CT of the abdomen and pelvis revealed a mass within the pancreatic head and uncinate process, most likely representing pancreatic neoplasm. There was mass effect noted with resultant mild intrahepatic and extrahepatic biliary duct and pancreatic duct dilatation. Also evidence of pancreatitis likely secondary to pancreatic tumor.
The patient's lipase level returned >2400
A subsequent endoscopic retrograde cholangiopancreatography (ERCP) revealed a dilated common bile duct and pancreatic duct but no significant intrahepatic biliary dilation. With ultrasound a hypoechoic 24 X 23 mm mass was seen in the head of pancreas with upstream dilation of both ducts. Vessels looked clear of the mass. Small amount of ascites noted. Small peritumor lymph node seen.
Preliminary diagnosis by fine needle aspiration of the mass suggested neoplasm.
Final biopsy results: pancreatic adenocarcinoma.
The patient was discharged on hospital day 3 with follow up with gastroenterology and oncology.
Pancreatic Cancer
Background
- 4th most common cause of cancer-related death in the United States
- Ductal adenocarcinomas account for 95% of malignant pancreatic tumors
- Pancreatic head involved in 70% of cases
- Especially lethal --> 5-year survival rate < 5%
- Few early symptoms --> most patients diagnosed late
Risk Factors
- smoking
- advanced age
- high fat diet
- positive family history
Presentation
- constant dull pain in the epigastrium
- weight loss (more due to anorexia than malabsorption)
- painless jaundice (75% of patients)
- enlarged palpable painless gallbladder = Courvoisier's sign
- glucose intolerance progressing to diabetes
- migratory inflammatory thrombophlebitis = Trousseau's sign of malignancy
Diagnosis = CT
Management
- complete resection = only effective treatment
- few tumors (<20%) diagnosed early enough for curative surgical therapy
- complications presenting to the ED
- bowel obstruction
- jaundice
- problems with pain control --> do not withhold narcotics
- consult oncology to address end-of-life issues
References:
Hemphill RR, Santen SA, Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 91: Disorders of the Pancreas
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