Mannish Rungta, MDSeries Editor: Richard Goodgame, MD


January 24, 2005

Case Presentation

A 47-year-old woman was referred to clinic for persistent abdominal pain.

The patient had a long history of very heavy alcohol abuse, complicated by pancreatitis. She had gone to a hospital 14 months ago because of epigastric pain, back pain, and jaundice. A computed tomography (CT) scan showed distal common bile duct obstruction and a mass in the head of the pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a distal common duct stricture, but brushings and biopsies were negative for malignancy. The pancreatic duct could not be cannulated. A plastic common bile duct stent was placed. A CT aspiration biopsy of the mass showed only chronic inflammation. She was referred to our hospital for surgery.

The outside imaging studies and pathology results were reviewed and the surgeons requested only an endoscopic ultrasound (EUS) prior to operating. The EUS showed a dilated pancreatic duct, the biliary stent, gallbladder sludge (Figure 1), and multiple hypodense lesions in the head of the pancreas (Figure 2). There were other findings suggestive of chronic pancreatitis. Aspiration biopsy was nondiagnostic.

Key: GB = gallbladder; CBD = common bile duct

Key: CBD = common bile duct

Surgery was performed. The operative impression was cancer of the head of the pancreas with invasion of the portal vein and peritoneal metastases. Frozen sections were read as compatible with cancer. No resection was performed. Permanent sections of the operative biopsies were read as negative for malignancy. Since this time, the patient has had progressively severe abdominal and back pain. Eight months ago, repeat CT scan of the abdomen was performed and showed a dilated pancreatic duct, the plastic stent, and no definite mass (Figure 3). Five months ago she developed jaundice. The occluded plastic biliary stent was removed at ERCP. A long common bile duct stricture was demonstrated (Figure 4). Brushings of the stricture were nondiagnostic; the pancreatic duct could not be cannulated. An expandable metal stent was placed across the biliary stricture (Figure 5).[1] Although the patient has had epigastric pain since her initial presentation, it had become severe -- the pain is constant, boring, and radiating to the back. She has no nausea or vomiting but has a very poor appetite because of pain. She has lost 30 pounds since her illness began, and most of this weight was lost in the last 3 months. She does not like to take narcotic analgesics because of dysphoric side effects. The patient indicates that her life would be very livable if she just "did not have the pain."

She takes propoxyphene, acetaminophen, and pancreatic enzymes. She does not drink alcohol. Her brother died of lung cancer at age 42.

Physical examination showed a thin woman with normal vital signs. She had mild pallor but no lymphadenopathy or jaundice. The heart and lungs were normal. The abdominal exam was normal except for mild epigastric tenderness without a mass or organomegaly.

Routine laboratory studies were all normal except for a hemoglobin level of 11 g/dL. Liver chemistries were normal, and the CA 19-9 value was below the limits of the assay.


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