SURGICAL CASE PRESENTATION

By
Dr.E.Kaviprabha
final year Surgery post graduate
HOD-PROF.DR.LEKSHMI NARAYANI M.S., DGO
GUIDE-Prof.DR.T.SRINIVASAN M.S
60 year old lady from Erode came with complaints of
Yellowish discolouration of eyes and urine for four month
• History of presenting illness

She was apparently well four month back then she noticed
yellowish discolouration of eyes and urine ,gradual in
onset,intensity of discolouration progressively increased for a
period of 4 months.
H/o passage of pale coloured stools present
H/o itching all over the body
H/o vomiting for past 1 month, 2 to 3 episodes per day, non
bilious, not blood stained,contains undigested food particles
which was ingested 12 hours back.
H/o abdominal pain present for past 1 month,insidious in
onset,dull aching type,upper abdominal pain,not related to food
intake,no aggravating ,relieving factors
H/o loss of appetite for past 4 months
H/o loss of weight present(she noticed it by loosening of clothes)
for the same duration
No h/o passage of black tarry stools
No h/o heamatemesis
No h/o fever with chills and rigors
No h/o abdominal distension
No h/o breathlessness,hemoptysis,cough
No h/o headache, seizure,dizziness
Past history
No h/o recurrent episodes of abdominal pain,jaundice,fever in the past

she is known hypertensive since 2 years for which she is on

antihypertensive medication

No h/o any blood transfusion in her past

Personal history
She takes mixed diet
Appetite reduced
Sleep disturbed
Her bowel,bladder habits normal
Not an alcoholic,not a smoker and no history of any other
substance abuse was present
Obstetric history
• 4 female children
• Sterilisation done.
• Breast fed to all children
Family history
• No h/o liver disease /any other malignancies in any of her
family members
• Summary
• 60 yr old post menopausal lady came with yellowish
discouration of eyes and urine for past 4 month,progressing
gradually,associated with passage of pale coloured stools and
pruritis all over the body,h/o vomiting for past 1 month
contains undigested food particles.h/o upper abdominal pain
for past 1 month,dull aching type with loss of weight and
significant loss of weight.
GENERAL PHYSICAL EXAMINATION
• Conscious,oriented,moderately built and nourished
• Vital signs
• PR-80BPM
• BP-140/80mmhg taken in right arm at sitting posture
• WT-56kg
• HT-146cm
• BMI-26.2
• ECOG score-1
• Icteric
• Pallor could not be assessed
• Scratch marks seen all over the body
• No bilateral pitting pedal edema
• No generalised lymphadenopathy
• No signs of liver cell failure
 Per Abdominal examination
• Inspection
Umbilicus normally inverted.
abdomen not distended.
No localised fullness seen,
No visible pulsation seen
Suprapubic horizontal scar of size 2cm noted
No dilated veins seen
All quadrants moves equally with respiration
No visible gastic peristalsis seen.
Inguinal hernial orifices normal
• Palpation
No localised raise in temperature noted over all quadrants of abdomen
tenderness felt over epigastric region
A well defined globular mass of size 6cm*5cm palpable over right
hypochondriac region and right lumbar region with smooth
surface,well defined margin,firm in consistency,moves with
respiration,lower and medial and lateral borders palpable,side to side
intrinsic mobility noted,
Can insinuate finger below right costal margin
No other mass palpable
Liver not palpable
No splenomegaly
No renal angle tenderness
Percussion
• Dull note over the mass present which is continuous with liver
dullness
• No shifting dullness
• No fluid thrill
• Liver span-12 cm at mid clavicular line
• Auscultation
Normal bowel sounds heard
No bruit or venus hum over mass

Auscultopercussion test –greater curvature of stomch marked

below the level of umbilicus
Succusion splash-present
• Per vaginal/per rectal examination-normal
• No left supraclavicular lymph node
enlargement noted
• Examination of other system
CVS-S1 S2 present
RS-B/L NVBS present
CNS-CLINICALLY NORMAL
• SUMMARY
• 60years old female presenting with complaints of yellowish
discouration of eyes and urine for past 4 month,progressing
gradually,associated with passage of pale coloured stools and
pruritis all over the body,h/o vomiting for past 1 month
contains undigested food particles.h/o upper abdominal pain
for past 1 month,dull aching type with loss of weight and
significant loss of weight.
• On examining the pt, a well defined globular mass felt in the
right hypochondriac and right lumbar region likely to be gall
bladder with positive auscultopercussion test and succussion
splash.
Probable diagnosis
• Obstructive jaundice due to CARCINOMA
HEAD OF PANCREAS with gastric outlet
obstruction probably due to duodenal
involvement
 Investigations pre operative
1.USG abdomen and pelvis
• Gall bladder distended,sludge seen,cystic duct ,common
bile duct dilated 11mm at porta.no claculus,there is abrupt
termination of distal CBD.
• P/O distal cbd stricture likely malignant with features of
biliary obstruction
2.OGD SCOPY-D2 obstruction due to growth,stagnant food
particle present
3.CECT Abd and pelvis-ill defined enhancing soft tissue lesion
in the periampullary region infiltrating the 2nd part of
duodenum with upstream EHBR,IHBR dilatation and gastric
outlet obstruction likely periampullary ca-For HPE correlation
• Liver function test
Total bilirubin-3.3mg/dl
Direct-1.2mg/dl
Indirect-2.1mg/dl
Alkaline phosphatase-830U/L
Total proteins-7.1g/dl
Albumin-3.2g/dl
Globulin-3.9g/dl
A/G ratio-0.82
AST-229.4U/L
ALT-76.8U/L
• URINE ROUTINE
• Colour-dark yellow
• Bile pigment- present
• Urobilinogen -absent
CECT SHOWING DISTNDED STOMACH