Abstract
Jaundice is a symptom and sign of yellowing of the skin, mucous membranes and sclera due to elevated bilirubin in the serum. Depending on the cause, it can be classified as hemolytic jaundice, hepatocellular jaundice and obstructive jaundice. Jaundice caused by obstruction of the biliary tract inside or outside the liver from various causes often requires surgical intervention, and is therefore often referred to clinically as “surgical jaundice”. Because of the complexity of the causes of jaundice, clinical management is often difficult. In this case, we analyze the diagnosis and management of a patient with obstructive jaundice caused by adenoma of the lower bile duct and ectopic pancreas in the duodenal papilla, so that students can understand the pathophysiological changes in jaundice, the differential diagnosis of jaundice, what non-invasive and invasive tests are available, how to read the relevant imaging data, and how to determine and optimize the surgical plan. This case features both a systematic review of the relevant basic knowledge and a thorough introduction to the current standardized diagnostic and treatment procedures and treatment options for the disease.
【Introduction
Clinically, there are many causes of jaundice, and the pathophysiological processes involved in the development of jaundice are complex; an accurate and timely diagnosis is important for the selection of treatment options. In recent years, with the advancement of imaging technology, the means for diagnosis and differential diagnosis of obstructive jaundice have become increasingly abundant, but for various reasons, it is still difficult to obtain an accurate diagnosis in some patients before surgery. We analyzed the diagnosis and treatment of a patient with obstructive jaundice caused by adenoma of the lower bile duct and ectopic pancreas in the duodenal papilla, hoping to enable students to grasp the standardized diagnosis and treatment process of surgical jaundice.
【Case】.
● Scenario 1 (Introduction of relevant information materials 5 min).
General information: patient, male, 64 years old, Han nationality, married, origin Wuhan, Hubei Province, retired.
1. Complaint: epigastric pain with intermittent vomiting for 1 month, yellow sclera of skin for half a month
2. Present medical history: right upper abdominal pain with no obvious cause appeared one month ago, which is persistent and worsens after eating fatty food; intermittent nausea and vomiting; no fever, no abdominal distension and diarrhea. After anti-inflammatory and antispasmodic treatment in a community hospital, the abdominal pain improved slightly; half a month ago, he developed yellow staining of the skin and sclera, with progressive deepening, accompanied by itchy skin, yellow urine, and normal stools. He came to our hospital accompanied by his family.
3. Past history: In 1999, he was treated conservatively by internal medicine for gastric bleeding, and in 2009, he was examined and found to have gallbladder stones, intrahepatic bile duct stones and hepatic hemangioma, which were not treated. No history of drug allergy or surgical trauma.
4. personal history: born and raised and worked in Wuhan for a long time, no history of exposure to epidemic water and toxic radiation, regular diet. Smoking 30 cigarettes per day for about 50 years, no drinking habits.
5. Family history: parents have passed away, cause of death is unknown. He has 3 children and is physically fit. Denies family history of hereditary diseases, other similar diseases and infectious diseases.
● Discussion.
1 What are the clues in the medical history that could help the diagnosis? List and rank the possible diagnoses; (5 minutes)
2 What other medical history do you think needs further refinement? (5 minutes)
3 What should you focus on during the next physical examination? (5 minutes)
● Scenario 2 (presentation of relevant information material 5 min).
6. Physical examination.
Body temperature: 37.8°C Pulse: 83 breaths/min Respiration: 21 breaths/min Blood pressure: 163/75 mmHg.
Normal development, moderate nutrition, clear consciousness, spontaneous expression, and cooperative examination. The skin and sclera were yellowish, no bleeding spots or petechiae, no liver palm or spider nevus, and no obvious enlargement of superficial lymph nodes all over the body. The neck was soft, the jugular vein was not angry, the carotid artery pulsation was normal, the bilateral thyroid glands were not enlarged, the thorax was not deformed, the respiratory motion was normal, there was no pleural friction, the percussion of both lungs was clear, the respiratory sounds were clear, there was no obvious dry or wet woven P that was confused with the confluence ∑Sheng collection of the hemorrhagic 7 segments ВM 83 times/min, the rhythm was still neat. The abdomen was flat and soft, no gastrointestinal type or peristaltic wave was seen, and there were no varicose veins in the abdominal wall. There were no obvious pressure points in the abdomen, no obvious masses were palpated, the liver and spleen were not palpated under the rib cage, Murphy’s sign (-), abdominal percussion was bulging, mobile turbid sounds (-), and there was no obvious percussion pain in both kidney areas. The physiological reflexes of both lower limbs were present and the pathological reflexes were not elicited.
7. Outpatient information.
2009/06/25 External ultrasound suggested: acute cholecystitis, gallbladder stones, hepatic hemangioma, intrahepatic bile duct stones.
2010/04/06 Outpatient blood biochemistry results.
TBIL 206.8μmol/L ↑ (0-25μmol/L), DBIL 140.70μmol/L ↑ (0-7μmol/L )
IBIL 66.10μmol/L ↑ (1.5-18μmol/L), TBA 338.59μmol/L ↑ (0-15μmol/L).
Urinalysis: urinary bilirubin ++, urinary bilirubin ++, hepatitis B marker test: anti-HBS +
● Discussion.
1 What clues to the diagnosis do the physical examination findings and outpatient information provide? Is there a need to reorder the diagnoses above? (5 minutes)
2 List the possible causes for the presence of jaundice; (10 min)
3 To further clarify the diagnosis, what additional ancillary tests will be required for this patient after admission? (5 minutes)
Break 10 minutes
● Scenario 3 (presentation of relevant information materials 5 min)
8. Results of various tests after admission.
2010/04/07
Blood routine: normal; stool routine: normal; urine routine: urine bilirubin: 2+
Coagulation function: PT 9.5S↓; INR 0.82↓, the rest of the results are normal range.
Blood biochemistry: ALT 89U/L ↑, AST 59U/L ↑, GGT 65U/L ↑, TBA 89.2μmol/L ↑, TBIL 193.6μmol/L ↑.
TBIL 193.6μmol/L↑, DBIL 103.0μmol/L↑, IBIL 90.6μmol/L↑
Hepatitis B markers and syphilis antibodies: all negative
Ultrasound of abdomen: substantial intrahepatic mass? (hemangioma?) ; intrahepatic bile duct stones;. Gallbladder enlargement (inflammatory changes);. Gallbladder stones with abnormal echogenicity of the gallbladder wall (calcified spots);. Widening of the internal diameter of the common bile duct (1.0 cm)
Chest x-ray: no abnormalities seen
Electrocardiogram: normal electrocardiogram
2010/04/09
MRI+MRCP of upper abdomen: small cyst or hemangioma in the right lobe of the liver; obstruction of the lower part of the common bile duct with mild dilatation of the intrahepatic bile duct; enlarged gallbladder with abnormal signals in the gallbladder considered as stones; mild dilatation of the pancreatic duct.
2010/04/15
ERCP examination showed that the duodenal bulb was deformed and narrowed, and the endoscope could not enter.
● Discussion.
1 Based on the current data, is it possible to make a definitive diagnosis of the patient? If yes, what is the basis? If not, what are the reasons? (5 minutes)
2 Is there any other aspect of the examination and treatment that needs to be done and why? (5 minutes)
3 What are the possible treatment options for this patient? What is the preferred option? What are the reasons? (5 minutes)
4 What other preoperative preparations are needed? What aspects should be taken care of during the operation? (5 minutes)
Scenario 4 (presentation of relevant information 5 min).
9. Intraoperative findings.
The liver was found to be jaundiced, the gallbladder was significantly enlarged, about 10 cm × 5 cm × 3 cm, and the common bile duct was thickened, about 1.2 cm in diameter; a mass of about 1 cm × 1 cm × 0.8 cm in the abdomen of the duodenal jug was palpable and hard, and the portal vein, superior mesenteric artery, and inferior vena cava were not invaded; other organs in the abdomen were found to be free of abnormalities. The decision to perform “pancreaticoduodenectomy + jejunostomy” was made during the operation. The operation went smoothly, and the patient was admitted to ICU for postoperative monitoring.
10. Post-operative pathology report (21003480).
The ectopic pancreas in the duodenal papilla, adenoma in the lower part of the common bile duct, chronic cholecystitis, and no abnormalities in the tissue of the duodenal section.
● Discussion.
1 Do the intraoperative findings coincide with the preoperative diagnosis? If there is deviation, what is the reason? (5 minutes)
2 Was the choice of surgical plan reasonable? (5 minutes)
3 What are the areas that need improvement during the consultation and treatment of this patient? (5 minutes)
Summary】
In this case, the patient had right upper abdominal pain as the first symptom and then jaundice; the cause of obstruction was not clearly identified by preoperative ultrasound, MRCP and other imaging examinations; further ERCP examinations were performed but were unsuccessful, and tissue biopsy could not be taken under direct vision to clarify the nature of the mass, so the cause and specific site of obstruction could not be determined preoperatively, and only a dissection was performed to clarify the cause and relieve the obstruction. Since ectopic pancreatic and lower bile duct adenomas in the duodenal papilla are uncommon, it is often difficult to obtain accurate diagnosis by imaging means alone before surgery. If preoperative benign lesions can be confirmed, local resection of jugular tumor with duodenal papilloplasty may be less traumatic than pancreaticoduodenectomy. Therefore, for patients with unexplained obstructive jaundice, duodenoscopy and, if necessary, tissue biopsy are important for the determination and optimization of treatment plans.
In this case, we analyze the diagnosis and treatment of a patient with obstructive jaundice caused by adenoma of the lower bile duct and ectopic pancreas in the duodenal papilla, so that students can grasp the pathophysiological changes in jaundice, the differential diagnosis of jaundice, what tests are available, the characteristics of the relevant imaging data, and how to determine and optimize the surgical plan. This case features both a systematic review of the relevant basic knowledge and a thorough introduction to the current standardized diagnostic and therapeutic procedures and treatment options for the disease.
【Figures and figures attached
Figure 1 The results of ultragraphy preoperative (Figure 1 The results of ultragraphy preoperative)
The preoperative ultrasound showed intrahepatic bile duct stones (1a); hepatic hemangioma (1b); gallbladder enlargement (inflammatory changes); gallbladder stones and abnormal echogenicity of the gallbladder wall (1c).
Figure 2 The results of MRCP preoperative and postoperative (Figure 2 The results of MRCP preoperative and postoperative)
The preoperative MRCP showed obstruction of the lower bile duct and mild dilatation of the intrahepatic bile duct, enlargement of the gallbladder, and mild dilatation of the pancreatic duct (2a). The postoperative MRCP showed that the bile-intestinal anastomosis was open and the pancreatic duct was still dilated (2b).
Figure 3 The results of ERCP preoperative (Figure 3 The results of ERCP preoperative)
ERCP examination suggested that the duodenal bulb was deformed and narrowed, and the endoscope could not enter (3a,3b,3c)
Figure 4 The results of pathology postoperative (Figure 3 The results of pathology postoperative)
The postoperative pathology reports were ectopic pancreas in the duodenal papilla (4a), adenoma of the lower bile duct (4b), and chronic cholecystitis (4c)