Obstructive Jaundice in Patients with Pancreatitis: A Case Study of Seven Patients, Study notes of Medicine

Download Obstructive Jaundice in Patients with Pancreatitis: A Case Study of Seven Patients and more Study notes Medicine in PDF only on Docsity! Obstructive Jaundice in Patients With Pancreatitis Without Associatedl Biliary Tract Disease WILLIAM B. McCOLLUM, M.D., PH.D., PAUL H. JORDAN, JR., M.D. Jaundice occurring in patients with pancreatitis is usually due to hepatocellular injury or to associated biliary tract disease. Com- mon duct obstruction is occasionally caused by pancreatic fi- brosis, edema or pseudocyst in patients who have neither hepatocellular injury nor biliary tract disease. We have studied 7 patients with obstructive jaundice du& to pancreatitis who dem- onstrated no other known cause for jaundice. The difficulty in making the differential diagnosis between benign and malignant disease in these patients, particularly when no pain is associated with obstructive jaundice, is discussed. In view of the fact that the terminal common duct traverses the pancreas, it is uncertain why obstructive jaundice associated with chronic pancreatitis does not occur more often unless the condition is sometimes transient and overloQked. Operative intervention is required in those patients in whom jaundice is persistent. Operation is intended to decompress the biliary tract and the pancreas. The approach used will be dictated by the operative findings in each patient. A PPROXIMATELY 20% of patients with pancreatitis have jaundice. Jaundice associated with pancreatitis in the absence of choledocholithiasis usually is related to hepatocellular involvement; however, the coexistence of obstructive jaundice and pancreatitis is a recognized phenomenon. The 7 patients presented in this paper (Table 1) dem- onstrate the problem of jaundice due to common duct obstruction caused by various forms of pancreatitis in the absence of choledocholithiasis. The judgment made at operation as to whether jaundice is due to obstruction by chronic pancreatitis or cancer involving the head of the pancreas is a critical decision but less so when the patient has pancreatic pain for then a Whipple resection is equally good treatment for both types of disease. On the other hand, the therapeutic decision is more difficult Submitted for publication March 21, 1975. This study was supported in part by Grant GM01965-06 from the United States Public Health Service. All correspondence to: Paul H. Jordan, Jr., M.D., 1200 Moursund Avenue, Houston, Texas 77025. From the Surgical Services of the Cora and Webb Mading Department of Surgery, Baylor College of Medicine and the Veterans Administration Hospital, Houston, Texas when jaundice is painless, for pancreaticoduodenectomy is unnecessary and undesirable therapy for benign pan- creatic disease whereas it is the indicated procedure for carcinoma of the pancreas. Chronic Pancreatitis Case 1. F. E. was a 53-year-old man. For 3 weeks he had had anorexia, nausea, vomiting, acholic stools, minimal epigastric discomfort, and a 20 pound weight loss. He was a heavy alcohol inbiber. He was afebrile. The abdomen was distended, non-tender, and the liver was enlarged. The total serum bilirubin was 15.5 mg %. At operation, the entire pancreas was hard; the head was enlarged; the pancreatic duct was not palpable. The common duct measured 2cm in width. The gallbladder was distended, contained no stones, and was not inflamed. The paraduodenal lymph nodes showed only inflamma- tory changes and pancreatic biopsy revealed fibrosis. The body and tail of the pancreas were resected and a pancreaticojejunostomy and cholecystojejunostomy were performed using a Roux-en-Y loop of jejunum. His jaundice did not recur but he died 3 months later with widespread metastatic carcinoma of the pancreas. The pancreas re- moved at operation revealed chronic pancreatitis and no cancer. Comments: Severe jaundice and diabetes were the first manifestations of this patient's pancreatic disease. Six weeks after noting jaundice and other vague symptoms he underwent exploratory laparotomy. Gross and mi- croscopic examinations were consistent with chronic pan- creatitis. Painless chronic pancreatitis has been em- phasized by Goulston* and is usually discovered after the onset of steatorrhea, pancreatic calcification or diabetes; or at the time of autopsy. Painless chronic pancreatitis presenting primarily because of jaundice is rare but has been reported by Weinstein and his collaborators.6 All the evidence in this patient suggested the diagnosis of pancreatitis rather than cancer. Our objective at opera- 116 Vol. 182 * No. 2 OBSTRUCTIVE JAUNDICE 117 TABLE 1. Patient Summaries Operative Operative Postoperative Case History Findings Diagnosis Operation Course 1 53 years old with pain- less jaundice for 4 weeks. Diabetic and alcoholic 2 38 years old, alcoholic with painful jaundice for one month 3 76 years old, diabetic who had painless jaun- dice for 6 months 4 44 years old, diabetic, alcoholic with pancrea- titis and cholelithiasis 4 Painless jaundice for 2 weeks 5 62 years old with pain- less jaundice and sus- pected pseudocyst that gradually disappeared, also had abdominal aortic aneurysm 5 62 years old with re- currence of painless jaundice and palpable pseudocyst 6. 53 years old with pain- ful jaundice for 2 weeks 7 33 years old, underwent vagotomy and partial gastrectomy. On the 9th postoperative day patient was re- explored for jaundice Entire pancreas was firm. G. B. was nor- mal but distended Entire pancreas was firm. A small cyst was present in the head. The biliary tract was distended but normal Enlarged edematous pancreas. The bil- iary tract was dilated but normal Entire pancreas was firm. Single stone in gallbladder Entire pancreas was firm. Common duct was dilated but normal Diffuse enlargement and edema of the pan- creas and abdominal aortic aneurysm. No pseudocyst 10 cm fluctuant mass in head of pancreas. Dilated biliary tract but otherwise normal 8 cm mass in head of pancreas. Dilated biliary tract but otherwise normal Edematous pancreas and saponification of fat. Distended bil- iary tract but otherwise normal Chronic pancreatitis Chronic pancreatitis Acute and chronic pancreatitis Chronic pancreatitis. Cholelith- iasis Chronic pancreatitis Pancreatitis and abdominal aneurysm Pseudocyst, head of pan- creas Pseudocyst of head of pancreas Postopera- tive acute pancreatitis Resection of body and tail of pancreas. Roux- en-Y Pancreaticojejun- ostomy and cholecysto- jejunostomy Longitudinal pancre- aticojejunostomy using Roux-en-Y limb. T-tube drain- age of the common duct Caudal pancreatectomy with Roux-en-Y pan- creaticojejunostomy and cholecystojejunostomy Cholecystectomy, Sphincterotomy longitudinal jejunostomy with Roux-en-Y loop Choledochogastrostomy Resection of abdominal aortic aneurysm Cystoduodenostomy Cystoduodenostomy, Placement of T-tube in common duct Cystoduodenostomy Died in 3 months with disseminated carcinoma of pancreas. Did well for 6 years. Developed pancre- atic insufficiency and died in 7 years Pancreaticojejun- ostomy leaked. Patient expired on 13th postoperative day Did well for one year Required ligation of bleeding point at pancreaticojejun- ostomy. Doing well 7 years after initial operation. Three months later pseudocyst returned Has done well for 6 months Expired on 10th postoperative day of aspiration pneumonia Patient became febrile and was re- explored 39 days later for abscess. Patient expired 12 hours later tion was therefore to preserve as much gland as possible and at the same time satisfactorily decompress the pan- creatic and common bile ducts. Distal pancreatectomy with pancreaticojejunostomy and decompression of the biliary system seemed more appropriate than pan- creaticoduodenectomy since pain was not the patient's major complaint. It was also preferable to the more dif- ficult lateral pancreaticojejunostomy since multiple stric- tures of the pancreatic duct did not exist. This patient illustrated the difficulty of distinguishing between cancer and pancreatitis in the presence of painless jaundice and emphasized the fact that both conditions may coexist. Case 2. T. C., a 38-year-old man, drank one pint of whiskey daily and had been treated previously for acute pancreatitis. One month before admission he developed epigastric pain which penetrated to his back. He became nauseated, was unable to eat, lost 20 pounds and developed progressive jaundice.