Problem case Department of Gastroenterology

C.C. : 우상복부 통증 O/S : 일주일 전부터 C.C. : 우상복부 통증 O/S : 일주일 전부터 P.I. 20 년 전부터 당뇨병과 고혈압으로 경구약 복용해오던 자로 상복부 불쾌감 있었으나 치료없이 지내던 중 내원 1 주일 전부터 증상 심해 져 개인병원서 급성 담낭염, 담낭 결석 의심하여 내과 입원 P.I. 20 년 전부터 당뇨병과 고혈압으로 경구약 복용해오던 자로 상복부 불쾌감 있었으나 치료없이 지내던 중 내원 1 주일 전부터 증상 심해 져 개인병원서 급성 담낭염, 담낭 결석 의심하여 내과 입원 PMHx 당뇨병 (+) : 20 년전 진단 인슐린 PMHx 당뇨병 (+) : 20 년전 진단 인슐린 고혈압 (+) : 15 년전 진단 칼슘길항제 고혈압 (+) : 15 년전 진단 칼슘길항제 PHx - Smoking : 40-pack-year - Alcohol : 1 주일에 2-3 번, 소주 1 병정도 PHx - Smoking : 40-pack-year - Alcohol : 1 주일에 2-3 번, 소주 1 병정도 윤 O M/66 입원일

Review of Systems General : fatigue (-) fever (+) chills (+) General : fatigue (-) fever (+) chills (+) night sweat (-) weight loss (-) night sweat (-) weight loss (-) Respiratory : cough (-) sputum (-) dyspnea (-) haemoptysis (-) cyanosis (-) Respiratory : cough (-) sputum (-) dyspnea (-) haemoptysis (-) cyanosis (-) Cardiac : orthopnea (-) chest pain (-) palpitation (-) Cardiac : orthopnea (-) chest pain (-) palpitation (-) GI : A/N/V/D/C (+/+/-/-/-) haematochezia (-) abd pain (+) : RUQ, 기침시 악화 GI : A/N/V/D/C (+/+/-/-/-) haematochezia (-) abd pain (+) : RUQ, 기침시 악화

Physical Examination Vital sign 130/70mmHg– 60/min– 22/min– 38.3 °C Vital sign 130/70mmHg– 60/min– 22/min– 38.3 °C General appearance - Acutely ill appearance General appearance - Acutely ill appearance Eyes and ENT - Isocoric pupils with pupilary light reflex (++/++) - Icteric sclera, Pinkish conjunctivae Eyes and ENT - Isocoric pupils with pupilary light reflex (++/++) - Icteric sclera, Pinkish conjunctivae Chest - Clear breath sounds without crackle or wheezing - Regular heart beats without murmur Chest - Clear breath sounds without crackle or wheezing - Regular heart beats without murmur Abdomen - Soft and flat abdomen - Normoactive bowel sound - RUQ tenderness but no rebound tenderness - No palpable abdominal mass Abdomen - Soft and flat abdomen - Normoactive bowel sound - RUQ tenderness but no rebound tenderness - No palpable abdominal mass - Murphy sign(+) - Murphy sign(+)

Initial Lab Findings (3-10) CBC/DC 12,320/mm 3 – 13.6 g/dL – 41.4 % - 241K/mm 3 (Seg 88.3%) CBC/DC 12,320/mm 3 – 13.6 g/dL – 41.4 % - 241K/mm 3 (Seg 88.3%) Chemisrty TB/DB 2.8 / 1.9 mg/dL ALP 404 U/L GGT 282 U/L Prot/Alb 6.4 / 3.5 g/dl AST/ALT 37/94 U/L Ca/P 8.2 / 2.7 mg/dl Bun/Cr 12 / 1.0 mg/dl Na/K/Cl 125 / 3.5 / 102 mmol/L Chemisrty TB/DB 2.8 / 1.9 mg/dL ALP 404 U/L GGT 282 U/L Prot/Alb 6.4 / 3.5 g/dl AST/ALT 37/94 U/L Ca/P 8.2 / 2.7 mg/dl Bun/Cr 12 / 1.0 mg/dl Na/K/Cl 125 / 3.5 / 102 mmol/L Urinalysis RBC 0~1 /HPF WBC 0~1 /HPF Urinalysis RBC 0~1 /HPF WBC 0~1 /HPF

Impression Acute cholecystitis with cholangitis

Diagnostic Plan Abdominal sonography Abdominal CT ERCP

Abdominal US

Abdominal CT

ERCP

Diagnosis Treatment Treatment Acute cholangitis due to biliary sludge Acute cholecystitis with GB stone Endoscopic sphincterotomy with CBD clearing Distal CBD stricture Biliary drainage (ENBD)

Further Treatment Further Treatment GS transfer Laparoscopic Cholecystectomy 3-12 LC 후 3-15 자의 퇴원

2 nd Admission (3-16) C.C : 우상복부 통증 C.C : 우상복부 통증 P.I : 3-15 퇴원후 3-16 오후부터 발열, 오한, 우상복부 통증 P.I : 3-15 퇴원후 3-16 오후부터 발열, 오한, 우상복부 통증 지속되어 응급실 통해 입원 지속되어 응급실 통해 입원 Lab finding Lab finding CBC/DC CBC/DC 11,950/mm 3 – 13.3 g/dL – 39.7 % - 224K/mm 3 (Seg 88.8%) 11,950/mm 3 – 13.3 g/dL – 39.7 % - 224K/mm 3 (Seg 88.8%) Chemisrty Chemisrty TB/DB 9.7/6.8 mg/dL ALP 430U/L GGT 320U/L Prot/Alb 5.8/2.8g/dl AST/ALT 36/36U/L TB/DB 9.7/6.8 mg/dL ALP 430U/L GGT 320U/L Prot/Alb 5.8/2.8g/dl AST/ALT 36/36U/L Ca/P 7.8/ 2.3 mg/dl Bun / Cr 6 / 1.2 mg/dl Na/K/Cl 133 / 2.6 / 98 mmol/L Ca/P 7.8/ 2.3 mg/dl Bun / Cr 6 / 1.2 mg/dl Na/K/Cl 133 / 2.6 / 98 mmol/L Tumor marker Tumor marker CA U/L CEA 9.17 ng/ml aFP 2.37 ng/ml CA U/L CEA 9.17 ng/ml aFP 2.37 ng/ml

ERCP Brushing cytology & biopsy(-)

Abdominal CT

PET CT Portocaval LN Cholecystectomy Site

F/U ERCP Brush Cytology & Bx: highly suspicious of adenocarcinoma

수술전 진단 수술전 진단 수술 수술 총담관 말단부 암 Whipple’s operation

최종 진단 Pancreatic adenocarcinoma CBD infiltration Liver Bx(+)

Abdominal CT

Clinical coarse 3-10 우상복부 통증 3-11 복부 CT GB stone Bile duct dilatation 3-11 ERCP Biliary sludge in CBD Distal CBD stricture 3-12 Laparoscopic cholecystectomy 3-17 ERCP Distal CBD stricture Biliary drainage Cytology(-) 3-17 복부 CT Narrowing and Wall thickening of distal CBD 3-21 PET CT suggestive malignancy GS t/f readm 3-22 ERCP Plastic stent insertion Plastic stent insertion Cytology & Bx.in distal CBD Cytology & Bx.in distal CBD Highly suspicious adenocarcinoma 4-7 Whipple’s OP Pancreaticadenoca. CBD infiltration GS t/f

T1: Restricted to pancreas T2: Extension to duodenum, bile duct, peripancreatic tissue T3: Extension to stomach, spleen, colon, large vessel (celiac axis,superior mesenteric artery) AJR:180,May 2003 Staging T3N1M1

AJR:180,May 2003

STAGING OF PANCREATIC CANCER Stage Clinical / radiographic criteria I resectable (T1-T2, selected T3, NX, M0) I resectable (T1-T2, selected T3, NX, M0) no encasement of celiac axis or SMA no encasement of celiac axis or SMA patent SMV confluence with portal vein patent SMV confluence with portal vein no extrapancreatic disease no extrapancreatic disease II locally advanced (T3, NX-1, M0) II locally advanced (T3, NX-1, M0) arterial encasement (celiac axis or SMA) or venous occlusion (SMV or portal vein) arterial encasement (celiac axis or SMA) or venous occlusion (SMV or portal vein) no extrapancreatic disease no extrapancreatic disease III metastatic (T1-3, NX-1, M1) III metastatic (T1-3, NX-1, M1) metastases typically to liver, peritoneum, and occasionally lung metastases typically to liver, peritoneum, and occasionally lung Resectable T3 lesions include those with isolated involvement of SMV, portal vein, or hepatic artery without encasement of the celiac axis or SMA Resectable T3 lesions include those with isolated involvement of SMV, portal vein, or hepatic artery without encasement of the celiac axis or SMA