Next patient linda lowry 937529 73 year old lady ct thorax abdomen and pelvis lungs are clear no thoracic lymph nodes aortic root myelin dilated 40 millimeters in diameter 24 millimeter hypodense mass in the head of the pancreas associated distal pancreatic duct dilatation and parenchymal atrophy marked cbd and intrahepatic duct dilatation also seen mass does not involve adjacent organs and the major vessels of no gallstones in the gallbladder simple cyst in the liver and kidneys no peritoneal deposits or ascites slightly prominent left para aortic lymph nodes no skeletal metastases original staging t 2 n 0 m x open brackets indeterminate paraortic lymph nodes close brackets tests biliary bin 94 up from 67 2 days ago alp 606 alt 5 0 9 normal I'm 7 crp 4 urea 4.3 full blood count microcytosis and lymphocytosis without anemia heat 6 left dcis treated with wide local excision mammogram surveillance no evidence of recurrence follow-up stopped january 2024 I'd recognize it when I was on the yeah I got to the top of the block cg sinus rhythm with first degree av block pr 214 milliseconds no evidence of ischemia okay maybe you're okay and try to grab a glass water sure go up yeah I'm not too much oh I'll see if I can I'm susan I'm 1 of the gastroenterology registrars last week I enrolled how are you I know you've got me enrolled exactly I had to be on tonight yeah very well so how are you feeling I feel rubbish it's just that nothing's rubbish there's no pain when did it all start with feeling rubbish like there was something going on bite coloured pee not dark coloured pee dark not like coca cola no no don't know a lot about that and any other symptoms and as well as the hip arthritis do have any other medical problems I don't operation super super early ductal carcinoma in situ was cut out you've had mammograms valids since then you've had any sign of recurrence as far as I can tell any other medical problems thyroid low thyroid I'm on thyroxine thyroxine for hypothyroidism stable for like your life more generally who do do you live with anyone yeah I know I live at but I live at darlington yeah yeah yeah so you walk up the that hill yeah no trouble briskly do you get short of breath as well yes yesterday I for walk but mostly yeah gardening and that must be quite active in terms of bending down with shovels and things like that yeah could you ride a bike yeah yeah do you have you worked in recent past I assume you're now is that fair to say now I go and look up for grandchildren yeah I bet yeah and did you did you work before that we don't what's your previous occupation scientist scientist bikes in the eye mortell mortell okay and yeah fine so you said that job was welcome okay that's time you've noticed itching you've already had it before got this because I've got the questions mhmm it's just yeah yeah fine but you telling me you're itchy to make me feel itchy so it's 1 of those weird things it's like you're me yeah it makes you itchy yeah yeah do you mind if I examine you can you put your hands and listen to your chest is that okay thank you so much so tell me lovely I'd love to feel your tongue yeah that'd be great thank you and I'll start my finger offence if that's okay okay okay you've got the line up in front of you I can see you okay thank you absolutely I have a quick list going with these these patients solid solid mhmm in what way just feels like I'm pushing on something yeah just feels like you're pushing I I just mhmm good so you've had some tests you've done yeah that's right that's a blood test which showed you're slightly jaundiced yeah your markers of jaundice have gone up and the liver tests look the bile ducts are irritated or blocked in some way and then you've had a ct scan yeah would like me to talk about it now or would you like to talk about it another time no no early it's late in the evening we can talk about it tomorrow anyone to be here with you no I am the scan shows a lump in the head of your pancreas the ring on the scan is that there's no sign of lymph nodes near the pancreas that look slightly enlarged yeah but there's no sign of spread of anything sinister you're very pragmatic I can tell that's a lump in the head of the pancreas has blocked your bile ducts slightly and that's why you've become jaundiced they've got those floaty stools it's because the pancreatic juices aren't able to fast the lump and so you're not able to help you with that by starting you on some medicine which supplements that will help you absorb things and eat things nutrition is so important in keeping you straight get you built back up as quickly lose as you any weight no of course yeah no we don't want to have you losing any more weight I'll grab you some nutritional supplements to go along obviously I've I've talked to about you're not very nice do you want to do anything fair enough alright you're not alright that's good so you picture of how it all works if you'd like to you'd like to understand it so your liver is up here and bile drains from the liver we need bile to help you digest fat so this is your liver this is your pancreas and this is your small intestine and this is your stomach just here and then if we follow that up we get to your mouth not very far it's like 50 centimetres down here your scan shows a lump in the head of your pancreas it shows some lymph nodes here which are near the large picture which runs down here I can't tell you 100% it is without sampling it and there are a couple of rare conditions that look like cancer but aren't I'll choose that I'll investigate you for those with some blood tests that I'll add on to your blood tests when I may need to come and get some more from you tomorrow on balance the chances are that this is cancer so the blockage here has been bile is backing up into your liver and that's what blocks this pancreatic duct which is what puts enzymes into your small bowel to let you digest fats so is my liver not working so your liver is working fine but it's just not so getting any bile products over time if we don't unblock this duct your liver will not be very happy it will start to stop working the jaundice will build up in the blood that will damage the kidneys you'll become quite sleepy and some people will die from that doctor like that doctor good what we need to do is unblock the ducts we do that through a procedure called erc it's an endoscopic retrograde cholangiopancreatography it's going to make you quite sleepy and lie you on your front in our endoscopy department 1 of my consultants then uses a camera through your mouth down your oesophagus into the first part of the small intestine then through our camera we can place a wire past the blockage and place a stent to open this up that's the most important thing to do before that's decompressed at that time we can also take some tissue from that area to try and determine what we need to talk about this with our surgical colic form in theory can perform an operation to cure this whipple's procedure it's a big operation that's the only curative option that will be available that will need to ascertain what this is whether these lymph nodes are involved so that's going to involve some tissue sampling and another type of scan I'll ask them to arrange this ercp if that's okay with you but that's gonna be very important with all this information we'll talk about you at our meeting which we have on the results of the biopsies the results of the tests you've had talk to our surgical know nutrition is so important as I've said starting on a few things to get your nutrition optimized want to know and we want to make sure you're as comfortable as possible so you can eat it sounds like you're very fit and active and would be okay but as I say the only chance so would that take the pancreas away it takes away the pancreas and a portion of the stomach the greater territory of the stomach is removed okay it's a large operation better hope I'll arrange the crcp to unblock your bile ducts I'll chat to my boss in the morning about whether we take some samples there and unblock your ducts or refer you straight to the surgeons I'll arrange you a pet scan to look at these lymph nodes to see whether they're involved I mean don't mind coming off keto rubbish for my system as soon as I'm introducing carbs you know I'm quite thin at the moment aren't you in terms of yeah I've you're at 9 to 10 in 3 very healthy weight and the most important thing is calories and I don't really mind how you consume those calories whether that's protein and would fat or whether that's it make any of these any different if I switched to carbs it would make no difference and a lot of our nutritional supplements are high in fats really they're mostly fat because that's got them high so you have some carbohydrate in yeah but I guess you have fats in your keto diet the reason you've cut down fats is because you can't absorb them but with this supplementation you wouldn't be able to absorb them and your stools would improve a part of having this operation is being fit enough for it I know I think you do but you've lost weight a lot more and probably some build up drinks and some creole oh tomorrow you'll see the consultant 1 of the gastroenterologists will be he's 1 of the liver specialists and he performs this ercp test I suggest you stay in hospital it's 2 in the morning no it's 11:00 at night so I would just stay in hospital now and then we can sort it all out tomorrow morning chat to the consultant work out what the next plan is to be honest there's nothing that makes you acutely ill and we could arrange all these things as very outpatients blood tests tomorrow are etc I'm rob from rob millett as well I'm 1 of the gastroenterologists rob yeah have this discussion in clinic in the middle of the day but I think it's good to just let you know what's going on so that you're not surprised by all the tests I'm about to order for you as I quickly as should reassure you that this is 1 of the only parts of the nhs that works well there'll be lots of tests and things moving but we'll try and keep you up to date that's the unfortunate thing about pancreatic cancer is that it only causes symptoms when it blocks the duct so it may have been developing for some time just block the ducts which is linked to symptoms your work in science you will find filtered unfiltered unfiltered yeah write your letter with everything we've talked about and we can follow everything up tomorrow okay questions don't lie here thinking about them just call yeah we'll we'll go ahead and have a look don't worry okay thank you have a rest of luck thank you do you wanna close to the chart yeah I'll have it okay so plan is number 1 I t g 4 levels number 2 ca 19 9 number 3 upper gi mdt referral number 4 upper gi cns referral number 5 ercp to decompress, gathered tissue versus consideration of hot whipples determining factor will be relevance of para aortic and lymph nodes which is likely to require pet ct assessment discussed with gastroenterology marnet no contraindication to ercp and no anticoagulation to stop if this is required blood test tomorrow to recheck bilirubin and inflammatory markers impression pancreatic cancer possibility of parietal lymph node involvement relevance of this will guide management options