# Clinical Cases: Pancreatic Surgery

## Case 1: Acute Pancreatitis

### Patient Demographics
- **Age:** 48 years
- **Sex:** Male
- **Occupation:** Sales manager

### Chief Complaint
"I have severe pain in my upper abdomen that goes through to my back."

### History of Present Illness
The patient presents with a 12-hour history of severe, constant epigastric pain radiating straight through to his back. The pain began after a business dinner where he consumed several alcoholic drinks. He has had multiple episodes of vomiting. The pain is somewhat relieved by leaning forward. He admits to heavy alcohol consumption over the past several years (6-8 drinks daily). He has had similar but milder episodes in the past that he attributed to "stomach upset."

### Past Medical History
- No formal medical history (does not see physicians regularly)
- Alcohol use disorder (undiagnosed)

### Social History
- Heavy alcohol use: 6-8 drinks daily for 15 years
- Smokes 1 pack/day
- Works in sales with frequent client dinners

### Physical Examination
- **Vitals:** BP 108/68 mmHg, HR 112 bpm, RR 22/min, Temp 37.8°C, SpO2 96%
- **General:** Distressed male, restless, leaning forward
- **Abdomen:**
  - Tender epigastrium with guarding
  - Decreased bowel sounds
  - No rebound
  - No ecchymosis (Cullen's or Grey Turner's signs)
- **Skin:** Mildly diaphoretic

### Laboratory Results
- WBC: 15,600/μL
- Hemoglobin: 16.2 g/dL (hemoconcentrated)
- Platelets: 168,000/μL
- BUN: 32 mg/dL
- Creatinine: 1.6 mg/dL
- Glucose: 186 mg/dL
- Lipase: 2,840 U/L (markedly elevated, normal <60)
- AST: 86 U/L
- ALT: 52 U/L (not significantly elevated - argues against biliary etiology)
- Total bilirubin: 1.4 mg/dL
- Calcium: 8.2 mg/dL
- LDH: 340 U/L
- Triglycerides: 180 mg/dL (normal)
- Lactate: 2.4 mmol/L

### Severity Assessment

**APACHE II Score:** 12 (moderate severity)

**BISAP Score:** 3
- BUN >25: +1
- Impaired mental status: 0
- SIRS criteria: +1 (HR >90, WBC >12,000)
- Age >60: 0
- Pleural effusion: +1 (on chest X-ray)

**Predicted mortality:** 5-10%

### Imaging

**CT Abdomen/Pelvis with IV contrast:**
- Enlarged, edematous pancreas
- Peripancreatic fat stranding
- Peripancreatic fluid collections
- No pancreatic necrosis (enhancement preserved)
- No gallstones visible
- **Balthazar Score:** D (moderate)

**Right Upper Quadrant Ultrasound:**
- No gallstones
- No biliary dilation
- Consistent with alcoholic etiology

### Diagnosis
Acute alcoholic pancreatitis, moderately severe

### Initial Management
1. Aggressive IV fluid resuscitation (Lactated Ringer's, goal-directed)
2. NPO initially
3. Pain control (IV hydromorphone)
4. Anti-emetics
5. Monitor for organ dysfunction
6. No role for prophylactic antibiotics

### Hospital Course

**Days 1-3:**
- Continued IV fluids (250-500 mL/hr initially, then adjusted)
- Pain improving
- No respiratory distress
- Renal function improved with hydration

**Day 4:**
- Attempted clear liquids - tolerated
- Pain well controlled with oral analgesics

**Day 5:**
- Advanced to low-fat solid diet
- Tolerated well

### Nutritional Management
- Early enteral nutrition preferred (within 24-72 hours if feasible)
- If not tolerating oral, nasojejunal feeding superior to TPN

### Alcohol Counseling
- Addiction medicine consultation
- Patient agreed to alcohol rehabilitation program
- CIWA protocol for alcohol withdrawal monitoring (not needed)

### Discharge
- Day 6
- Oral analgesics
- Low-fat diet instructions
- Alcohol cessation resources
- Follow-up with GI and addiction medicine

### Teaching Points
1. Lipase is highly sensitive and specific for acute pancreatitis
2. Severity scoring (APACHE II, BISAP) guides ICU admission
3. Goal-directed fluid resuscitation is critical in first 12-24 hours
4. Early enteral nutrition when feasible
5. CT with contrast should be delayed 48-72 hours (to assess necrosis)
6. Address underlying etiology (alcohol, gallstones)
7. Prophylactic antibiotics not recommended

### Clinical Image
![Acute Pancreatitis CT](case_01_image.jpg)

**Image Description:** CT scan demonstrating acute pancreatitis with diffuse pancreatic enlargement, peripancreatic fat stranding, and peripancreatic fluid collections. The pancreatic parenchyma shows preserved enhancement indicating absence of necrosis.

**Attribution:** Image from Wikimedia Commons, Category:Pancreatic cancer. Source: https://commons.wikimedia.org/wiki/Category:Pancreatic_cancer

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## Case 2: Pancreatic Adenocarcinoma

### Patient Demographics
- **Age:** 68 years
- **Sex:** Female
- **Occupation:** Retired accountant

### Chief Complaint
"I've turned yellow and my urine is very dark."

### History of Present Illness
The patient presents with a 3-week history of progressive jaundice, dark urine, and clay-colored stools. She reports generalized pruritus that has been keeping her awake at night. She has had vague epigastric discomfort and back pain for approximately 2 months. She has lost 7 kg over the past 2 months with decreased appetite. She denies prior episodes of jaundice, biliary colic, or pancreatitis. She has new-onset diabetes diagnosed 4 months ago.

### Past Medical History
- New-onset diabetes mellitus (4 months ago - potentially paraneoplastic)
- Hypertension
- No prior surgeries

### Family History
- Brother: Pancreatic cancer at age 71

### Social History
- Never smoker
- Minimal alcohol use

### Physical Examination
- **Vitals:** Normal
- **General:** Cachectic, jaundiced female
- **Abdomen:**
  - Soft, mild epigastric tenderness
  - Palpable, non-tender gallbladder (Courvoisier's sign)
  - No hepatomegaly
  - No ascites
- **Skin:** Markedly icteric, excoriations from scratching

### Laboratory Results
- Total bilirubin: 14.8 mg/dL
- Direct bilirubin: 12.4 mg/dL
- ALT: 186 U/L
- AST: 142 U/L
- Alkaline phosphatase: 486 U/L
- GGT: 620 U/L
- CA 19-9: 584 U/mL (markedly elevated)
- CEA: 4.2 ng/mL (mildly elevated)
- Albumin: 3.2 g/dL
- Hemoglobin: 11.2 g/dL
- Glucose: 186 mg/dL

### Imaging

**CT Abdomen/Pelvis (pancreatic protocol):**
- 3.2 cm hypodense mass in pancreatic head
- Dilated intrahepatic and extrahepatic bile ducts (CBD 15 mm)
- Dilated pancreatic duct (double duct sign)
- Distended gallbladder
- Superior mesenteric vein abutment (<180 degrees) - borderline resectable
- No superior mesenteric artery involvement
- No liver metastases
- No ascites or peritoneal nodules

**MRI/MRCP:**
- Confirms pancreatic head mass
- Abrupt cutoff of CBD and main pancreatic duct
- No liver lesions

**EUS with FNA:**
- 3.2 cm hypoechoic mass in pancreatic head
- FNA: Positive for adenocarcinoma
- No celiac axis involvement

### Staging
- Borderline resectable pancreatic adenocarcinoma
- cT3N0M0 (Stage IIA) - pending final pathology

### Multidisciplinary Tumor Board
- Borderline resectable due to SMV abutment
- Recommendation: Neoadjuvant therapy followed by surgery

### Preoperative Biliary Decompression
- ERCP with plastic stent placement
- Bilirubin decreased to 3.2 mg/dL over 2 weeks
- Improved nutritional status and operative candidacy

### Neoadjuvant Therapy
- FOLFIRINOX x 4 cycles
- Restaging CT: Tumor stable, SMV abutment unchanged
- CA 19-9 decreased to 86 U/mL

### Operative Procedure
Pancreaticoduodenectomy (Whipple procedure):
- Exploratory laparotomy - no metastases
- Standard Whipple with portal vein resection (tangential) and primary repair
- Reconstruction:
  - Pancreaticojejunostomy (duct-to-mucosa)
  - Hepaticojejunostomy
  - Gastrojejunostomy

### Pathology Results
- Pancreatic ductal adenocarcinoma, 2.8 cm (treatment effect present)
- Moderately differentiated
- Margins: R0 (negative)
- Lymph nodes: 1/22 positive
- Portal vein involved (negative margin after resection)
- ypT3N1M0 (Stage IIB)

### Postoperative Course
- ICU x 2 days
- Delayed gastric emptying (common complication)
- Started on enteral feeds via J-tube
- Eventually tolerating oral diet
- Discharged POD 14

### Adjuvant Therapy
- Complete 6 months of perioperative therapy with FOLFIRINOX

### Surveillance
- CA 19-9 every 3 months
- CT every 3-6 months for 2 years

### Teaching Points
1. Painless jaundice + palpable gallbladder = Courvoisier's sign (suggests malignant obstruction)
2. New-onset diabetes can be presenting sign of pancreatic cancer
3. CA 19-9 useful for monitoring (not screening)
4. Resectability determined by vascular involvement
5. Neoadjuvant therapy for borderline resectable disease
6. Whipple procedure is standard for pancreatic head cancer
7. Median survival improved with multimodal therapy

### Clinical Image
![Pancreatic Cancer CT](case_02_image.jpg)

**Image Description:** CT scan demonstrating a hypodense mass in the pancreatic head with associated dilation of the common bile duct and pancreatic duct (double duct sign). The mass causes biliary obstruction leading to painless jaundice.

**Attribution:** Image from Wikimedia Commons, Category:Pancreatic cancer. Source: https://commons.wikimedia.org/wiki/Category:Pancreatic_cancer

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## Case 3: Pancreatic Pseudocyst

### Patient Demographics
- **Age:** 52 years
- **Sex:** Male
- **Occupation:** Construction worker

### Chief Complaint
"I have pain and fullness in my stomach that won't go away since my pancreatitis 2 months ago."

### History of Present Illness
The patient was hospitalized 8 weeks ago with acute alcoholic pancreatitis. He was treated conservatively and discharged after a 7-day hospital stay. Since discharge, he has had persistent epigastric pain, early satiety, and occasional nausea. He reports feeling a fullness in his upper abdomen. He has been unable to eat normally and has lost 5 kg. He stopped drinking alcohol after his hospitalization.

### Past Medical History
- Acute alcoholic pancreatitis (8 weeks ago)
- Alcohol use disorder (now abstinent)
- Hypertension

### Physical Examination
- **Vitals:** Normal
- **General:** Thin male, appears uncomfortable
- **Abdomen:**
  - Palpable, tender mass in epigastrium
  - Non-pulsatile
  - No peritoneal signs
  - Mild epigastric distension

### Laboratory Results
- WBC: 8,200/μL
- Hemoglobin: 12.8 g/dL
- Amylase: 168 U/L (mildly elevated)
- Lipase: 124 U/L (mildly elevated)
- Liver function tests: Normal
- CA 19-9: Normal

### Imaging

**CT Abdomen with contrast:**
- 10 cm well-defined, round, fluid-filled collection in lesser sac
- Thick, enhancing wall (>6 weeks old - mature wall)
- Adjacent to stomach and pancreatic body
- No solid component
- No gas within collection
- Main pancreatic duct appears normal
- Consistent with mature pancreatic pseudocyst

**MRI/MRCP:**
- Confirms pseudocyst
- No communication with main pancreatic duct visible
- No pancreatic duct stricture or dilation

### Diagnosis
Symptomatic pancreatic pseudocyst (>6 weeks, mature wall)

### Indications for Intervention
- Symptomatic (pain, early satiety, nausea)
- Size >6 cm (risk of complications)
- Persistent symptoms despite conservative management

### Treatment Options Discussed
1. **Endoscopic drainage:** EUS-guided cystogastrostomy (preferred if anatomy favorable)
2. **Surgical drainage:** Cystogastrostomy or Roux-en-Y cystojejunostomy
3. **Percutaneous drainage:** Generally avoided (risk of external fistula)

Patient referred for endoscopic evaluation.

### EUS-Guided Cystogastrostomy
- EUS confirmed direct apposition of pseudocyst to stomach
- Transmural puncture and tract creation
- Lumen-apposing metal stent (LAMS) placed
- 150 mL of dark, non-purulent fluid drained
- Fluid analysis: High amylase (12,000 U/L), no bacteria

### Post-Procedure Course
- Pain improved significantly
- Tolerating regular diet within 48 hours
- Discharged POD 2

### Follow-up
- CT at 4 weeks: Pseudocyst collapsed to 2 cm
- CT at 8 weeks: Complete resolution
- Stent removed at 8 weeks via endoscopy
- Alcohol abstinence maintained

### Chronic Pancreatitis Evaluation
- Given alcoholic etiology, patient counseled about chronic pancreatitis risk
- Endocrine/exocrine function monitoring
- Alcohol cessation essential

### Teaching Points
1. Pseudocyst forms >4 weeks after acute pancreatitis (encapsulated collection)
2. Distinguished from walled-off necrosis (WON) by contents (fluid vs. necrosis)
3. Most pseudocysts resolve spontaneously; intervene if symptomatic or complicated
4. Mature wall (>6 weeks) required for drainage procedures
5. Endoscopic drainage preferred when pseudocyst abuts stomach/duodenum
6. Pseudocyst communication with pancreatic duct affects treatment
7. Address underlying etiology (alcohol cessation crucial)

### Clinical Image
![Pancreatic Pseudocyst CT](case_03_image.jpg)

**Image Description:** CT scan demonstrating a large, well-defined pancreatic pseudocyst in the lesser sac adjacent to the stomach. The collection has a mature, enhancing wall and homogeneous fluid contents, characteristic of a pseudocyst more than 4 weeks after acute pancreatitis.

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Pancreatic_cancer