Case 23: Jaundice

Kenny Cheung is a 48 year old nightclub manager who has been referred to the Gastroenterology Outpatient clinic with a recent history of intense pruritis and progressive jaundice.

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Letter from Kenny’s GP:

Dear Colleague, 

Kenny is an otherwise fit and well 48 year old nightclub manager who i’m very concerned about. He came to see me today as his diabetic control has been a bit worse over the last  two months but when he came in I was quite shocked to see he was visibly jaundice. His wife said he’d been a ‘bit yellow’ for the last month and had been complaining of itching for longr than that. On further questioning he told me he has not been eating much and has lost nearly 4KG in the last few months, he thought this was because he was not eating much as he has been stressed at work. He does not report any pain.

Kenny was diagnosed with diabetes in his late teens but has always had excellent blood sugar control, he has no other past medical history. He tells me his mother died of ‘yellow jaundice’ when he was only six but we don’t have any more information as that was back in China. He has lived in the UK since he was eleven.

Kenny has cut down his alcohol to zero over the last three months, before that he did drink a number of shots of rum at the weekend when he was working. He does still smoke 30 cigarettes a day and has done since he was 28. 

I’ve taken some blood tests and hepatitis serology today, the results should be attached to this letter. His BM was 9.2 in the surgery. Please can you see him as soon as possible. 

Regards

Dr Stoker

Bloods:

HB 9.6 g/dl (11.5-15.5)

MCV 105 fl (80-99)

WCC 12.5 x109/L (3.0-10.0)

Neutrophil 8 x109/L (2.0-7.5)

PLT 468 x109/L (150-400)
Na 134 mmol/l (135-145)

K 4.2 mmol/l (3.5-5.1)

Ur 1.2 mmol/l (1.7-8.3)

CR 45 mmol/l (49-92)

Bili 210 (total) 195 (conjugated) umol/L (0-20)

ALP 656 iu/l (35-104)

ALT 444 iu/l (10-35)

AST 421

GGT 599

ALB 30 g/l (34-50)

PT 9 secs (<12)

CRP 125 mg/L (0-5)

HIV (negative)

HAV IgG (positive), IgM (negative).

HBV sAg (negative), sAb (positive), core Ab (positive).

HCV Ab (negative).

CA 19-9: 5400 kiu/l (0-27)

AFP: 6 kiu/l (0-6).

Question 1: What’s the most likely diagnosis? 

Kenny is seen by the StR in Gastroenterology clinic.

Examination in clinic reveals scleral icterus. Scratch marks on upper limbs. Palpable 1cm circular swelling in left supraclavicular fossa. Normal abdominal examination.

He organises further imaging:

Abdominal USS:

Normal liver size, shape and echotexture. Dilated CBD 15mm to the level of the head of pancreas. GB is thick-walled (no filling defects seen). Pancreas not well visualised due to overlying bowel gas but no obvious HPB masses. Normal spleen. Absence of Doppler signal in right and left portal vein. 

Question 2. What investigations should be arranged next?

CT Chest, Abdomen & Pelvis:

5cm mass in head of pancreas with associated biliary obstruction. Dilated CBD 15mm. Portal vein thrombosis (bilateral) with involvement of SMV and SMA.

A provisional diagnosis of Pancreatic cancer is made.

Question 3: What is the next best interventional procedure? 

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates. Further information and follow-up questions will appear on Twitter throughout the week.

Question setter: Dr Bharat Paranandi, Gastroenterology ST7, UCLH

 

For tips on following hashtags read more, and try one of our recommended Twitter plugins.

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