The Curious Case of John Dick

1. The Curious Case of John Dick Group 3 Clinical Clerk Batch 2012 SY 2011-2012

2. 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

3. Identifying Data • L.S. • 64-year-old • Widow • Vegetable vendor • Tondo, Manila

4. Chief Complaint Generalized jaundice of 1 month duration

5. Temporal Profile Weight loss Loss of appetite Tea-colored urine Colicky Abdominal Pain Jaundice 6 mos PTA 4 wks PTA 2 wks PTA 1 wk PTA 4 days PTA Admission

6. 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

7. 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

8. 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

9. Physical Examination

10. Physical Examination

11. Physical Examination

12. Pertinent Findings

13. Pertinent Findings

14. Assessment • Primary Impression • Obstructive Jaundice secondary to Pancreatic Head Mass • Differential Diagnoses: • TB Lymphadenitis • Peribiliary cancer • Choledocholithiasis

16. Excessive intake of carotene containing food such as carrots, leafy vegetables, squash, peaches, and oranges Yellowish discoloration concentrated on palms, soles, forehead & nasolabialfolds

17. Excessive intake of carotene containing food such as carrots, leafy vegetables, squash, peaches, and oranges Yellowish discoloration concentrated on palms, soles, forehead & nasolabialfolds

18. Uniformly distributed in skin and icteric sclera Intake of quinacrine or rifampicin

19. Uniformly distributed in skin and icteric sclera Intake of quinacrine or rifampicin

21. (-) Murphy’s sign (-) fluid wave, bulging flanks and shifting dullness (-) spider angioma and caput medusae (-) Hepatomegaly (liver span = 9 cm) (-) splenomegaly (+) Jaundice (+) Tea-colored urine (+) yellow discoloration of the skin (+) Ictericsclerae

22. Ssx of anemia (pallor, fatigue, weakness, dizziness, confusion, shortness of breath, and potential for heart failure) • Usually normal colored urine and stool • jaundice, splenomegaly, hepatomegaly, tachycardia, murmur • If inherited symptoms should have been present at an earlier age

26. (-) spider angioma and caput medusae (-) Hepatomegaly (liver span = 9 cm) (-) fluid wave, bulging flanks and shifting dullness (-) splenomegaly

29. Primary Impression Obstructive jaundice secondary to Pancreatic head mass r/o pancreatic ductal adenocarcinoma

30. Pancreatic 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%

31. 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)

32. 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

33. Diagnosis and staging • 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.

34. Pancreatic Adenocarcinoma • 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.

35. 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