Unusual Case of Obstructive Jaundice in Elderly Patient

Abstract

In elderly patents the commonest causes of obstructive jaundice are choledocholithiasis and pancreatic and biliary causes. Here we present an unusual cause of obstructive jaundice. Case: 65 year old male patient presented with 3 weeks of jaundice and progressive right upper quadrant pain. Patient denied any fever or weight of loss. Social history was significant for heavy alcohol use and tobacco smoking. Physical examination reflected only deep icterus and mild epigastric tenderness. Lab findings revealed obstructive jaundice with total bilirubin 17.7 mg/dl, direct bilirubin 16.8 mg/dl and WBC count of 16000 mm3. Imaging studies done at an outside hospital which showed biliary dilatation with common bile duct of 15 mm. No pancreatic or hilar mass was identified. ERCP which revealed lot of edema proximal to the ampulla of Vater with ulceration of the duodenum. This ulcerated area was biopsied. Examination of the ampulla revealed a large ampulla with a compressed and pushed down papillary orifice. Free deep cannulation of the bile duct could not be achieved, though on opacifaction smooth narrowing of the common bile duct was visualized. Cytology could not be succesfully obtained. Considering above findings repeat imaging including magenetic resonant cholangiopancreatogram (MRCP) and spiral computed tomography (CT) were done. MRCP reflected the findings on ERCP but showed no mass lesion in the pancreas or peripancreatic area. Spiral CT showed findings of a soft tissue fullness in the periampullary area. Serum CA 19–9 was minimally elevated with a normal CEA. Biopsies from the duodenal ulcer surprisingly reflected squamous cell carcinoma (SCC). Further extensive investigations including magnetic resonant imaging and CT imaging of the lungs, head and neck failed to reveal the primary site. Exploratory laprotomy was done which showed a peripancreatic mass along with jejunal and ileal metastasis. A Roux-en-Y choledochojejunostomy and gastrojejunostomy was done. Histology from surgical specimens reflected SCC.Paient is presently followed by oncology service. Discussion: A wide variety of neoplastic lesions may involve the ampulla of Vater, but SCC is very rare at this location. Tobacco smoking may be considered as risk factor for the SCC of the ampulla of Vater. The management of these patients involves the extensive workup to rule out any other synchronous lesions and the involvement of the surgical team.