In view of the clinical and laboratory findings, the patient was referred to our institution for further investigation and treatment.

The laboratory exams on admission showed a normocytic normochromic anemia (hemoglobin 10,7 g/dL, hematocrit 35,60%, mean corpuscolar hemoglobin 28,1 pg, mean cell volume 93,4 fl) with peripheral eosinophilia (850/mm³) and thrombocytosis (618000 platelets/mm³) with a compatible picture of cholestasis, showing high levels of canalicular enzymes and transaminases(alkaline phosphatase 714 UI/L, gamma-glutamyl transferase 179 UI/L, oxaloacetic transaminases 60U/L, glutamic-pyruvic transaminase 71 U/L), aswell direct hyperbilirubinemia (Total Bilirubin 6,1 mg/dL, direct bilirubin 5,8mg/dL, indirect bilirubin 0,4 mg/dL). His pancreatic enzymes were normal (amylasis 27U/L). Tests for HIV, hepatitis B and C, and syphilis were non-reactive. His chest x ray hadn’t signs of consolidation or diffuse infiltrates (Figure 2-A).

His electrocardiogram showed sinus rhythm with an electrical axis within normality. The contrast tomography (CT) of the abdomen and pelvis on admission, in turn, similar to the external examination, presented an image suggestive of heterogeneous expansive formation with cystic density (necrosis) adjacent to the head/unciform process of the pancreas, including the papilla, and with involvement of the bile duct, suspected for advanced-stage pancreatic neoplasm, with maintenance of intra and extrahepatic biliary tracts dilatation and signs of residual aerobilia upon biliary prosthesis implantation. It also showed multiple foci of pathological lymph node enlargement, some clustered and coalescents, notably periaortocavals, in the hepatic hilum and peripancreatic, the latter measuring up to 4.1 x 4.0 cm (Figure 2-B).