Question

Part V – CT Scans

“Here is your CT scan, Frank. Just to orient you, it shows a slice across your abdoment just below your diaphragm (inset on right). This scan (Figure 2) is taken from a healthy individual; we use it in teaching and you can see labels on the various organs. Now look at your scan (Figure 3), which was taken at a similar plane. I have drawn arrows to show your pancreas,” explained the doctor.

“My pancreas looks larger; and what are those dark blobs?”

Questions

1. Speculate on the identity of the “dark blobs” Frank noticed in Figure 3.
2. Do you think these “dark blobs” could affect the secretion of insulin?
3. Do you think these “dark blobs” could inhibit the liver from producing conjugated bilirubin?

4. Frank’s CT scan shows the “head” of the pancreas in the vicinity of the small intestine and the stomach. What do you think would be the effect of an enlarged pancreas on the ability of the gall bladder to send bile down the bile duct and into the small intestine?

5. Why does Frank have elevated levels of bilirubin in his blood? 6. Would you like to modify your diagnosis?

NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE

Figure 2. Healthy Patient’s CT Scan Figure 3. Frank’s CT Scan

Figure 2: University of Leeds, http://www.bmb.leeds.ac.uk/teaching/visible/, used with permission.
Figure 3: Thoeni R F. The revised Atlanta classification of acute pancreatitis: Its importance for the radiologist and its effect on treatment. Radiology 2012;262:751–764. Used with pemission.

Part VI – The Final Diagnosis

“So what’s the problem doctor?” asked Frank.

“Your CT scan shows that your pancreas contains some unusual growths, what you called ‘dark blobs’,” replied the doctor. “These growths may be interfering with your ability to secrete insulin.”

“So does that mean I do not have diabetes?”

“We’ll need to do more tests to determine that, but I am very concerned about the size of your pancreas, which seems to be so big that it’s blocking the bile and pancreatic ducts.”

“So these growths are blocking the duct that takes bile from the gall bladder into the small intestine and are the source of my pain?”

“That seems possible,” replied the doctor. “With a blocked bile duct, bilirubin cannot get into your small intestine and will build up in your gall bladder, your liver, and ultimately in your blood.”

“That would explain why I am jaundiced. Are those ‘dark blobs’ cancerous, doctor?”

“We’ll need to take a biopsy to be certain, but I am afraid they may well be. I’m sorry, Frank. Still, we’re very lucky that we discovered these growths at such an early stage. If you had waited we could be looking at more serious problems.”

“So, what’s the next step?”

“We’ll need to do more tests, but I think you’ll probably need surgery to remove the growths. I know that this may sound drastic, so I think you should see a specialist. We are fortunate because we have a very good gastroenterologist and an excellent abdominal surgeon on staff. I have scheduled an appointment for you to see them this afternoon. One advantage of having them in this hospital is that it will be easy to get your test results and CT scans to them before your meeting. They can refer you to other doctors if you wish, but I think they will advise you to get this treated as soon as possible.”

1. How is cancer staged after a biopsy is conducted?

2. How could a blocked bile duct effect digestion in the small intestine?

   Think about what substances flow through the bile duct and what they

   do in the small intestines.

3. In addition to issues with insulin, if the pancreas is not working properly

   or flow out of the pancreas is impaired due to a tumor, what implications could this have on digestion? Hint what is the role of the pancreas in digestion?

4. What are some nutrients that someone could become deficient in based on your answer for #2&3

Answer 1

1. The large pancreas with dark blobs indicates the anomalous growth of the pancreatic tissue which can be tumors as well.

2. The dark blobs can affect the insulin secretion and distribution through obstruction in bile and pancreatic duct .

3. No, conjugated bilirubin production increases in case of dark blobs due to blockage of common bile duct.

4. Due to enlarged pancreas, it tends to exert enormous pressure on bile duct and as a result it constricts .Therefore, it can't carry the excretory waste efficiently. So, it restricts the ability of gall bladder to send bile down the bile duct and in small intestine.