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1、DavidM.DudzinskiGillianLieberman,MDSeptember2004PainlessJaundice...PainfulDiagnoses:RadiologicEvaluationofPeriampullaryMalignanciesDavidM.Dudzinski,HarvardMedicalSchoolYearIIIGillianLieberman,MDDavidM.DudzinskiGillianLieberman,MDPATIENT#1:FSEDPresentation;BIDMCw/u°85M
2、°May2004,presentedtoOSHEDs/pfall•Scleralicterusnoted.•CTforworkupoffallrevealedpancreaticmass.°ReferredtoBIDMC•Noabdominalpainorbackpain.Jaundiceoverpastseveraldays=“painlessjaundice”–Nopruritis,weightloss,orotherGIsymptoms•Exam:“palpable,firmmassintherightupperquadra
3、nt,compatiblewithaCourvoisier’sgallbladder”•Labs:indicativeofobstructivejaundice–Bilirubin(total)18.3mg/dL(ref.0-1.5mg/dL)–Alkalinephosphatase749IU/L(ref.39-117IU/L)2DavidM.DudzinskiGillianLieberman,MDPATIENT#1:FSCTImage:PancreaticMass2cmPancreaticHeadMassCBDStentSMA(
4、shiftleft2°toscoliosis)RenalarteriesIMVIVC06/02/04BIDMCPACS3DavidM.DudzinskiGillianLieberman,MDPeriampullaryAnatomyANTERIORVIEWPOSTERIORVIEWHepaticAmpulla,CeliacAxisTriadCBD,PDPortalSystemBiliaryTreeSMASMVNetterFH.AtlasofHumanAnatomy.2ded.1997.4DavidM.DudzinskiGillian
5、Lieberman,MDPeriampullaryMassLesions°Differentialdiagnosesbasedonimaging•Malignantneoplasms•Focalpancreatitis•Benignneoplasms•Pancreaspseudocyst,traumaticcyst,necrosis•Abscess•Biloma,Hematoma•Lymphadenopathy•Aneurysm•Duodenalcyst,polyp,diverticulum°OverlapwithDDxofobs
6、tructivejaundice?ReederMM.ReederandFelson’sGamutsinRadiology.4thed.2003.5DavidM.DudzinskiGillianLieberman,MDPainlessJaundice°Signclassicallyassociatedwithmalignantetiologiesofextrahepaticorobstructivejaundice•CarcinomaofampullaofVater•Extrahepaticcholangiocarcinoma(“C
7、CA”)•Ductaladenocarcinomaofthepancreatichead(“ACA”)°Diagnosticcaveat•Painlessjaundiceinsomecasesofcholecystitis•Advancedmalignanciesmayoftenpresentwithpain°Painlessjaundiceisthemostcommonpresentationassociatedwitharesectableandcurablemalignancy.•Thus,theradiologistcan
8、facilitaterapid,lifesavingdiagnosisandsurgicalintervention.KalserMH,etal.Cancer.1985;56:397-402.MolodellI,etal.AnnalsOncol.1
