DEPARTMENT OF SURGERY

KULIYYAH OF MEDICINE
INTERNATIONAL ISLAMIC UNIVERSITY OF
MALAYSIA

CASE WRITE-UP 1
OBSTRUCTIVE JAUNDICE
WITH CHOLECYSTITIS
SECONDARY TO
AMPULLARY TUMOR
NAME

NOOR AINI BTE ISMAIL

MATRIC NO

0715932

GROUP

C2

POSTING

SURGERY

YEAR

YEAR 3 ( 2009/2010)

SUPERVISOR

DR. KHAIRUSSSALEH BIN JALALUDIN

HISTORY TAKING
1) IDENTIFICATION DATA
Name
Registration Number
Identification Number
Age
Race
Sex
Occupation
Address
Date Of Admission
Date of Clerking
Date of Discharge
Sources of History

: Ruhani Bt. Ibrahim

: 612568
: 600508-11-5140
: 49 years old
:Malay
: Female
: Housewife
: Taman Mentakab Indah, Mentakab,
Pahang.
: 27th October 2009
: 28th October 2009
: 12th November 2009
: The Patient and her mother

2) CHIEF COMPLAINT
A 49 years old Malay lady came with the complaint of generalized
abdominal pain for one week duration.
3) HISTORY OF PRESENTING ILLNESS
Pn, Ruhani was apparently well until in March 2009 when she
suddenly developed
generalized abdominal pain. The pain was continuous, gradually increasing
in intensity and pulling in nature. The pain was so severe that she was
unable to do anything but just lying in bed. She went to Hospital Sultan Haji
Ahmad Shah, Temerloh to get treatment and she was admitted for 20 days
there. During her stay at the hospital, patient mentioned that the doctor
suspected that she is suffering from gall stone so doctor did an endoscope
from mouth which was oesophageal gastro duodenal scope. The result
revealed that it was not significant of gall stone. She was discharge and
was asked to come again a week later at surgical clinic but she did not go.
According to the patient the abdominal pain still persisted since the
first occurrence. The pain was so severe until it disturbs her daily activities.
The pain was associated with yellowish discoloration of the sclera and also
the skin. Patient also noticed that the color of the urine changes from
usually pale yellow color into tea color since March 2009 also. She
mentioned that at night she would urinate 3 to 4 times but the volume did
not increase and there was no pain during urination. The abdomen also
3

feels distended and since the start of abdominal pain, there was on and off
occurrence of high grade fever. The pain does not radiate to other place
and there was no relieving or aggravating factor.
Patient mentioned that she loss her appetite since then and claimed
of losing weight because before this her weight was 60kg and now her
weight is 43kg. She became lethargic due to loss of appetite.
Otherwise, there was no history of nausea, vomiting and vomiting of
blood. No history of passing of pale or black stool or fresh blood or
constipation and there was no history of gall stone before. Despite the
yellow discoloration of her skin, she does not complain of itchiness of the
skin.
Usually when the pain was too painful, she went to private clinic to
get pain killer but a week before admission the pain became too painful
and on Tuesday, 20th October 2009, she went to Hospital Rompin because
at that time she was staying at her mothers house in Rompin and the
doctor there referred her to Hospital Tengku Ampuan Afzan, Kuantan with
the diagnosis of obstructive jaundice secondary to tumour for further
management.
4) SYSTEMIC REVIEW
General

There is no fever, but there is lethargy.

Head & Neck

There is no abnormal swelling, eye or ear

discharge or pain noted. Lymph nodes are also

Urogenital

not palpable.
There is no hematuria, no increase or decrease
in urination, no dysuria, no polyuria, no nocturia,

Cardiovascular

no discharge, and no any loin or groin pain.

There is no dyspnea or orthopnea. Patient

System

denied of having chest pain. There was no

palpitation, no calf tenderness, and no
decreased effort tolerance. But patient

Respiratory

complaint of bilateral ankle edema.

There is no cough, night sweat, hemoptysis, or

System
Haematopoitic

epistaxis. There is no wheezing or stridor.

There is pallor and fatigue. No gum bleeding,

System

easy bruising, nor epistaxis.

4

Musculoskeletal

Patient was able to move all four limbs. There is

System

no joint pain, no bone pain or muscle pain. There

is no swelling of the joints. There is no stiffness,

Central Nervous

no deformity or weakness.
Patient had never experienced any fits, or

System

seizure. There is also no history of

unconsciousness (faint) before this. No
headache.

5) PAST MEDICAL HISTORY

This is the second time being admitted to hospital. First admission
was due to the same complaint. There is no significant medical illness
except that her mother has history of hypertension. Patient also does not
have any blood disorder like thalassaemia.
6) PAST SURGICAL HISTORY
No or never had operation before.
7) DRUG HISTORY
Before this she took pain killer which was prescribed to her from clinic
and currently she was not on any drug. During the sick period, she took
some alternative medicine like misai kucing herbal tea.
8) MENSTRUAL HISTORY
Puan Ruhani attained menarche at the age of 11 years old, lasted for
7 days in 30 days cycle. Her menses was regular and no delay in
menstruation. Patient was menopause at the age of 43 years old.
9) DIET HISTORY
She usually controls her daily diet intake by not taking fatty food
before and especially after she got sick.
10)

FAMILY HISTORY

Patient is married to 53 years old man and now she has 6 children
altogether. There was no similar illness in her family. No any significant
history of cancer identified.
11)

PERSONAL AND SOCIAL HISTORY

Puan Ruhani is currently living with her mother in a single wooden house
with 2 rooms in Rompin. The house is supply with tap water, electricity and flush
type toilet with good waste disposal system. Patient is a housewife. No history of
travelling and she is a non smoker.

PHYSICAL EXAMINATION

GENERAL EXAMINATION
Patient was conscious, alert and looks restless due to the abdominal
pain she was having. She looks lethargic and had mild dehydration. She
was not cyanosed or even in respiratory distress or tachypnoeic. There was
jaundice noted at the sclera and skin to the extant of her abdomen but no
clubbing noted. Pallor can be noted on the conjunctiva and palm. Presence
of flapping tremor can be demonstrated but only mild liver flap. There was
no presence of lymphadenopathy noted. There was no evidence of splinter
haemorrhage, duputyrens contracture, palmar erythema, parotid swelling
or koilonychia noted. Bilateral ankle edema can be noted in this patient.
VITAL SIGNS:
a) Blood pressure: 100/60 mmHg
b) Pulse rate

: 80/min

c) Respiratory rate

: 25/min

d) Temperature

: 37C

ABDOMINAL EXAMINATION
On inspection, the abdomen a little distended and moved with
respiration. The umbilical was centrally located and inverted. There was no
visible scar, spider nevi, hyperpigmentation, dilated veins or abnormal
pulsation seen.
On soft palpation, the abdomen was soft and tenderness was felt all
over the abdomen. There was no guarding or rebound tenderness. On deep
6

palpation, there was no mass but there was presence of hepatomegaly.

There was no splenomegaly and the kidney was not ballotable. Murphys
sign was absent.
On percussion, the liver span was about 3 finger breadth. Shifting
dullness was positive so mild ascites was noted.
On auscultation, bowel sound can be heard and was normal. No bruits
detected.
In per-rectal examination, on inspection of the anus, there were no
skin abnormalities, no anal fissure, no fistula, no ulcers, no masses, no
haemorrhoids and no fecal discharge noted. The anal canal was soft and
there is no tenderness or thickening over the border. The anal tone was
normal. For the rectum, the mucosa was mobile and non tender and it is
empty.

RESPIRATORY SYSTEM EXAMINATION

The respiratory rate was 25 per minute with no difficulty in breathing.
On inspection, the chest was symmetrical and of normal shape. It moved
with respiration and there was no use of accessory muscles. There were no
scars seen.
On palpation, chest expansion was normal and tactile vocal fremitus was
normal on both sides.
On percussion, both lungs were equally resonance.
On auscultation, vesicular breath sounds with normal air entry were
heard at both of the lungs. The lungs were clear with no crepitations or
abnormal sounds during respiration. The vocal resonance was normal on
both sides.

CARDIOVASCULAR EXAMINATION
The radial pulse was 80 beats per minute, regularly regular with normal

volume. All peripheral pulses were palpable, regularly regular and no radiofemoral delay.

The jugular venous pressure was not raised.

On inspection of the precordium, there was no obvious pulsation or any
bulging. There were no scars or pigmentation on the skin.
On palpation, the apex beat was at left 5th intercostals space,
midclavicular line and it was normal in character.
On auscultation, the first and second heart sounds were heard and
normal. There was no splitting of heart sounds, no murmur and no added
heart sounds were detected

HAEMATOPOETIC SYSTEM EXAMINATION

There was no petachiae or purpura noted on inspection. On palpation, there

was no any enlargement of occipital, pre & post auricular, cervical,

submandibular, axillary, epitrochlear and inguinal lymph node. There was also no
sternal tenderness.

MUSCULOSKELETAL SYSTEM EXAMINATION

No abnormality detected in this system. Gait & posture were both normal.

Vertebral spine was also normal. There was no limbs and long bones deformity or
tenderness. All joints are normal muscles showed no weakness, wasting &
fasciculation.

NERVOUS SYSTEM EXAMINATION

No abnormalities detected where. Mental status was normal muscle in

which patient was alert, orientated to visual and auditory stimuli and habituate to
various stimuli.
Motor functions elicit normal muscle tone with no spasticity and flaccidity
present. Triceps reflex was normal with no sustained ankle clonus.

SUMMARY

Pn Ruhani , 49 years old Malay lady complaint of generalized abdominal

pain since 8 months ago which associated with jaundice, abdominal distention,
loss of appetite, lethargic, loss of weight about 17kg in 8 months, passing tea
color urine and on and off fever. There was no night sweat, pale color stool or
constipation or diarrhea, no nausea and vomiting and there was no significant
family and social history.

PROVISIONAL DIAGNOSIS
Obstructive jaundice with cholecystitis secondary to pancreatic
tumor
Factor support

Constant generalize
abdominal pain

Factor Against

No abdominal mass

No association with

Jaundice

Abdominal distension

No pale stool

Loss of appetite and weight

Negative Murphys sign

Fertile, Female, forty

Tea color urine

On and off fever

eating

DIFFERENTIAL DIAGNOSIS
Differential

Factors support

Factors against

diagnosis
Obstructive

jaundice
secondary to
Periampullary
tumour

Constant generalize
abdominal pain

No abdominal mass

No association with

Jaundice

Abdominal distension

No pale stool

Loss of appetite and

Negative Murphys

eating

weight

Cholelithiasis

Tea color urine

On and off fever

Fertile,

Jaundice

sign

No history of
gallstone before

Generalize
abdominal pain and
constant.

Not associated with

food intake

Benign Stricture

Fever

Tea color urine

Fever

Jaundice

Loss of appetite and

weight

Ascending
Cholangitis

Fever

Tea color urine

Loss of appetite and

Chronic in onset

No history of

weight

Parasitic

Jaundice

Abdominal pain

Signs of obstructive

infestation

Chronic

jaundice

Fever

Chronic abdominal

Pancreatitis

travelling

Tea color urine

pain

Jaundice

Loss of appetite

Fever

10

INVESTIGATIONS
1) BLOOD TESTS
a. FULL BLOOD COUNT
Purpose

Result

To look for evidence of anemia (if any) and its type

To assess the white cell count for any infections.

Hb
TRBC
PCV
MCV
MCH
MCHC
Platelets
TWBC
WBC:
NEUT
LYMPH
MONO
EOSI
BASO
All results are within

:
:
:
:
:
:
:
:

10.5 g/d.L (L)

3.65
32.1 (L)
87.7 fL
28.7 PG
32.7 g/dL
615 x 109/L
17.65 x 109/L

: 77.6%
: 14.6%
: 6.3%
: 1.0%
: 0.5%
normal range, except for haemoglobin,

haematocrit, and white cell value. The reduction in

haemoglobin and haematocrit value may indicate anaemia
Commen

which is nomochromic and normocytic because MCV and

ts

MCH value are normal. This is manifested as pallor in the

patient. Increases in total white count indicate infection
occurs or sepsis and increase in neutrophil indicate
bacterial infection.

b. RANDOM BLOOD SUGAR

To detect any underlying disease such as diabetes
Purpose
Result
Commen
t

mellitus.
To evaluate patients blood sugar status
4.5 mmol/L
The blood sugar is in normal range of 3.9 6.1 mmol/L

c. LIVER FUNCTION TEST

Purpose

To look for causes of jaundice and also the severity of disease

11

Failed to copy the result from the case note. But the result
shows increase in all total, direct and indirect bilirubin.

Result

Normal result:
Total bilirubin
Direct bilirubin
Indirect bilirubin
Protein
Albumin
Globulin
Albumin to
globulin ratio
ALP
ALT
AST
ALP is a ductal enzyme and

:
:
:
:
:
:

0-20 umol/L
2.0-8.6umol/L
0.0-12umol/L
55-82g/L
35- 50g/L
20-35 g/L

: 1.0-2.2
: <129 u/L
: <45u/L
: 0-35u/L
increased in obstructive causes

of jaundice.
ALT and aspartate transaminase(AST) are hepatocellular
Commen
ts

enzymes, which are increased in hepatocellular dysfunction.

The result of liver function tests should never be interpreted
in isolation because severe obstructive jaundice can cause
hepatocellular failure.
Increase in all total, direct and indirect bilirubin indicate
obstructive cause of jaundice

d. SERUM AMYLASE
Purpose
Result

To assess the function and condition of the pancreas

To rule out pancreatitis

Not obtained
The serum amylase normally is in the range of 25 125 u/L.
An increase in amylase indicates pathology of the pancreas.

Commen

Acute pancreatitis may be a sequel of obstructive jaundice

due to a stone at the lower end of the common bile duct,

but chronic pancreatitis may also be the cause of bile duct
obstruction.

e. Other BLOOB TESTS

HEPATITIS SEROLOGY: check for hepatitis A, B and C.
Auto antibodies should be performed in suspected autoimmune
chronic active hepatitis and primary biliary cirrhosis.
12

COAGULATION FACTORS: PT, APTT INR

-

To show the effect of disease to the coagulation factors.

2) TUMOUR MARKERS
The marker CA19-9 is not specific and rises in both pancreatitis and
pancreatic carcinoma. If liver metastases are suspected, measurement of
other tumour markers, such as CEA for colon cancer, may be useful if the
primary is unknown.
3) URINALYSIS
Urine dipstick for bilirubin: if positive indicate hepatocellular
dysfunction (intrahepatic cholestasis) and duct obstruction (extra hepatic
cholestasis). Decrease markedly in the level of urobilinogen also indicates
obstructive or post hepatic cause of jaundice.
The presence of bilirubin in the urine demonstrates the presence of
conjugated bilirubin which is water soluble. Normally the urine has negative
bilirubin and positive presence of urobilinogen.
Jaundice without bilirubin in the urine is seen with:
-haemolytic jaundice
-Gilbert syndrome and Crigler Najjar syndrome.
Result not obtained from the case notes.
4) ULTRASONOGRAPHY
It is very useful in investigating jaundice. It can demonstrate any
dilated biliary ducts (intra and extrahepatic) associated with biliary
obstruction, common bile duct stones, architectural disturbance of liver
itself in association with liver parenchymal disease, metastases, pancreatic
swelling or masses.
Result: ultrasound or the hepatobiliary system was done on 29th
October 2009 and revealed that there was cholecystitis with cholangitis
probably secondary to worm, dilated and thickened cystic duct probably
secondary to chronic inflammation because of worm and there was also
multiple liver cysts.
Comments: there was no presence of stones based on the ultrasound
so this indicates that the obstruction was not due to stones. Probably there
13

was mass that obstruct the common bile duct. Dilated of biliary tree
indicate obstructive cause like stones or pancreatic tumour but in this case
there was no presence of stones detected.
5) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY( ERCP)
This investigation are use to demonstrate the presence of stones or tumour.
A shincterotomy can be performed to remove stones or a stent can be
inserted if there is tumour.
On 1st November 2009, ERCP was done and the results revealed that
there was growth in the ampulla, biliary stenting was done and biopsy was
taken. There was also dilated common bile duct, injected dirty bile and the
pancreatic duct was not cannulated.
On 2nd November 2009, the result of histopathological examination
(HPE) punch biopsy of the ampulla showed fragment of intestinal mucosa
with villous structures and few normal mucus glands. The lamina propia
was infiltrated by lymphoplasmacytoid cells and neutrophils. The
interpretation of punch biopsy of ampulla region was acute on chronic
inflammation.
Comment: these result showed that the lesion or obstruction was at
the ampulla of vater area. It may be just a benign stricture or even
ampullary carcinoma. But in the HPE, there was no malignant cells
detected just inflammatory cells. It may be in early development of the
cancer cells.
6) COMPUTED TOMOGRAPHY (CT) SCAN
CT is better than ultrasound for imaging the pancreas and contrasenhanced CT can provide good visualization of metastases. It also can
demonstrate other intra-abdominal malignanacies.
On 4th November 2009, CT scan was done and showed that there
were multiple hypodense liver lesions likely multiple liver cysts however
still cannot rule out metastasis or early abscesses. CT also revealed
cholecystitis with biliary dilation with stent in situ and vague hypodense
lesion of ampullary region appears more likely artefactnal however small
tumor is still a possibility. Ascites and bilateral pleural effusions were also
showed in the CT scan.
14

Comments: there were multiple liver cysts with unknown cause,

confirmed diagnosis of cholecystitis with biliary dilation due to tumour of
ampulla and presence of ascites and bilateral pleural effusions probably
due to hypoalbuminemia secondary to liver impairment.
7) ENDOSCOPIC ULTRASOUND (EUS) to evaluate benign and malignant
disease of pancreatobiliary tree.
EUS was planned on 17th November 2009, but it was made early on
10th November 2009. The result showed there was a lesion seen at the
periampullary region and it was irregular outlined. The common bile duct
was about 1cm and the gall bladder was dilated.
Comments: based on the result, confirmatory of lesion at the
periampullary region and biopsy must be planned to confirm whether it is a
tumour or not.
8) LIVER BIOPSY
When no extrahepatic cause for jaundice is found (i.e. there is no duct
dilation and no evidence of haemolysis) liver biopsy may be indicate the
cause of liver dysfunction or provide histological proof of metastatic
disease.
This investigation was not done to this patient.
Comments: biopsy must be taken to make sure that cysts at the liver
were not due to metastasis.

FINAL DIAGNOSIS
Obstructive jaundice with cholecystitis secondary to periampullary tumor.

MANAGEMENT AND PATIENT PROGRESS IN THE WARD

After admission, patient was having generalized abdominal pain. Upon
clerking, she was still having pain and intravenous Tramal was given to reduce
the pain. Besides that she was also given metronidazole to treat her fever. She
was also given intravenous human albumin 20% and tablet spironolactone to
treat hypoalbuminemia and ascites.

15

The jaundice and pain still persistent and on 1st November 2009, single
biliary stenting was done to relieve jaundice temporarily until the real underlying
cause was treated. After a week, patient was feeling well and do not experience
any pain. Her appetite also improved compare to before the admission and the
jaundice reduced a little.
She was discharged on 12th November 2009 with a planned operation on 3rd
December 2009 to take biopsy at the ampulla of Vater and laparotomy was also
planned. If there is growth, it will be resected and then proceed to Whipples
operation.

DISCUSSION
As the patient was diagnosed to have obstructive jaundice with
cholecystitis secondary to ampullary tumor, the discussion are based on
obstructive jaundice, ampullary tumour or ampullary carcinoma and Whipples
operation.
Obstructive Jaundice
The Normal Enterohepatic Circulation
Haem of spent red cells is normally broken down to bilirubin and bound to
albumin and transported to liver. The bilirubin is conjugated with glucuronic acid
in liver to become water soluble. Then the protein-pigment complex is converted
in the gut to urobilinigen and urobilin by bacterial action. This product of
conjugation is also water soluble. Some urobilinogen reabsorbed and returned to
liver via portal blood. In the intestine, urobilin turns faeces into brown color but
this step does not occur in obstructive jaundice thus producing pale stools. If the
bile ducts are obstructed, conjugated bilirubin reaches high blood levels and is
excreted in urine producing dark urine high in bilirubin.
Pathophysiology of Obstructive Jaundice
If biliary outflow becomes obstructed, conjugated bilirubin is dammed back
in the liver and enter the blood thus causes a gradual increase inplasma bilirubin.
Once it exceeds 30mol/L, jaundice should be clinically detected and about
60mol/L, jaundice is obvious. The conjugated bilirubin is water soluble and got
excreted in the urine thus turning it dark.

16

When there is diminished excretion of bile into the intestine, it causes less
urobilin to darken the stool and fewer bile acids, resulting to defective fat
absorption. Lack of both things lead to putty color stool. Together with defective
in fat absorption, there is malabsorption of vitamin K which eventually leads
decreased hepatic synthesis of clotting factors, notably prothrombin. The patient
coagulation profile must be checked before any invasive procedure. The
coagulopathy is corrected by parenteral vitamin K or if urgent give fresh frozen
plasma. Itching can also occurs due to bile acids accumulate to the body.
History and Examination
History: has episodes of pain typical of gallstone disease, previous episodes of
obstructive jaundice which resolve spontaneously, or previous biliary tract
surgery, previous attack of acute pancreatitis. Besides that, important points:
-

Change in color of urine and stools

Drug history

Risk factor of viral hepatitis : blood transfusion, intravenous drug

abuse, tattoo

Alcohol intake

Symptoms associated with malignancy

History of inflammatory bowel disease predispose to sclerosing

cholangitis.

Examination
-jaundice
-some develop pruritus, and scratch marks may be apparent.
-General stigmata of liver disease presence when primary liver disease.
Besides that, on abdominal examination, enlarge liver may be caused by primary
or secondary malignancy while splenomegaly with hepatomegaly is an important
sign of chronic parenchymal disease and indicates portal hypertension. Ascites is
almost always due to disseminated intra abdominal malignancy.
Courvoisiers Law states that in the presence of jaundice if the gallbladder
is palpable then the jaundice is unlikely to be due to a stone because the
gallbladder is usually shrunken and fibrotic with gallstones. The exception to this
rule is a stone stuck in Hartmans pouch with another stone in the common bile
duct. In malignancy, progressive obstruction occurs over a short period and the
gallbladder distends easily.
17

On rectal examination, pale color stool is characteristic of obstructive

jaundice. The urine color is usually dark yellow or orange from the presence of
conjugated bilirubin and froths when shaken due to the detergent effect of bile
acids
Causes of obstructive jaundice
1) Stones in common bile duct( common)
2) Carcinoma of head of pancreas (common)
3) Pancreatitis ( uncommon)
4) Mirizzis syndrome ( rare)
5) Periampullary malignant tumours ( uncommon)
6) Benign strictures of the common bile duct ( uncommon)
7) Other malignant tumours( rare)
8) Intrahepatic or hilar bile duct obstruction eg. Primary cholangiocarcinoma,

sclerosing cholangitis( rare)

9) Intrahepatic cholestasis( common)
Principles of management of obstructive jaundice
Treatment of Jaundice
Jaundice is treated by the usage of stent for inoperable malignant tumours.
If it was caused by gallstones, remove it by ERCP. Besides that, laparoscopic or
open cholecystectomy with common bile duct exploration can also be done to
manage the jaundice.
Three categories of obstruction may be defined according to surgical treatment
options:
-

Potentially curable obstructions

Obstruction due to incurable tumour

Terminal disease

Potential curable obstructions:

Bile duct stones, stricture, small tumours of lower bile ducts, duodenum or
ampullary region ( periampullary tumours). Stones can be removed at ERCP by
dividing the ampullary sphincter using a bow string diathermy wire via the
duodenal endoscope. Small tumours in the periampullary region may be
amenable to complete excision, so relieving biliary obstruction. Adenocarcinoma
18

of head of pancreas has poor long term prognosis even after a successful radical
pancreaticoduodenectomy.
Obstruction due to incurable tumour
Commonly due to carcinoma of the head of pancreas, less often with lymph node
metastasis in the porta hepatis and rarely from carcinoma of gallbladder. Trend
now is to go for palliative like stenting. Endoscopic stent placement : the
sphincter of Oddi may require a preliminary endoscopic shincterotomy prior to
intubation.a self-retaining plastic stent, placed endosopically or percutaneously,
lies in situ across the biliary stricture. The pig tail ends of this type of stent
which curls up when the wire is removed, retaining the stent in the correct
position.
The alternative is bypass surgery and triple bypass for carcinoma of head
of pancreas as the classic palliative treatment. Triple bypass operation involves
first gastro-jejunostomy to bypass duodenal obstruction, second cholecystojejunostomy to bypass obstructed common bile duct and lastly jejunojejunostomy to divert food away from biliary tract. Percutaneous celiac ganglion
blockade provides effective palliation for intractable pain.
Terminal disease
When patients have reached a terminal stage of their cancer, stenting may
still be indicated but surgical interference may be difficult to justify. The aim is to
relieve distress and allow a dignified death. Severe itching can be lessened by
drugs like antihistamines or chlorpromazine.
Complication of Obstructive Jaundice
Before any invasive procedure, precaution should be taken to prevent
complication of obstructive jaundice like:
-

Cholangitis- infection manifest as rigors, pyrexia and hypotension.

Renal failure precipitated by septicemia and also endotoxin

absorbed from the bowel and their reduced hepatic clearance.
Endotoxin can cause acute tubular necrosis and peritubular fibrin
deposition.

Disseminated intravascular coagulation

Delayed wound healing and gastrointestinal haemorrhage.

19

To prevent any of above, patient need to be maintained renal perfusion.

Abnormal clotting is corrected by administering vitamin K and other clotting
factors. Administration of oral lactulose decreases the risk of endotoxaemia. Any
infection is treated and prophylactic intravenous antibiotics are given before an
invasive procedure.
Periampullary tumour
Occasionally a small periampullary tumour presents early with obstructive
jaundice. An unusual part of spectrum of periampullary lesions is
adenocarcinoma arising at the ampulla of Vater. Here it forms a polypoid lesion
projecting into the duodenum and obstructing biliary drainage causing jaundice.
The tumours are friable and tend to bleed persistently, giving a positive result for
fecal occult blood testing. An association of intestinal polyposis syndromes has
been described.
Diagnosis is made at endoscopy where the tumour is visible and accessible
to biopsy. Very rarely, adenocarcinoma arises in the duodenal mucosa itself and
causes obstructive jaundice if situatedclose to the ampulla. An ERCP may
demonstrate a periampullary tumour and enable biopsies to be taken from it or
brush cytology from the pancreas. Tumour markers such as CA19-9 allow disease
progress to be assessed. Periampullary tumours may be small and resectable by
a pancreaticoduodenectomy (Whipples operation). The prognosis of these
tumours is better and 50% of patients are alive at 5 years.
Whipples procedure
The distal stomach, duodenum, common bile duct and the head of pancreas are
removed. The stomach, pancreas and proximal common bile duct are then joined
to a loop of jejunum. Operative morbidity and mortality are similar to the
operation of pancreatic cancer, but prognosis is often better because the
obstructing tumour is usually still small, with less extensive local and regional
spread.
REFERENCES

20

1) Browse s Introduction to the Signs and Symptoms of Surgical

Diseases, Fourth Edition. By John Black , William Thomas, Kevin
Burnand, Sir Norman Browse.
2) Crash Course Surgery, 2nd edition. By Helen Sweetland, Kevin
Conway, James Cook.
3) Essential Surgery problems, Diagnosis and Management, 4th
Edition. By H. George Burkitt, Clive R.G Quick, Joanna B. Reed.

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