WorkUp

The great majority of patients presenting with pancreatic or periampullary neoplasms are studied with helical computed tomography (CT) scan, which anatomically places the lesion and gives information about morphology, such as whether it is solid or cystic. A multidetector, dual-phase CT scan of the pancreas with three-dimensional reconstructions is preferable. This technique gives exquisite detail about the possible involvement of the nearby vascular structures, such as the portal vein, superior mesenteric vein (SMV), superior mesenteric artery (SMA), celiac axis, and hepatic artery. Additionally, the liver and peritoneal cavity can be screened for possible involvement at the same time. Because the chest also represents a potential site of metastatic spread, it should also be screened. This may be accomplished by either a chest CT or chest radiograph.

Patients who present with biliary duct obstruction can be further worked up with biliary imaging. These include both invasive and noninvasive techniques. The most common

TABLE 141-2. Periampullary Neoplasms (Including Adenocarcinomas)

Pancreatic neoplasms (see Table 141-1) Distal bile duct neoplasms Ampulla of Vater neoplasms Duodenal neoplasms technique is magnetic resonance cholangiopancreatography. This technique has the advantage of being noninvasive and can be accomplished without bacterial seeding of the obstructed biliary system, and without the risk of bleeding or pancreatitis. This technique has the disadvantages of being without the possibility of making a tissue diagnosis or draining an obstructed biliary system. The common invasive techniques include endoscopic retrograde cholangiopancreatography and percutaneous trans-hepatic cholangiography with or without drainage. These techniques have the converse advantages and disadvantages just previously discussed. Obstructive jaundice does not need to be relieved prior to bringing a patient to the operating room if the patient is not suffering any septic or nutritional consequences of the obstruction. Several authors have reported on the increased rate of infectious and bleeding complications in patients who have undergone manipulation of their biliary trees prior to definitive resection.

In certain cases, endoscopic ultrasound (EUS) with or without biopsy may be of benefit. This technique can especially be helpful in smaller lesions not well characterized by CT or magnetic resonance imaging. This test should only be used in situations where the outcome will effect subsequent management. For example, it is rare that EUS and biopsy changes the decision to explore an elderly patient with painless obstructive jaundice, a good quality CT scan demonstrating a resectable solid mass in the head of the pancreas, no evidence of metastatic disease, and who is a good operative candidate. Additionally, patients with a good quality three-dimensional CT demonstrating resectability might be best served with exploration even if the EUS shows possible vessel involvement because of the low but real false-positive rate of the test. EUS and fine needle aspiration are discussed in a separate chapter (see Chapter 5, "Endoscopic Ultrasonography and Fine-Needle Aspiration").

Patients who present with signs and symptoms of hormonal excess or who are suspected of having a neuroendocrine tumor may benefit from other specialized testing. The value of performing the various specific biochemical and imaging tests are quite variable from patient to patient and often depend on the degree of suspicion and possible clinical consequences. Each of the specific neuroendocrine disorders that can affect the pancreas or the periampullary region has specific hormones or peptides that can be assayed for in the blood or urine. Additionally, the majority of pancreatic and periampullary neuroendocrine lesions will be detectable with octreotide scan. It is sometimes of benefit to place patients with functional carcinoid lesions on octreotide prior to resection to block the potential systemic consequences of a sudden release of serotonin with manipulation. There are separate chapters on secretory diarrhea (see Chapter 72, "Secretory Diarrhea") and on gastrinoma (see Chapter 31, "Gastroparesis").

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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