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).