The Curious Case of John DickGroup 3 Clinical Clerk Batch 2012SY 2011-2012
Objectives To discuss an intriguing case of an elderly
woman with abdominal pain To elaborate on the approach to jaundice To discuss the diagnostic approaches to
jaundice To present the management of
obstructive jaundice and review therapeutic options
Identifying Data L.S. 64-year-old Widow Vegetable vendor Tondo, Manila
Chief ComplaintGeneralized jaundice of 1 month duration
6 mos PTA
4 wks PTA
2 wks PTA
4 days PTA
1 wk PTA Admission
Colicky Abdominal Pain
Temporal Profile
Weight loss
Jaundice
Tea-colored urine
Loss of appetite
Past Medical History: Osteoarthritis, right ankle – took unrecalled
medication for 1 month Exposure to Tuberculosis G4P4 (4004) via NSD without complications No history of cancer No history of heart failure or valvular defects No history of Hepatitis B or C No hemolytic disorders No dyslipidemia No history of blood transfusion No history of needle prick injury No history of prolonged or high-dose intake of drugs
(e.g. Quinacrine, Rifampicin, etc) No previous hospitalization, surgery, dental surgery
Family History Tuberculosis – Mother No history of Cancer No history of hemolytic disorders
Social History: Non-smoker, non-alcoholic beverage drinker No IV illicit drug use
Review of Systems Weight loss (~50 kg ~36 kg in 1 month) No weakness No persistent cough, night sweats, hemoptysis,
fever No edema, difficulty of breathing, orthopnea No breast lump, pain or discharge No abnormal vaginal bleeding No history of abdominal trauma, changes in bowel
movement, nausea and vomiting, fatty food intolerance
Physical ExaminationGeneral Awake, conscious, coherent, not in pain,
appears ill-looking
Vital Signs BP 90/50 mmHg HR 64 bpm Ht 154 cmRR 18 cpm T 36.4 0C Wt 36 kg BMI 15.1 kg/m2
HEENT Icteric sclerae, yellowish palpebral conjunctivae, yellowish oral mucosa, no tonsillopharyngeal congestion, no cervical lymphadenopathies
Chest Equal chest expansion, no retractions, clear breath sounds, No spider angioma
CVS Adynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs, concordant apex beat and PMI at 5th ICS LMCL
Physical ExaminationAbdomen Globular, No caput medusae, No bulging
flanks,Abdominal girth = 29 inchesNormoactive bowel sounds, Tympanitic, Soft, Positive direct tenderness over epigastric area, No palpable masses, Liver span = 9cm, Spleen not palpable,No fluid wave, No shifting dullness, Negative Murphy’s sign
Physical ExaminationExtremities Full and equal pulses, no edema, no cyanosis,
Generalized jaundice
Mental Status Exam
Oriented to person, place and time. Remote, recent past, immediate memory not impaired.
Cranial Nerves Intact
Motor, Sensory,Cerebellar
Intact
Pertinent FindingsPositive NegativeWeight loss Drug or alcohol useAbdominal enlargement Blood transfusion or donationJaundice Tattoos or IV illicit drugsTea-colored urine History of HepatitisAnorexia Family history of Hemolytic
disordesChanges in bowel movementNausea and vomitingFeverFatty food intoleranceHistory of abdominal trauma
Pertinent FindingsPositive NegativeIcteric sclerae Fluid wave, shifting dullness,
bulging flanksJaundice Spider angioma, caput
medusaeGlobular abdomen, soft Hepatomegaly
SplenomegalyMurphy’s sign
Assessment Primary Impression
Obstructive Jaundice secondary to Pancreatic Head Mass
Differential Diagnoses: TB Lymphadenitis Peribiliary cancer Choledocholithiasis
JAUNDICE
CAROTENEMIA
DRUG INTAKE OF
PROBENECID/RIFAMPICIN
HYPERBILIRUBINEMIA
EXCESSIVE PRODUCTIO
N (Hemolytic
Anemia)
IMPAIRED CLEARANCE
UPTAKE/CONJUGATION EXCRETION
HEPATIC POST-HEPATIC
Jaundice
CarotenemiaDRUG INTAKE
PROBENECID/RIFAMPICIN
HYPERBILIRUBINEMIA
Excessive intake of carotene containing food such as carrots, leafy vegetables, squash, peaches, and oranges
Yellowish discoloration concentrated on palms, soles, forehead & nasolabial folds
Jaundice
CarotenemiaDRUG INTAKE
PROBENECID/RIFAMPICIN
HYPERBILIRUBINEMIA
Excessive intake of carotene containing food such as carrots, leafy vegetables, squash, peaches, and oranges
Yellowish discoloration concentrated on palms, soles, forehead & nasolabial folds
Jaundice
CarotenemiaDRUG INTAKE
PROBENECID/RIFAMPICIN
HYPERBILIRUBINEMIA
Uniformly distributed in skin and icteric sclera
Intake of quinacrine or rifampicin
Jaundice
CarotenemiaDRUG INTAKE
PROBENECID/RIFAMPICIN
HYPERBILIRUBINEMIA
Uniformly distributed in skin and icteric sclera
Intake of quinacrine or rifampicin
Jaundice
CarotenemiaDRUG INTAKE
PROBENECID/RIFAMPICIN
HYPERBILIRUBINEMIA
Jaundice
CarotenemiaDRUG INTAKE
PROBENECID/RIFAMPICIN
HYPERBILIRUBINEMIA
(+) Jaundice (+) Tea-colored urine (+) yellow discoloration of the skin (+) Icteric sclerae
(-) Murphy’s sign(-) fluid wave, bulging flanks and shifting dullness(-) spider angioma and caput medusae(-) Hepatomegaly (liver span = 9 cm)(-) splenomegaly
HYPERBILIRUBINEMIA
EXCESSIVE PRODUCTION (Hemolytic
Anemia)
IMPAIRED CLEARANCE
Ssx of anemia (pallor, fatigue, weakness, dizziness, confusion,
shortness of breath, and potential for heart failure)
Usually normal colored urine and stool
If inherited symptoms should have been present at an earlier age
jaundice, splenomegaly, hepatomegaly, tachycardia, murmur
HYPERBILIRUBINEMIA
EXCESSIVE PRODUCTION (Hemolytic
Anemia)IMPAIRED
CLEARANCE
IMPAIRED CLEARAN
CE
UPTAKE/CONJUGATION
EXCRETION
HEPATIC POST-HEPATIC
IMPAIRED CLEARAN
CE
UPTAKE/CONJUGATIO
NEXCRETIO
N
HEPATIC POST-HEPATIC
(-) spider angioma and caput medusae
(-) fluid wave, bulging flanks and shifting dullness
(-) Hepatomegaly (liver span = 9 cm)
(-) splenomegaly
IMPAIRED CLEARAN
CE
UPTAKE/CONJUGATIO
NEXCRETIO
N
HEPATIC POST-HEPATIC
POST-HEPATIC
Gallbladder Biliary Tree Pancreas Intestine
Primary ImpressionObstructive jaundice secondary to Pancreatic head mass r/o pancreatic ductal adenocarcinoma
• Incidence rate 37,700 cases in the US, leading to 34,300 deaths.• No predilection between genders• Incidence is more common within the elderly
population• No established early warning symptoms• Overall 5-year survival rate, <5%
Pancreatic Adenocarcinoma
•Causes are still unknown although it is considered that environmental causes play a role:
• Cigarette smoking
• Obesity
• Chronic pancreatitis
• History of diabetes mellitus
• Diet (increased intake of red meat or dairy products)
Pancreatic Adenocarcinoma
• Said to arise from a series of gene mutations• Early on its onset, the mass would originate
within the area of the ductal epithelium and would gradually spread to adjacent areas.• Pancreatic intraepithelial neoplasia
invasive carcinoma• Activation of the KRAS2 oncogene and
inactivation of the tumour suppressor genes CDKN2A and TP53
Pancreatic Adenocarcinoma
•Presentation of the symptoms would greatly depend on the area where the tumour is located.
•In 80% of cases, the tumour would be located within the area of the pancreatic head and this would have a great likelihood to cause obstructive cholestasis.
•Abdominal pain or discomfort as well as nausea are common clinical presentations.
Diagnosis and staging
• Systemic signs would include weakness, weight loss as well as anorexia.• Physical examination:
• Signs of jaundice• Wasting • Hepatomegaly• Ascites
• Routine laboratory tests might reveal anemia, abnormal liver function tests and hyperglycemia.
Pancreatic Adenocarcinoma
Pancreatic Adenocarcinoma•Common complaints would include
abdominal pain with the possibility of radiating to the back.
•Weight loss•Splenomegaly, varices in the stomach
and esophagus, GI bleeding•DM symptoms, glucose intolerance