Jaundice

An example of a typical case of jaundice in surgical practice.

A 50-year-old man presented to the emergency department with jaundice for the past 4 weeks. It is associated with tea coloured urine and pale stool. He denies any abdominal pain or fever. He has lost 6kg for the past one year. He did not notice any loss of appetite although his wife claims he eats less than before.  The systematic review was unremarkable.

Physical exam
Jaundice, pale and cachexia
No stigmata of chronic liver disease

PA: vague mass at the epigastrium region, disappear during sitting up.
BS normal

Investigation
White cell normal
Liver function test; raised bilirubin and ALP with normal ALT

Differential
Carcinoma head of the pancreas (pancreatic cancer)
Cholangiocarcinoma (cancer of biliary duct)
Hepatocellular carcinoma (liver cancer)

Most likely diagnosis
Head of the pancreas carcinoma

Point towards
painless obstructive jaundice with cachexia
vague mass at the epigastrium. An enlarge a tumour are typically palpable only when size is significant due to the retroperitoneum location.

Imaging
CT scan abdomen would be the best modalities to assess
-resectability
-vasculature
-metastases

Surgery
Classical pancreaticoduodenectomy (Whipple’s) or Pyloric preserving pancreaticoduodenectomy (PPPD). The choice depends on the size, location and the extension of the tumour.

Prognosis
The 5-year survival rate range between 3-15%. In a metastatic disease, 5-year survival rate of <1%.