
Pancreatic cancer occurs in patients between 60 and 80 years of age, with a higher incidence in males than females. It is associated with chronic pancreatitis and smoking. The majority are adenocarcinomas and occur in the head of the pancreas. Roughly three-quarters have metastases at presentation, which is responsible for the very poor overall 5-year survival rate of less than 5 per cent. Ca 19-9 is the most useful tumour marker for pancreatic cancer with a sensitivity of 80 per cent and a specificity of 75 per cent. Abdominal ultrasound has a sensitivity of about 80 per cent for the detection of pancreatic cancer and excludes gallstones. Spiral CT has a sensitivity of greater than 90 per cent for detecting pancreatic tumours. Endoscopic ultrasound is now being used more frequently to stage tumours and is especially useful in periampullary tumours. ERCP can be used to aid diagnosis, but is often reserved for therapeutic intervention.
Resectability of the tumour depends on the tumour size, whether the tumour invades the superior mesenteric artery or portal vein, the presence of ascites, or the presence of nodal, peritoneal or liver metastases. Both ultrasound and CT scans often fail to detect small (<2 cm) metastases, so laparoscopy is used to identify liver or peritoneal disease. Laparoscopy detects metastases in about a quarter of patients who are negative after conventional imaging.
Only 15 per cent of tumours are resectable by pancreatic–duodenal resection (Whipple’s operation). Operative mortality is reported to be less than 5 per cent, with a 5-year survival of approximately 35 per cent. Patients have a high incidence of postoperative morbidity, with a significant proportion becoming diabetic or requiring pancreatic supplementation.
The majority of patients are not suitable for resection. These patients require endoscopic stenting to relieve the bile duct obstruction. Duodenal obstruction can be relieved with a bypass procedure (gastrojejunostomy).
KEY POINT
• only approximately 15 per cent of pancreatic malignancies are surgically resectable.
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Upper Gastrointestinal
CASE 30: intermittent abdominal pain
history
A 50-year-old woman was referred to the surgical outpatient clinic by her GP. She had been complaining of intermittent bouts of abdominal pain over the preceding 6 months. When the pain occurred, it was constant, associated with nausea and usually lasted for a couple of hours. She had also noticed that fried foods triggered the attacks. In the referral letter, the GP also mentioned that her body mass index (BMI) was 38 but that she had been actively trying to lose weight. She has no past medical history and has recently been started on hormonereplacement therapy.
examination
On examination, the patient is afebrile with a pulse rate of 80/min. She has no evidence of jaundice and no palpable lymphadenopathy. On palpation of her abdomen there is mild tenderness in the right upper quadrant. Rectal examination is normal and urinalysis is clear.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
12 g/dl |
11.5–16.0 g/dl |
mean cell volume |
80 fl |
76–96 fl |
White cell count |
11.0 × 109/l |
4.0–11.0 × 109/l |
platelets |
315 × 109/l |
150–400 × 109/l |
Sodium |
137 mmol/l |
135–145 mmol/l |
potassium |
4.2 mmol/l |
3.5–5.0 mmol/l |
urea |
5.0 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
77 μmol/l |
44–80 μmol/l |
amylase |
72 iu/dl |
0–100 iu/dl |
alp |
69 iu/l |
35–110 iu/l |
aSt |
30 iu/l |
5–35 iu/l |
ggt |
45 iu/l |
11–51 iu/l |
albumin |
45 g/l |
35–50 g/l |
bilirubin |
12 mmol/l |
3–17 mmol/l |
Questions
•Which radiological investigation should be ordered, and what might it show?
•What advice would you give the patient?
•What are the next steps in the management of this patient?
65
100 Cases in Surgery
ANSWER 30
The history suggests a diagnosis of chronic cholecystitis or biliary colic. An ultrasound of the abdomen should be requested, which may reveal gallstones situated within a thick-walled gallbladder (arrow in Figure 30.1).
Figure 30.1 ultrasonography showing multiple calculi within the gallbladder (arrow).
Gallstones are present in up to 10 per cent of females in their 40s and are less common in males. Typically, they are believed to be more common in ‘fair, fat, fertile females of forty’, but in fact can occur in any individual. Impaction of a gallstone in the gallbladder outlet causes contraction of the smooth muscle leading to pain. It is usually continuous and may radiate to the lower pole of the right scapula.
Biliary colic is the presenting symptom in over 80 per cent of patients with gallstones. More than two-thirds of those patients have a second episode within 2 years. If the pain persists or the patient becomes febrile, then the patient may have developed cholecystitis. This occurs when the gallstones remain impacted in the gallbladder outlet, leading to inflammation of the gallbladder wall.
Initially, patients are advised to avoid high-fat meals, although there is little evidence to show that this reduces further attacks. Laparoscopic cholecystectomy should be offered to patients with persistent symptoms.
Patients with cholesterol gallstones can be offered treatment with ursodeoxycholic acid. This drug aims to dissolve the gallstones. Dissolution typically takes between 6 and 18 months and is only successful with small, purely cholesterol stones. Patients remain at risk of gallstone complications throughout this time, and treatment fails in many cases. After treatment, most patients will form new gallstones over the subsequent 5–10 years.
KEY POINTS
•gallstones are present in 10 per cent of females in their 40s.
•the majority of gallstones remain symptomless.
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