Originally Posted: January 15, 2015

BILIARY-ENTERIC OBSTRUCTION
FROM RECURRENT CANCER
Resident(s): Osama Abdul-Rahim
Attending(s): Jeffrey Weinstein
Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation
Abdominal pain

History of Present Illness

57 y/o male with pancreatic adenocarcinoma s/p Whipple 8 months
prior presents with abdominal pain

RELEVANT HISTORY
Past Medical History
Spinal stenosis
Hypertension
GERD
Arthritis
Anxiety

Past Surgical History

Jaw surgery, Whipple

Family & Social History

1 pack/day x 40 years, no EtOH or drug use

DIAGNOSTIC WORKUP
Physical Exam
Mild right upper quadrant tenderness to palpation

Laboratory Data
Total Bilirubin: 7 mg / dL

DIAGNOSTIC WORKUP - IMAGING

Pancreatic adenocarcinoma
prior to Whipple

1 month s/p Whipple - No local or distant

disease recurrence

DIAGNOSTIC WORKUP - IMAGING

8 months post Whipple there is a mass in right perinephric space (green arrow)
causing afferent limb (yellow arrow) and biliary ductal dilatation (red arrow)

DIAGNOSIS
Metastatic pancreatic adenocarcinoma
CT abdomen and pelvis shows recurrent tumor in the right
perinephric space
Resultant mass effect is obstructing the afferent jejunal limb
causing secondary biliary obstruction, indicated by the
intrahepatic bile duct dilatation and elevated bilirubin

INTERVENTION

Left hepatic internal/external percutaneous

biliary drain was placed

3 days later, ductal dilatation improved but

afferent jejunal limb remains dilated

INTERVENTION

Transhepatic enterography shows persistent afferent

limb obstruction due to extrinsic compression

Guidewire was advanced across the

obstruction

INTERVENTION

Initially, an 18 x 60 mm Wallstent was placed. Due

to foreshortening, it was thought to be too short

A 14 x 100 mm Nitinol stent was deployed within the

Wallstent. Contrast flowed freely through the stent

CLINICAL FOLLOW UP
Follow up CT showed improvement in both
biliary ductal and afferent jejunal limb
dilatation after intervention

QUESTION 1
1) Why was endoscopic guided therapy less feasible in this scenario?
A: Endoscopy is not indicated for biliary obstruction.
B: Endoscopy can never be performed following a Whipple procedure.
C: Endoscopy is technically challenging following a Whipple procedure.
D: Whats endoscopy?

SORRY, THATS INCORRECT.

1) Why was endoscopic guided therapy less feasible in this scenario?
A: Endoscopy is not indicated for biliary obstruction. (Endoscopy is often a good option for
evaluation and treatment of biliary obstruction)
B: Endoscopy can never be performed following a Whipple procedure. (Endoscopy is
sometimes possible following a Whipple and requires a double-balloon technique. It is very
difficult however and often unsuccessful.)
C: Endoscopy is technically challenging following a Whipple procedure. (Due to the
anatomic alterations resulting from a Whipple complicating the endoscopic approach,
transhepatic approach to a dilated biliary system was a good choice for intervention in
this patient.)
D: Whats endoscopy? (Small, flexible camera that enters the mouth or anus and can travel
through the proximal small bowel or colon, respectively, allowing direct visualization and
possible therapeutic intervention.)
CONTINUE WITH CASE

CORRECT!
1) Why was endoscopic guided therapy less feasible in this scenario?
A: Endoscopy is not indicated for biliary obstruction.
B: Endoscopy can never be performed following a Whipple procedure.
C: Endoscopy is technically challenging following a Whipple procedure.
Although endoscopy is often a good option for evaluation and treatment of
biliary obstruction, due to the anatomic alterations resulting from a Whipple,
although endoscopy is sometimes possible using a double-balloon technique, it
is very difficult and often unsuccessful.
D: Whats endoscopy?
CONTINUE WITH CASE

QUESTION 2
What are some of the more common uses of stents in the GI tract?
A: Esophagus
B: Stomach
C: Common Bile Duct
D: Colon
E: All of the above

CORRECT!
What are some of the more common uses of stents in the GI tract?
A: Esophagus (Can be used for palliation of dysphagia from esophageal or

gastric cardia cancer, tracheoesophageal fistula, esophageal rupture)

B: Stomach (Gastric outlet obstruction, pseudocyst drainage)

C: Common Bile Duct (Relieve obstruction or leak)
D: Colon (Relieve obstruction either as a bridge to surgery or for palliation)
E: All of the above
CONTINUE WITH CASE

SORRY, THATS INCORRECT.

What are some of the more common uses of stents in the GI tract?
A: Esophagus (Can be used for palliation of dysphagia from esophageal or

gastric cardia cancer, tracheoesophageal fistula, esophageal rupture)

B: Stomach (Gastric outlet obstruction, pseudocyst drainage)

C: Common Bile Duct (Relieve obstruction or leak)
D: Colon (Relieve obstruction either as a bridge to surgery or for palliation)
E: All of the above
CONTINUE WITH CASE

SUMMARY & TEACHING POINTS

57 y/o male with recurrent metastatic pancreatic
adenocarcinoma s/p Whipple causing afferent jejunal limb and
biliary obstruction
Biliary obstruction was initially relieved with internal/external
percutaneous transhepatic biliary drain placement
Persistent afferent jejunal limb obstruction was subsequently
successfully relieved by placing an enteric stent
transhepatically

REFERENCES
Lee JM, Han YM, Lee SY, Kim CS, Yang DH, Lee SO. Palliation of postoperative
gastrointestinal anastomotic malignant strictures with flexible covered metallic
stents: preliminary results. Cardiovasc Intervent Radiol 2001;24:25-30.
Yim HB, Jacobson BC, Saltzman JR, Johannes RS, Bounds BC, Lee JH, et al. Clinical
outcome of the use of enteral stents for palliation of patients with malignant upper
GI obstruction. Gastrointest Endosc 2001;53:329-32.
Feretis C, Benakis P, Dimopoulos C, Manouras A, Tsimbloulis B, Apostolidis
N. Duodenal obstruction caused by pancreatic head carcinoma: palliation with selfexpandable endoprostheses. Gastrointest Endosc 1997;46:161-5