1) Definizione del paziente e della storia
name: A.O.
sex: male
age: 63 years
nationality: italian
employment: doctor
weight: 67 kg
height: 159cm
BMI: 26,5
Allergy: denies
Family history: married, two children in good health, parents died of old age
Drug history: PPI about 1 month
Medical history:
* common childhood rashes
* benign prostatic hypertrophy
* hiatal hernia
* GERD
has never performed EGD
Medical history next
Has always enjoyed good health.
From about 1 month appearance of iporessia, occasional mild heartburn, diarrhea and weight loss of about 4 kg.
Last week appearance of feces hypocholic, dark urine and jaundice.
Performes blood tests and abdominal Us that showed:
* total bilirubin 8 mg/dl,
* dilatation of the common bile duct of 15 mm,
* pancreas doesn't evaluable for flatulence.
Is hospitalized with a diagnosis of "cholestasis and dilatation of the common bile duct".
Blood tests at admission:
| Hb | 11,9 g/dl |
| Hct | 35,8% |
| RBC | 4,28×10^6/microL |
| AST | 156 U/L |
| ALT | 220 U/L |
| GGT | 448 U/L |
| ALP | 239 U/L |
| LDH | 723 U/L |
| amilase | 121 U/L |
| total bilirubin | 2,1 mg/dl |
| direct bilirubin | 1,6 mg/dl |
| CRP | 39,2 mg/dl |
| fibrinogen | 670 mg/dl |
| AFP | 3,35 ng/ml |
| CEA | 2,2 ng/ml |
| Ca19.9 | 17,9 ng/ml |
| HBsAg | negative |
| anti HBs | 133 mU/ml |
During hospitalisation has never complained about pain despite regular feeding. Cholestasis has gradually resolved.
Also performed the following instrumental examination:
TC abdomen:
* dilatation of the common bile duct (14mm), of the cystic duct and minimal dilatation of the intrahepatic bile ducts,
* mild hyperemia tract prepapillary of the common bile duct in presence of weakly solid hyperdense area at the papillary level,
* minute interaortocaval lymphoadenopathy
* further investigation is needed to define the nature of the lesion.
EGD:
* papilla of Vater massive with normal mucosa and limited outcroup to the pore of hyperplasic mucosal ectropion,
* no biopsies for the risk of pancreatitis by edema periorificial.
EUS:
* ampulloma be defined histologically,
* no infiltration of the surrounding areas.
ERCP:
* in doubt to ensure good pancreatic drainage (pancreas divisum?) don't run papillectomi but only papillotomy with biliary stent placement,
* section exposes the ampullary mucosa without obvious focal lesion,
* performing biopsies.
MRCP:
* no pancreas divisum,
* preserved pancreatic function.
histological examination:
* inflamed flpas of ampullary mucosa and scrap of fibrous tissue with severe crush artifacts and focus of adenocarcinoma.
2) Le basi molecolari degli eventi descritti, tenendo conto di tutti i sintomi ed utilizzando i link alle informazioni pertinenti
Ampullary tumors are generally low grade malignancy with a predominance of the fibrous component.
The incidence is increased to 60 years of age with a male:female ratio 2:1.
The tumor determines obstacle, both organic and functional, to the transpapillary passage of bile and pancreatic juices and then episodes of biliary colic and pancreatitis, sometimes with relapsing.
We therefore have:
* dilatation of the common bile duct and duct upstream with:
## cholestatic joundice
## right upper quadrant pain
## palpable gallbladder (Courvoisier's sign)
## rare cases of cholangitis...
* obstructions of the MPD at the site of penetration in the bulb with expansion and possible rupture af the ducts and acinous upstream with episodes of pancreatitis.
The tumor may extend to the:
* bile ducts,
* second portion of the duodenom with bleeding risk,
* head of the pancreas,
* regional lymphonods,
* splenic and port vein with thrombosis risk.
Possible distant metastases to the liver and lungs.
3) Eventuali proposte di terapia, volta al ripristino delle condizioni ottimali
Therapy depends on the histology of the tumor and the stage of disease:
* papillectomy with endoscopic therapy and follow-up,
* ampullectomia with reimplantation of the common bile duct and the MPD, following cholecystectomy,
* pancreaticoduodenectomy
* palliation with biliary-digestive bypass or endoscopic prothesis.
In general the ERCP allows:
* direct vision of the tumor
* biopsies
* placement of stent to relieve obstruction
* eventual removal of the ampulloma for a better histological characterization.
Surgery performed in this case was the pancreaticoduodenectomy.
4) Bibliography
- Colombo e Paletto "Trattato di Chirurgia" ed. Minerva Medica
- en.wikipedia.org/wiki/Endoscopic_retrograd_cholangiopancreatography
- en.wikipedia.org/wiki/MRCP
- en.wikipedia.org/wiki/Bilirubin
- en.wikipedia.org/wiki/Acute_pancreatitis
- en.wikipedia.org/wiki/Jaundice
- en.wikipedia.org/wiki/Ampulla_of_Vater
- en.wikipedia.org/wiki/Pancreaticoduodenectomy
- www.update.com/.../ampullary_carcinoma_treatment
- www.aisponline.it
- emedicine.medscape.com/article/276413-overview
