Patient has obstructive jaundice due carcinoma of head of pancreas

1. A 56 years old female presented with jaundice
Dr. S.M.Arafat
Registrar,department of Hepatology,
Faridpur Medical College Hospital,
Faridpur

2. Particulars of the patient
• Name: Mukta Begum
• Age:56 years
• Sex: Female
• Religion: Muslim
• Marital status: Married
• Address: Madhukhali, Faridpur
• Date of admission: 26th
April, 2025
• Date of examination: 26th
April, 2025

3. Chief complaints:
• Yellow discoloration of eyes and urine for 3 weeks
• Generalized itching for same duration

4. History of present illness
According to the statement of the patient, she was reasonably well about 3
weeks back. Then she developed yellow discoloration of eyes and urine which
was increasing day by day and not associated with any prodromal features like
anorexia, nausea & vomiting. There was no history of intake of contaminated
water or street food.
She also complained of generalized itching which was more marked at night &
interferes with her sleeping . Her stool is pale colored, voluminous &
occasionally mixed with mucus but not mixed with blood.
She also noticed that a constant dull aching pain at upper abdomen not related
with food intake and relieved after taking meditation.
.

5. History of present illness (Continue)
On query she gave history of loss of weight which is not documented but
evidenced by loosening of her cloth.
She has no previous history of fever, Jaundice ,blood vomiting, passage of
black tarry stool, altered behavior, abdominal distension, blood transfusion,
IV drug abuse, any surgery and sexual exposure.

6. History of past illness:
• No significant past illness present.

7. Treatment/drug history
• Patient received various medications for her illness from local pharmacy but couldn’t
mention their name. There is no history of taking herbal medications.

8. Personal history
• She is non-smoker and non alcoholic but used to chew betel nuts for a long period.

9. Socioeconomic history
• She used to be a housewife and lives with her son who earns around 30k per month.
She drinks arsenic free deep tubewell water.

10. Family history
• Her parents and 5 siblings are all healthy. She has 1 son and 1 daughter, both are
healthy. She doesn’t have any family history of liver diseases.

11. Menstrual/Obstetric history
• She is amenorrheic for about 8 years.
• She has two children, both were conducted by NVD and those procedures were
uneventful.

12. Immunization history
• She is not immunized as per EPI schedule, she received three doses of COVID-19
vaccines.

13. Travel history
• No recent travel history present.

14. General examination
• Appearance:Ill looking
• Bodybuilt: Below Average
• Nutrition: Average
• Decubitus: On choice
• Anaemia: Mild
• Jaundice: Present(deep)
• Cyanosis: Absent
• Clubbing: Absent, nail is shiny
• Koilonychia: Absent
• Leukonychia: Absent

15. General examination
• Oedema: Absent
• Dehydration: Absent
• Pigmentation and scratch mark: scratch marks are present all over the body more on
the extensor surface of leg and forearm,no pigmentations
Lymphnode: No lymphadenopathy
• Thyroid gland: Not enlarged
• Bony tenderness: Absent
• Pulse: 80beats/min
• BP: 130/70 mmHg
• Temperature: 99 degree F
• Respiratory rate: 16 breaths/min

16. Systemic examination
• Gastrointestinal system:
• Mouth ans oral cavity: Yellow tinge on ventral surface of tongue.
• Abdomen
• Inspection
• Shape of the abdomen: normal in shape, no distension
• Movement: No visible peristalsis is seen
• Umbilicus is centrally placed and inverted
• Multiple Scratch marks are seen
• No visible veins, pigmentations seen.

17. Continue
Palpation :
• Liver is enlarged about 4cm from right costal margin along the mid clavicular line,
firm in consistency with smooth surface, sharp margin, non tender. Upper border of
liver dullness is in the right fifth intercostal space in midclavicular line.
• Gall bladder is palpable, smooth surface and non tender
• Spleen is not palpable.
• Hernial orifices are normal on cough impulse
• Per rectal examination not done.

18. Continue
 Percussion:
Percusssion note is resonant all over the abdomen.
Shifting dullness is absent.

19. Continue
 Auscultation:
Normal bowel sound and there is no added sounds/bruit/rub

20. Other system examination:
• Respiratory, Cardiovascular, Nervous ,Musculoskeletal & other system
examination reveals no abnormalities

21. Salient feature
Mrs Mukta Begum, 56years old non diabetic, non hypertensive lady hailing from
Madhukhalu, Faridpur was admitted in female Hepatology ward, FMCH, with the
complaints of yellow discoloration of eyes and urine which was increasing day by day
and not associated with any prodromal features like anorexia, nausea & vomiting. There
was no history of intake of contaminated water or street food.
She also complained of generalized itching which was more marked at night &
interferes with her sleeping . Her stool is pale colored, voluminous & occasionally
mixed with mucus but not mixed with blood.
She also noticed that a constant dull aching pain at upper abdomen not related with
food intake and relieved after taking meditation.

22. Salient feature
She also noticed that a constant dull aching pain at upper abdomen not
related with food intake and relieved after taking meditation.
On query she gave history of loss of weight which is not documented but
evidenced by loosening of her cloth.
She has no previous history of fever, Jaundice ,blood vomiting, passage of
black tarry stool altered behavior, abdominal distension, blood transfusion,
IV drug abuse, any surgery and sexual exposure.

23. Salient feature
On general examination she is anaemic and icteric, deep jaundice is
present,have shiny nails and scratch marks all over her body.
On examination of abdomen there is hepatomegaly of about 4cm from right
costal margin along the midclavicular line.Upper border of liver dullness is
in 5th
intercostal space in midclavicular line. Gall bladder is palpable. Other
system examination reveals no abnormalities.

24. Provisional diagnosis
???

25. Provisional diagnosis
Obstructive jaundice most probably due to periampullalry carcinoma
carcinoma of head of the pancreas.
Distal cholangiocarcinoma.
Carcinoma ampulla of vater.
Duodenal growth.

26. Differential diagnosis
Choledocholithiasis.
Carcinoma Gall bladder with billiary invasion.
Acute viral hepatitis in cholestatic phase.

27. Investigations
• CBC with ESR:
• Hb:9.6gm/dL
• WBC:10400/mm3
• Neutrophil:63%
• Lymphocyte:31%
• Eosinophil:4%
• Monocyte:2%
• Basophil:0%
• Platelet:3,21,000/mm3
• MCV: 80.1 fL (83-101)
• MCHC:31.5 g/dL(31.5-34.5)
• MCH: 24.8 pg(27-32)
• ESR:50 mm in 1st
hour

28. Investigation:
S.creatinine: 0.92 mg/dL

29. Investigation:
• S.bilirubin: 10.6>23 mg/dL
• S. ALT: 77U/L
• S.ALP: 787 U/L
• PT: 19.3(INR-1.36)
• Anti HAV IgM:Negative
• Anti HEV IgM: Negative
• HBsAg: Negative
• Anti HCV: Negative
• Anti Hbc(total): Negative

30. Investigation:
•USG of whole abdomen:
 Mildly Enlarged liver with dilated intrahepatic and
extrahepatic biliary channels
 GB is distended
 MPD dilated

31. Investigations:
• Endoscopy of upper GIT:
• Erosive gastritis

32. CXR P/AView :

33. MRCP:

34. MRCP

35. MRCP

36. MRCP

39. CT scan of abdomen

40. CT Scan of abdomen:

41. CT Scan of abdomen

42. CT Scan of abdomen

43. CT Scan of abdomen

44. CT Scan of abdomen

45. CT Scan of abdomen

46. Investigation:
• CA 19-9: 14,515 U/mL(<35)

47. Our patient:

48. Our patient:

49. Confirmatory diagnosis:
• Obstructive jaundice due to carcinoma of head of the
pancreas.

50. Management
• Diet : Normal.
• Tab. Ursodeoxycholic acid(300) -1+0+1 (A/M)
• Tab. Domperidone(10)-1+1+1 (B/M)
• Inj. Vitamine K -1 amp. I/V daily for 3 days.
• Tab. Tiemonium Methylsulphate – 1+1+1
We consulted with surgery & oncology department for further management.
We also had plan to consult with department of Gastroenterology, but eventually
patient was migrated to Dhaka.

51. .
Thank You