A case on periampullary carcinoma.

PRESENTED BY DR SUMAIYA TASNIM TANIMA

Particulars of the patient :

 Name: Mrs.Chandra Banu

 Age: 55 y/o
 Sex: Female
 Religion: Islam
 Occupation : Housewife
 Marital status: Married
 Address(Both present & permanent):Patuakhali, Barishal.
 Date of admission:1.11.21
 Date of examination: 3.11.21
 Ward no: FSU-2, SBMCH
Chief complaints:

 Yellow colouration of the sclera, skin & urine for 4 months.

 Anorexia & weight loss for 3 months.
History of present illness

 According to the statement of the patient, She was reasonably well 4 months
back.Then she developed yellow colouration of sclera, skin of whole body,
passage of high coloured urine and clay coloured stool for 4 months. The
yellowish discolouration was gradually deepening for about 2 months and
afterward there was diminution of yellowish discolouration for about 1 month.But
for last 1 month the yellowish discolouration is again increasing in intensity. She
also complaints of severe itching of whole body.She has history of weight loss in
past 3 months. She complaints of anorexia for same duration.She has no history of
fever,abdominal pain, cough,haemoptysis but she complaints of passage of black
tarry stool 1 month back, which lasted for about 7 days. Otherwise,no alteration of
bowel & bladder habit.
History of past illness

 Past surgical history : Nothing contributory.

 Past medical history: She is a hypertensive patient for last 2 years.
Family history

 She has no family history of diabetes mellitus, hypertension.

Personal history

 She is non alcoholic, non smoker and has no other addiction.

Socio-economic history

 She comes from a low socio-economic family.

Immunization history

 The patient is immunized against 6 EPI diseases.

Drug history

 The patient is taking antihypertensive drug( Amlocard 5 mg) for 2 years.

Menstrual history

 Menarche:14 years
 Menstrual flow: Average
 LMP: 21.03.2010
Transfusion history

 None
Allergic history

 Not allergic to any food,drink,drug she has taken so far

General examination

 Appearance: Ill looking

 Body built: Below average
 Co-operation: Cooperative
 Decubitus: On choice
 Intelligence: Intelligent
 Anemia: Present
 Jaundice: Present
 Cyanosis: Absent
 Dehydration: Absent
 Oedema: Absent
 Pulse: 72 beats / min
 Blood pressure: 130 / 90 mm Hg
 Respiratory rate: 16 / min
 Temperature: 99° F
 Neck vein: Not engorged
 Thyroid gland : Not enlarged
 Lymph nodes: No lymphadenopathy
 Hernial orifice: Intact
 Skin condition: Diffuse yellowish skin coloration with multiple scratch marks in
different places of the whole body.
Local examination(of abdomen)

Inspection:
Shape of the abdomen: Scaphoid shaped.
Skin colour:Yellowish.
Scratch mark present in the skin of whole abdemon in different places.
Muscle guarding: Absent.
Umbilicus: Centrally placed & inverted.
Any visible swelling: Absent.
Visible peristalsis,engorged vein,scar mark: Absent.
Palpation:
Superficial palpation:
Abdomen is soft.
No tenderness present in the right hypochondrium.

Deep palpation:
Murphy’s sign:Negative
Duodenal point tenderness:Absent
Any deep mass:Palpable mass in the right hypochondriac region which is fixed,irregular,hard and
painless.
Organ palpation:No organomegaly
Others:Succusion splash absent.
 Percussion:
 Percussion note:Tympanic.
 Upper border of liver dullness:Right 6th intercostal space.
 Shifting dullness and fluid thrill are absent.

 Auscultation:
 Bowel sound present.
 Digital Rectal Examination:
Normal findings.
 Other system examination:
 Cardio-vascular system examination:No abnormality detected.
 Respiratory system examination:No abnormality detected.
 Urinary system examination:No abnormality detected.
 Nervous system examination::No abnormality detected.
Salient feature:

Mrs. Chandra Banu, 55 years old, non smoker, non alcoholic, hypertensive hailing
from Patuakhali, Barishal was admitted into this hospital on 1.11.21 at female surgery
unit 2 presented with yellowish discolouration of eyes,skin of whole body,urine,clay
coloured stool for 4 months and anorexia and weight loss for 3 months.The yellowish
discolouration was gradually deepening for about 2 months and afterward there was
diminution of yellowish discolouration for about 1 month.But for last 1 month, the
yellowish discolouration is again increasing in intensity.Patient complaints of itching
all over the body.She also complaints of anorexia and significant loss of weight over
3 months and complaints of fullness after meal for 3 months.No history of
vomiting,haematemesis.History of passage of black tarry stool 1 month back, which
lasted for 7 days.No alteration of bowel habit.No urinary complaints.Patient has no
other systemic findings.
On general examination, patient is ill looking, cooperative,nutrition is poor,pallor is
present and the patient is highly jaundiced.No cervical lymphadenopathy.On
abdominal examination,shape of abdomen is normal,umbilicus is normal.Liver and
spleen are not palpable.A lump is palpable in the right hypochondriac region which is
fixed, irregular in shape, hard and painless.There is no free fluid in the
abdomen.Bowel aounds are audible.Per rectal examination was done.
Provisional daignosis:

 Obstructive jaundice due to periampullary carcinoma.

Differential diagnosis:

 Cholangiocarcinoma.
 Ca of head of pancreas.
 Biliary stricture.
Investigations:

 Hb% - 55%
 ESR – 40 mm
 WBC – 6000/c.mm
 DC – Neutrophil -36%
 Lymphocyte – 60%
 Monocyte – 02%
 Eosinophil – 02%
Liver function tests:

 Serum bilirubin:
 7.10.21 – 8.5 mg/ dl
 17.10.21 – 16.6 mg/dl
 21.11.21 – 21.07 mg/dl

 Serum Albumin – 3.01 gm/dl

 SGPT – 81.0
 SGOT- not done
 Alkaline phosphatase – 1966.0U/L
 Prothrombin time: Patient – 16 seconds
 Control – 14 seconds
 INR – 1.19
 Investigations for GA fitness:
 RBS – 79.1 mg/dl
 Serum creatinine – 1.7 mg/dl
 ECG – Normal study
 Chest x- ray P/A view: Normal findings
 rT- PCR: Negative
 HBsAg – Negative.
Confirmed daignosis:

 Obstructive jaundice due to periampullary carcinoma.

Treatment:

 General treatment:
 Nothing by mouth till further order.
 Infusion of 1 L 5% DA + 2 L of DNS ( @30 drops/min)
 Inj Konakion 10 mg ( 1 amp I/V stat for 3 days)
 Plenty of glucose
 Continuous monitoring of vital signs such as pulse, blood
pressure,temperature,urine output and respiratory rate.
Specific treatment:

 Palliative treatment:
 Double bypass surgery
 1: Gastrojejunostomy
 2:Cholecystojejunostomy
Follow up:

 1st POD:
Pulse:84 bpm
BP:165/80 mm HG

Dehydration: Present
Urine output:400 mll

7th POD:: Drain off

10th POD:Stitch off
12 th POD: Patient is discharged from hospital.
Thank You.