Adenocarcinoma of the pancreas complicated by obstructive jaundice in pregnancy

摘要

A 34-year-old multiparous woman at 30 weeks' gestation was admitted with a sudden onset right upper quadrant pain and vomiting for 6 weeks. Of note was a 2-week history of obstructive jaundice, pruritus, pale coloured stool and darkened urine. On examination, she was found to be jaundiced, afebrile with minimal right upper quadrant tenderness and no stigmata of chronic liver disease. Preliminary biochemical investigations revealed deranged liver function tests with a total bilirubin of 200 mumol/l (reference range 3-20), conjugated bilirubin 163 mumol/l (0-5), aspartate transaminase 63 IU/l (10-50), alkaline phosphatase 457 IU/l (30-120)and gamma glutamate transferase 103 IU/l (5-55). Abdominal ultrasound revealed common bile duct (CBD) and intrahepatic duct dilatation (IHD), a thin-walled gallbladder with solitary calculus and debris. There was no evidence of ampullary abnormality on upper gastrointestinal duodenoscopy. She was then referred to the regional centre for further management. A magnetic resonance cholangio-pancreatography showed intrahepatic, common bile duct and pancreatic duct dilatation down to the head ofpancreas. Endoscopic ultrasound revealed a 2-3 cm mass in the head of pancreas. Ultrasonic fetal assessment revealed a well grown fetus with normal liquor volumes and umbilical artery Dopplers. A multidisciplinary consensus was made for early delivery by elective caesarean section. Consideration was given to performing an endoscopic retrograde cholangio pancreatogram (ERCP) antenatallydue to the high bilirubin levels. However, in view of a potential suboptimal view in the presence of a gravid uterus and possible radiation exposure to the fetus, this was arranged postoperatively. A female infant with normal apgars was delivered at 32 weeks.At caesarean section a mass suspicious of a tumour was palpated in the head of pancreas. Postoperatively urgent staging by computerised tomography confirmed a 3 cm mass in the head of pancreas and possible infiltration of the superior mesenteric vessels. An ERCP performed revealed a CBD stricture with gross common hepatic duct (CHD) and IHD dilatation beyond this. A stent was inserted to facilitate biliary drainage and improve obstructive jaundice symptoms. At laparotomy, a large lesion was found in the head of pancreas involving the superior mesenteric vein and also infiltrating into the infracolic compartment through the transverse mesocolon. In addition she had some liver metastases. Histology ofthe liver metastasis showed extensive infiltration with moderately differentiated adenocarcinoma in keeping with a pancreatic origin. Hence a palliative biliary and gastric bypass was performed. She was referred for palliative chemotherapy. She unfortunately died 3 months later in the community.