Ca head of pancreas

Ca head of pancreas

Ca head of pancreas

70% of the cases occurs in the head of the pancreas including periampullary region

AETIOLOGY:-

1. Tropical pancreatitis and hereditary pancreatitis r associated with pancreatic cancer such malignancies can be multifocal
2. Haemochromatosis:-produces extensive calcification of pancreas.Also a precancerous condition
3. Diabetes:-diabetic patients r 10 times more vulnerable for carcinoma of pancreas
4. Other possible aetiological factors:-alcohol and smoking:-it is related to tobacoo specific nitrosamines
 -westernization of diet:-fatty food,rich in animal proteins can cause pancreatic cancer
 -indusrial carcinogens:-B11-naphthylamine,benzidine,gasoline r the possible agents

PATHOLOGY

 -Periampullary refers to carcinoma arising from ampulla of vater,the duodenal mucosa or the lower end of the common bile duct
 -microscopically,types are:
1. Mucus secreting carcinoma of ductal origin
2. Non mucus secreting carcinoma of acinar origin
3. Anaplastic carcinoma are poorly differentiated and tend to arise from the body of the pancreas
4. Cystadenocarcinomas are rare,slow growing and tend to attain a large size

CLINICAL FEATURES

1. Age: 50-70 years
2. Sex: comon in both sexes equally
3. Duration of symptoms: short duration( 1-3 months)
4. Symptoms:
 -pain: there may be some discomfort in abdomen but colicky pain is not a feature.Pain is relatively rare in carcinoma head of pancreas
 -fever: when obstruction becomes severe,there is bile stasis.Cholangitis,fever with cills and rigors can occur
 -jaundice: as a result of slow developing obstruction at periampullary region,jaundice is persistent,progressive,painless,pruritic,in 5% of cases growh may ulberate into the duodenum.It can cause melaena and jaundice may temporarily subside.
 -stools: clay coloured stools are common and when mixed with blood it is called silvery stools or aluminium paint stools
 -pruritus: severe due to bile salts in the circulation
 -loss of appetite: significant
 -loss of weight
5. Signs
 -jaundice: sometimes greenish yellow
 -anaemia: it is usually present
6. Per abdomen
 -liver can be enlarged due to back pressure.If it is nodular,with sharp border,hard in consistency,it is due to secondaries in liver
7. Gall bladder
 -gall bladder is palpable in 70-75% cases
8. Metastasis
 -left supraclauicular node,ascites etc.

D/d:

1. Carcinoma stomach
 such mass may not be mobile.It does not move with respiration because it is fixed to pancreas
 -these patients will have vomiting first followed by backache at a later date
2. Ca transverse colon
 -produces constipation and bleeding per rectum.Vertical mobility may be present.
 -right to left peristalsis may be present
3. Para aortic lymph mass may be due to
 -intra abdominal malignancies,lymphoma,testicular tumor etc

invest

1. Hb% is low in malignancy
2. BT,CT,PT r altered
3. Urine for urobilinogen is negative
4. Serum alkaline phosphatase: increased >500 units
5. Abdominal usg: it is most useful,noninvasive,reliable and quick investigation for obstructive jaundice
 -dilated biliary radicles,both intrahepatic n extrahepatic can be demonstrated
 -stones can be diagnosed with their postier acoustic shadow
 -mass lesion in the head region can be made out in cases of chronic pancreatis or ca head of the pancreas causing obstructive jaundice
7. CT scan:-
8. Endoscopy:-useful to diagose a periampullary carcinoma which may be seen as an ulcerative lesion in the 2nd part of the duodenum,biopsy can also be taken which shows adenocarcinoma
9. Barium meal:
 distortion of the medial border of the duodenum giving rise to inverted 3 sign
 -in ca head of the pancreas there may be widening of C loop of deodenum -Pad sign
10. ERCP ( Endoscopic Retrograde Cholangio Pancreatography)

TREATMENT

surgical treatment

 1. Radical pancreaticoduodenectomy -"whipple's operation"
 -in this operation growth along with 'C' loop of duodenum upto DJ flexure,removal of the head of pancreas upto the neck n partial gastrectomy is done followed by
-pancreaticojejunal anastomosis,gastrojejunostomy n choledochojejunostomy
 2. Pylous preserving pancreaticoduodenectomy PPPD
 in this operation,pylorus is preserved. Thus ,gastric motility is not disturbed
 3. Triple bypass: cholecystojejunostomy +enteroenterostomy +gastrojejunostomy
 this is a palliative surgery in which distended gall bladder is anastomosed to a long loop of jejunum to relieve jaundice.To prevent food particles entering into the gall bladder,enteroenterostomy is done.

Non surgical treatment

 -very elderly patients who r not fit candidates for surgery n patents who have metastasis can be treated by palliative stenting.Howerver,results of a surgical bypass is superor to stenting