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Neoplastic obstructive jaundice

  1. Gastroepato
  2. Oncology
  3. Neoplastic obstructive jaundice
  4. Gastric cancer: macroscopic classification and TNM
  5. Gastric cancer
  6. Colon carcinoma
  7. Colorectal and stomach cancer
  8. Gastric polyps
  9. Gastric polyps

Notes by dr Claudio Italiano 

Neoplastic obstructive jaundice (see pancreatic cancer and papillary cancer of Vater's cancer of the biliary tract) only rarely can be treated surgically with intent of oncological radicality since the etiologic diagnosis of biliary obstruction (see also biliary calculosis) comes almost always placed when the disease is no longer localized but has spread, both locally and remotely. 
In recent times, probably due to the improved diagnostic capacity of jaundice imaging, the comparison of periampollar neoplasms has increased, recognizing the most frequent tumor (80-85%) in the carcinoma of the pancreas head and a more unfavorable prognosis.

The toxic-septic condition from cholestatic jaundice synergizes unfavorably with the frequent finding of expired general patient conditions due to neoplastic disease and any geriatric age. The duodenocefalopancreasectomy, a radical surgical operation common to all periampollar neoplasms, can be performed in a small number of patients (15-25% of pancreatic head tumors, 50% of the remaining locations.) Palliative therapy for endoscopic lesions is indicated in the reason that, in fact, only 10-30% of pancreatic cancer, diagnosed in the symptomatic phase, is resectable and the 5-year survival of resected patients does not exceed 0.4%, few cholangiocarcinomas of the proximal third of the Main Biliary Path (VBP) they can be attacked surgically, metastatic hepatic tumors are considered by definition to be unresectable It is also to be remembered that the demolition interventions are difficult to perform, are burdened by postoperative complications responsible for a mortality of 5-10% and 5 to 90 years after surgery, 80% to 90% of the neoplasms relapse.

Diagnostic approach

Making a diagnosis of neoplastic diseases responsible for pre-icteric bile stenosis is a purely incidental event. As a rule, the diagnostic suspicion arises in the presence of a progressive cholestatic jaundice, almost always painless, which frequently is associated with intense itching. In cases where the stenosis is supported by a papillary neoplasm, the jaundice may be intermittent and may be accompanied by fever; anemia or bleeding may occur due to ulceration of the neoplastic mass.

A moderate hepatomegaly is commonly seen on the physical examination and, in patients in whom the neoplasm is located below the cystic outlet, the distended gallbladder can be palpated. The biohumoral parameters are characterized by an increase in bilirubinemia values, mainly of the conjugated one, of the alkaline phosphatase, of the gamma-GT and to a lesser extent of the transaminases (see cholestasis indices). If the anamnesis, the clinical examination and the laboratory investigations, advance the hypothesis of a biliary obstruction, are the instrumental diagnostic techniques that will allow to confirm or exclude the presence of the obstruction, to establish its location and nature. At the same time, diagnostic imaging will verify the resectability or not of the neoplasm. The choice of investigations to be used depends on the presumed location of the obstruction and, as regards the method, on the degree of invasiveness and diagnostic accuracy, on the percentage of complications related to it and on the ability to simultaneously perform any therapeutic treatment.

Imaging

Trans-parietal ultrasound
It is the investigation commonly performed in the first instance in the presence of a painless jaundice. The method highlights the dilatation of the VBP and the site of the stenosis. It can hardly differentiate a neoplasm of the distal part of the choledochus from a pancreatic neoplasm or to evaluate the neoplastic involvement of the vessels and adjacent structures. The main advantages of trans-parietal ultrasound are the non-invasiveness, the contained costs, the possibility to transport the instrumentation. The disadvantages are related to reduced accuracy, in the presence of fat or intestinal gas, and to the difficulty in visualizing small pancreatic neoplasms; it is also an operator-employee survey. Recent developments such as Color-Doppler, harmonic tissue images, the use of contrast media, 3 D reconstruction have elevated the diagnostic capabilities of the methodology in highly specialized centers.

>> neoplastic jaundice: instrumental diagnostic

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