ANSWER 69
The patient has an obstructive jaundiceas indicated by the history of dark urine and pale
stools and the liver function tests. The pain has two typical features of carcinoma of the
pancreas: relief by sitting forward and radiation to the back. An alternative diagnosis
could be gallstones but the pain is not typical.
As with obstruction of any part of the body the objective is to define the site of obstruc-
tion and its cause. The initial investigation was an abdominal ultrasound which showed a
dilated intrahepatic biliary tree, common bile duct and gallbladder but no gallstones. The
pancreas appeared normal, but it is not always sensitive to this examination owing to its
depth within the body.
Further investigation of the region at the entrance of the common bile duct into the duode-
num and head of the pancreas was indicated and was undertaken by computed tomography
(CT) scan. It showed a small tumour in the head of the pancreas causing obstruction to the
common bile duct, but no extension outside the pancreas. No abdominal lymphadenopathy
was seen. No hepatic metastases were seen on this investigation or on the ultrasound.
The patient underwent partial pancreatectomy with anastamosis of the pancreatic duct to
the duodenum. The jaundice was rapidly relieved. Follow-up is necessary not only to
detect any recurrence but also to treat any possible development of diabetes.
- Carcinoma of the pancreas can present with non-specific symptoms in its early stages.
- It is an important cause of obstructive jaundice.
- Patients who have had a partial removal of the pancreas are at risk of diabetes.