‫بثينه عناد‬
‫‪50 Years‬‬
‫ديالى‬
o Classic history of obstructive jaundice for 2
months duration.
o Occasional episodes of fever, rigor and
abdominal pain.
o Wt loss and ↓appetite.
Biochemical tests:
Test
Result
TSB
3.2
D
mg/dl
Mg/dl
DGOT
136
u/l
SGPT
198
u/l
S. ALP
977
u/l
RBS
mg/dl
TSP
g/l
Albumin
g/l
B. Urea
28
mg/dl
S. creatinine
0.7
mg/dl
Ultrasonography:
A known case of CA head pancreas seen as hypoechoic mass seen at
pancreatic head measures 55 x 37 x 28 mm with few localized
metastatic LND largest 24 mm
Bilateral IHBT dilatation with convoluted tubules-like cystic structures
at gallbladder fossa measures 54 x 27 mm mostly GB.
Attenuated extra hepatic CBD that couldn’t be traced.
MRCP is better to evaluate CBD.
Target lesion seen at segment 3 measures 3 cm mostly secondaries.
Rim of ascites.
CT scan:
Evidence of enhancing soft tissue mass in the head of
pancreas. Irregularity of wall of adjacent duodenum with
dilated CBD and mild dilatation of the pancreatic duct with
evidence of multiple regional and para aortic LN
enlargement with enhancing hypodense mass about 1.5 cm
in inferior part of right lobe of liver.
Image finding suggestive of CA head of pancreas with
lymphatic and hepatic secondaries.
MRI:
Enlarged liver size showing marked dilatation of the intrahepatic BT. Multiple
metastatic lesion seen as a target sign in segment 6 and 7.
No intra ductal mass or stone but abrupt obstruction of the narrowed CHD.
No ascites seen.
Gallbladder was distended, no obvious stone or mud or solid mass lesion but
septations seen with tortuous dilated cystic ducts behind the Hartman’s
pouch.
Pancreas irregular ill-defined hypo intense T1 and T2 enhancing solid mass
arising from lower aspect of head of pancreas and shows obvious invasion of
lower CBD infiltrating upward along the portal region causing abrupt high
level obstruction of CBD.
Multiple LNs seen in retro pancreatic region and around the celiac
axis. The pancreatic duct is seen only at it’s pre-ampullary aspect and
seems to be partially duplicated on tracing the rest of the pancreas.
Invasion of the posterior gastric wall and first and second parts of
narrowed duodenum.
Mild enlargement of the spleen.
Conclusion: CA pancreas with CBD and cystic duct obstruction with
liver metastasis.
EUS:
Scanning of pancreas revealed hypo-echoic heterogeneous mass at
the head of pancreas with multiple celiac, para aortic peri
pancreatic LNs with multiple mediastinal LN.
EUS FNA from celiac LN was done.
Conclusion: pancreatic tumor T3 N1
Cyto-pathology report:
Smears are infiltrated with inflammatory cells and few groups of
malignant epithelial cells in background of blood and cellular
debris. The picture is consistent with metastatic carcinoma to the
LN. pancreas could be the primary site.
ERCP
After successful deep
biliary cannulation by
burdick procedure,
cholangiogram showed
dilated right intra hepatic
biliary system with nonvisualized Lt systm.
CBD not dilated.
Plastic stent 10 cm x 8.5 fr
inserted