Neoplasm at the Head of the Pancreas: A Case Study

Clinical Laboratory Science, Spring 2004 by Griffin, Kristina Marie

ABBREVIATIONS: DVT = deep vein thrombosis; ERCP = endoscopic retrograde cholangiopancreatography; INR = international normalized ratio; PTCA = percutaneous transhepatic cholangiogram.

INDEX TERMS: Courvoisier gallbladder; hemostasis; obstructive jaundice; pancreatic neoplasm.

Clin Lab Sci 2004;17(2):70

Case PRESENTATION

A 68-year-old male was seen by his anticoagulation clinic doctor for a scheduled warfarin check up. he had been diagnosed with deep vein thrombosis (DVT) about two years ago. The patient's international normalized ratio (INR) was 6.31; his target range is 2.0 to 3.0. The patient was referred to the evaluation clinic, where he was administered 2.5 mg of vitamin K. Consideration was given to his initial complaints of stomach ailments at the start of fluctuating INRs in the following weeks (Table 1).

In addition to unintentional weight loss, physician examination revealed that the patient claimed episodes of hematuria. he also complained of recent lower back and stomach pain, and for the past four weeks, blood-tinged sputum in the mornings. The patient has a history of smoking.

A urinalysis was performed and was negative for blood. Upon palpitation, his abdomen was non-tender and without masses. A 48-hour follow-up appointment was made with the anticoagulation clinic.

On the second day, the patient's prothrombin time (PT) was redrawn, and demonstrated an INR of 4.29. he maintained his directed warfarin dosage and was scheduled to return in 12 days.

At 14 days he displayed a critical INR of 6.58 and was administered another 2.5 mg of vitamin K. However, at this appointment, the patient confessed missing a warfarin dose within the last ten days. Plans were documented to decrease his warfarin dosage when the patient's INR fell to within his target range. His next appointment was scheduled for two days later. At this next appointment (16 days), the patient had an acceptable INR of 2.82. His warfarin dosage was decreased and he was asked to return in ten days for a follow-up.

On the 26th day, the patient's INR had increased to 4.68. he also stated that his urine was "dark, then light" when voiding. As well as decreasing his warfarin dosage once more, the attending doctor referred him to the evaluation clinic for the second time.

The patient reported to the evaluation clinic the following day. The attending physician acknowledged that the patient endured weight loss, yellow eyes, dark urines, light colored stools, and periumbilical tenderness. A new urinalysis revealed a large amount of bilirubin and urobilinogen (Table 2). Hepatomegaly was not apparent. A metabolic panel (Table 2) was also ordered; there was an obvious increase in alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT). The attending physician assessed the patient as suffering from jaundice, and to rule out malignancy, advised him to have an abdomen and pelvic contrast-enhanced computed tomography (CT) scan.

DISCUSSION

Pancreatic cancer is the third leading neoplasm of the gastrointestinal system and has a dismal prognosis.1 Most pancreatic tumors arise as adenocarcinomas of the ductal epithelial.2 Only about 20% of pancreatic cancers seem contained entirely within the pancreas at the time of diagnosis, and any secondary metastases would insinuate the presence of a malignancy versus a cyst or inflammation.3

Some 95% of pancreatic cancers begin in the exocrine pancreas, where digestive juices are produced.3 Primary neoplasms discovered at the head of the pancreas tend to cause many complications; the main complaint being pain. Symptoms include jaundice, weight loss, abdominal pain, indigestion, back pain, clay -colored stools, blood clots, gallbladder enlargement, and nausea.2,3

Pancreatic cancer is slightly more common in men than women, and the risk increases with age.4 The exact cause is unknown, but the incidence is greater in smokers; almost one-third of pancreatic carcinoma cases can be linked to cigarette smoking.4 A minority of cases are known to be related to hereditary syndromes.4

CLINICAL PRESENTATION AND PATHOPHYSIOLOGY

Cancer of the head of the pancreas usually is detected earlier because of its proximity to the bile duct with onset of pain.2 Partial obstructive jaundice can be experienced in these cases from impaired flow of bile into the intestines due to the pushing of the pancreatic mass. Conjugated bilirubin accumulates in the liver and, therefore, can be expressed in the blood and urine. Since the bilirubin does not travel to the intestines to be broken down into urobilin, the feces is mostly deficient of pigmentation and becomes clay -colored.

Bile travels through ducts from the liver to the gallbladder for storage, and then to the small intestine.4 It is not uncommon for patients with carcinoma at the head of the pancreas to experience Courvoisier's law, where the gallbladder is enlarged and palpable, again from tumor pressure.5

The liver plays a crucial role in hemostasis. all clotting factors (except VIII) are synthesized in the liver.2 The PT is used to monitor the extrinsic pathway, which consists of factors II, VII, IX, and X. This group is considered vitamin K dependent. For a patient on warfarin, the PT is a very important test because hemorrhage is the most serious side effect.