Case of the Month
Case of the Month - January 2008
PATIENT: This is an alert and vital 70 year-old lady referred by her Palm Springs gastroenterologist following an unsuccessful ERCP for a CT scan-identified retained common bile duct stone (Fig. 1). The ERCP was complicated by a seven-day hospital stay for ERCP-induced acute pancreatitis. The patient had experienced a 70 lb. weight loss over three years, because of continued nausea and inability to eat. Liver tests were SAP 120, SGOT 27 and SGPT 61.
PAST MEDICAL HISTORY: Lap-choly 1997, laparoscopic hiatal hernia repair in 2005.
INITIAL COURSE: On 11/27/07, ERCP by us showed a tiny ampulla of Vater with a common ductal opening (Fig. 2a) (Fig. 2b). Both ducts were very difficult to access. The common bile duct was entered selectively, injection of contrast showed a dilated common bile duct with a distal tight stricture and no evidence of stone. The cystic duct remnant was hugely dilated (Fig. 3a)(Fig. 3b). Sphincterotomy on the distal CBD was performed, the stricture dilated, and a pigtail stent was placed in the CBD. Although cytology brushings were negative for malignancy, a provisional diagnosis of cancer of the head of the pancreas was still entertained.
SUBSEQUENT COURSE: On 12/12/07 a repeat ERCP with removal of the stent and further dilatation of the distal common bile duct and cystic duct remnant strictures was performed . A tight proximal stricture of the main pancreatic duct was then dilated under high PSI. (Fig. 4). Brushings from both the common bile duct and main pancreatic duct strictures were again negative for malignancy.
FOLLOW-UP: Patient now has complete relief of symptoms, feels fine and is eating well and gaining weight.
|