Anatomy Thorax Abdomen · Year 1 · from Anatomy Thorax Abdomen
Case 3: Pancreatic Head Adenocarcinoma
Clinical Presentation
A 68-year-old male presents with progressive jaundice over 3 weeks. His wife noticed yellow discoloration of his eyes, and he reports dark urine and pale stools. He has lost 8 kg over 2 months and describes vague epigastric discomfort. He has no history of gallstones, alcohol abuse, or liver disease.
On examination, he is deeply jaundiced with scleral icterus. The abdomen is soft with a non-tender, palpable gallbladder (Courvoisier sign - a palpable, non-tender gallbladder in a jaundiced patient suggests malignant biliary obstruction rather than stones). Total bilirubin is 12 mg/dL with elevated direct fraction. CA 19-9 tumor marker is elevated at 850 U/mL. CT scan reveals a 3 cm mass in the pancreatic head encasing the superior mesenteric vein with biliary dilation. ERCP with biliary stent placement provides symptomatic relief. Staging evaluation shows no distant metastases, and he undergoes neoadjuvant chemotherapy followed by Whipple procedure (pancreaticoduodenectomy).
Key Anatomical Points
- The common bile duct passes through or behind the pancreatic head before entering the duodenum
- Tumors of the pancreatic head obstruct the bile duct, causing painless jaundice
- The superior mesenteric vein and artery lie immediately behind the pancreatic neck
- The Whipple procedure removes the pancreatic head, duodenum, distal common bile duct, gallbladder, and often distal stomach
Key Learning Points
- Courvoisier's law: painless jaundice with palpable gallbladder suggests malignant obstruction; gallstone obstruction causes a contracted, scarred gallbladder
- The portal vein forms behind the pancreatic neck from the junction of the SMV and splenic vein
- Vascular involvement (SMA, SMV, portal vein) often determines surgical resectability
- The head of the pancreas receives blood from the pancreaticoduodenal arcades, sharing supply with the duodenum