Patient Kantaben Shah, 78years, came to Endoscopy Asia with severe jaundice and intractable vomiting for last one week. Patient had severe itching all over the body. She is a known case of diabetes.

The past history of patient revealed that she was diagnosed with carcinoma head of pancreas 4 months back. She was not considered fit for surgical intervention. So patient had received chemotherapy. Patient had consulted some leading oncosurgeons who after evaluating her refused to operate on her and had given an impression of a very painful course of the disease and had advised no further treatment as she had ascites (free fluid in the abdomen).

Endoscopy Asia’s Intervention
Diagnosis: Patient was evaluated at Endoscopy Asia with upper GI Endoscopy and Endoscopic Ultrasound. Endoscopic evaluation revealed tumor invading at the duodenum (initial part of small intestine) causing obstruction to the outflow of stomach. Endoscopic Ultrasound revealed obstruction of the bile duct by the tumor overgrowth causing jaundice and severe itching.

Treatment: Considering the advanced stage of the cancer and poor general health of the patient, palliative treatment was offered to the patient. A self expandable metallic stent was placed in the CBD to relieve the jaundice. And another self expandable metallic stent was placed in the duodenum communicating to the stomach, thus relieving the outflow obstruction of the stomach. The patient was relieved of all her symptoms which she had complained.

Endoscopy Asia’s Observation:
Up to 80% of adenocarcinomas of the head of the pancreas are not resectable at presentation. Pancreatic adenocarcinoma is a frequent cause of malignant obstruction of the common bile duct (CBD) (70-80%) and duodenum (5-10%). Self-expanding metallic stents can be used to relieve obstruction of bile duct and duodenum in patients with unresectable pancreatic cancer. Traditionally conventional surgery is performed named as triple bypass, but due to ascites surgery was contraindicated in this case.
Endoscopic palliation of biliary obstruction and duodenal obstruction has almost replaced triple bypass performed with conventional surgery, in all leading Gastroenterology & Endoscopy centres of the world.

Prognosis: Patient was completely relieved of the intractable vomiting, which she was complaining before the procedure. The jaundice and generalized itching subsided in next 4-5 days. The patient is performing well and is able to continue her daily activities as usual.

1. Narrowing of the stomach opening before placement of stent
2. After stent placement the opening of the stomach is wider immediately
3. Narrow opening of the bile duct prior to stent placement
4. Opening of the bile duct immediately after the stent placement

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