GAS5 Pancreatic carcinoma versus cholangiocarcinoma as gastric outlet obstruction. (Gastroenterology).

GAS5 PANCREATIC CARCINOMA VERSUS CHOLANGIOCARCINOMA AS GASTRIC OUTLET OBSTRUCTION. Rochelle Cox, MD, and Brian van der Linden, MD. University of Virginia School of Medicine, Roanoke-Salem Internal Medicine Program, VAMC, Salem.

A 73-year-old man with a medical history significant for hypertension, hyperlipidemia, CAD, and S/P cholecystectomy initially presented to the VAMC ER for approximately 3 months of intermittent nausea and vomiting especially after eating, along with a 10 pound weight loss in less than 6 weeks. Initial labs revealed elevated LFTs; however, a CT of the abdomen with contrast medium reported a normal liver and pancreas without specific common duct dilatation and only minimal ductal prominence at the common hepatic duct. In addition, the tumor markers, CA 19-9 and AFP were both within normal range. ERCP performed shortly thereafter was not completed due to pyloric stenosis. Therefore, a percutaneous cholangiogram (PTC) was undertaken, which revealed a left hepatic duct abnormality. A left hepatic duct stent was placed during the PTC, with cytology brushings eventually reported as negative for malignancy. Subsequently, pyloric dilatations were done via several EGDs. Repeated ERCP later involved placement of a right hepatic duct stent. Since the patient's initial symptoms still had not resolved, further pyloric dilatations occurred by a series of EGDs. At this point, surgical exploration was deemed necessary for further evaluation and to relieve the gastric outlet obstruction. Exploratory laparotomy of the abdomen found significant amounts of small implants of the peritoneum and omentum revealing metastatic adenocarcinoma by frozen sections intraoperatively. After the kocher maneuver, a significant mass at the proximal duodenum appeared to emanate from either the head of the pancreas or common bile duct. Since this tumor was not amenable to resection, a duodenotomy with right hepatic stent removal, and gastrojejunostomy were done. Several days after surgery, the patient was discharged home on a soft regular diet with instruction to eat several small meals per day. In summary, this case report shows that the typical findings for carcinoma of the pancreas and periampullary area such as painless obstructive jaundice, a pai nful enlarged gall bladder, and abdominal pain with radiation to the back may not be present. This patient, instead, manifested typical features of gastric outlet obstruction.