A surgical case of haemothorax

Abstract

An 83-year-old female presented with a 6-day history of painless jaundice, anorexia, dark urine, steatorrhea and weight loss of 10 kg over the past year. The only past medical history was a monoclonal gammopathy of unknown significance. She was a never-smoker and did not drink alcohol. On examination, she was apyrexial and normotensive. She was clinically jaundiced, and had 4 cm non-tender hepatomegaly. Initial blood tests revealed a bilirubin concentration of 166 μmol·L−1 (normal range 0–21 μmol·L−1), alkaline phosphatase of 371 units·L−1 (normal range 30–150 units·L−1) and an alanine transaminase of 145 units·L−1 (normal range 0–40 units·L−1). Her renal function and inflammatory markers were normal. An abdominal ultrasound showed intra-hepatic biliary dilatation, suggesting obstruction in the lower common bile duct. She went on to have a computed tomography (CT) scan of her abdomen, which showed a small amount of ascites, peritoneal nodularity, bile duct dilatation and a mass in the body and tail of the pancreas involving the aorta and left adrenal gland. Several attempts at a percutaneous trans-hepatic cholangiogram (PTC) were made, but the radiologist was unable to cannulate the biliary ducts. A stent was then inserted at endoscopic retrograde cholangiopancreatography (ERCP) and a biopsy of the mass was carried out. 24 h later the patient deteriorated with pyrexias, hypotension and new onset atrial fibrillation with a fast ventricular rate. Her white blood cell count rose to 16.5×109 cells·L−1 from 12.4×109 cells·L−1 and her C-reactive protein to 52 mg·L−1 (normal level less than 5 mg·L−1). Her haemoglobin dropped from 116 g·L−1 to 93 g·L−1. Her kidney and liver function tests also deteriorated and a chest radiograph showed a new right pleural effusion (fig. …