Pancreatic Head Mass: A Textbook Case

Abstract

Pancreatic Cancer is one of the deadliest malignancies, accounting for over 330,000 deaths per year. Unfortunately, due to its vague symptoms, the diagnosis is often initially missed. Thus it is important to be familiar with some of the classic findings associated with this malignancy. Here we report an interesting case of a patient with a textbook presentation of pancreatic cancer. A 51-year-old male with no significant past medical history presented with dehydration, jaundice, pruritus and loose, grey bowel movements (Image 1) that began 3 weeks prior to presentation. The patient reported severe pruritus leading to scratching and extensive excoriations involving his entire body. He reported 2-3 episodes of “explosive” clay-white diarrhea daily. He denied hematochezia, melena, nausea, vomiting, unexpected weight loss, fevers, and chills. He reported drinking 4 beers a night and has a 45-pack year smoking history. On physical exam, the patient was ill appearing with moderate scleral icterus and jaundice. Initial lab work revealed elevated alkaline phosphatase, total and direct bilirubin, and lipase levels. CT abdomen and pelvis showed significant intra- and extrahepatic biliary ductal dilatation with a distended gallbladder and dilated pancreatic duct known as the “double duct sign” (Image 1). ERCP was performed and a biliary stent was placed for symptomatic relief. Biopsy from this procedure was highly suspicious for pancreatic adenocarcinoma. Given lack of metastasis, the patient underwent a pancreaticoduodenectomy to remove the mass and plans were made chemoradiation. Pancreatic adenocarcinoma is a highly morbid condition that can present with painless jaundice, pruritus, and Thomas' Sign (Image 2). Thomas' sign is the production of silver stool from combination of acholic stool and melena. This is diagnostic for pancreatic cancer that also affects the ampulla of vater. 5 year survival for patients who undergo surgery is 34.5%. Treatment options include surgical resection of the tumor, chemotherapy, radiation therapy or a combination of all of these. Given the poor prognosis in these patients, early identification of signs and symptoms such as the triad seen in this patient is important in allowing for prompt diagnosis and initiation of treatment.1306_A.tif Figure 1: No Caption available.1306_B.tif Figure 2: No Caption available.