Case Discussion: Gastroenterohepatology

Semester 4

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Denina Setya Ningtyas
Moderator : dr. Singgih Pudjo Wahono, Sp.PK
▪ Female, 59 months old
▪ Chief complaint: abdominal pain
▪ Current medical history :
The patient complained of abdominal pain since about
3 weeks. The patient also complains of nausea and
vomiting and decreased appetite. Since 1 week the
patient seems weak. According to the patient's
husband, the patient appeared thinner in the last 1
month, but the body weight was not weighed. There is
no complained of fever, cough, and shortness of
breath.
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History of past illness:
HT (-), DM (-), disease with same symptom (-)

Social History:
Smoking (-), alcohol consumption (-), her husband is a smoker

Family Medical History:

Cancer (-), HT (-), DM (-)

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General Looked moderately ill, GCS: 4-5-6, BW: 52 kg, height: 156 cm,
appearance Nutritional status: normal
Vital sign HR: 120x/m, RR: 20x/m, Tax: 36.7oC, BP: 110/60 mmHg,
SpO2: 98% with 3 lpm nasal canule
Head and Anemic conjungtiva +/+ , icteric sclera -/-
neck
Thorax Cor: ictus invisible, palpable at ICS V 2 cm lateral MCL sinistra,
LHM ≈ ictus, RHM≈SL dextra, S1S2 single, murmur, gallop (-)
Pulmo: Rh-/-,Wh -/-
Abdomen Convex, bowel sound (+) normal, liver span 9 cm, traube
space: timpani (+), shifting dullness (+)
Extremity Warm acral, CRT <3 second, leg edema +/+
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Hematology 12/6 14/6 18/6 Reference
Hb 8.00 9.50 7.5 10.85-14.9 g/dL
Post transfusi hematemesis
PRC
Erythrocyte 3.03 3.50 2.82 4.11-5.55 x 106/µL
Leukocyte 7.97 7.30 3.55 4.79-11.34 x 103/µL
Hct 25.9 30.00 24.1 34-45.1 %
Plt 333 198 36 216-451 x 103/µL
MCV 81.5 81.7 81.5 71.8-82.0 fL
MCH 26.4 27.1 26.6 22.6-31.01 pg
MCHC 30.9 31.7 31.1 30.8-35.2 g/dL
RDW 15.7 16.4 16.8 11.3-14.6 %
Eo/Ba/Neut/Ly/Mo 0/0/74/14 0/0/80/12 0/1/84/10 ≤4/≤1/51-67/25-33/2-5
/13 /9 /5 5
▪Coagulation test
Parameter 12/6/22 Reference

PPT
•Patient 12,4 9,4 – 11,3
•Control 11,4
•INR 1,2 < 1,5
APTT
•Patient 32,2 24,6-30,6
•Control 25,8

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Clinical 12/6 14/6 15/6 18/6 Reference
Chemistry

Bilirubin total 0.58 < 1.0 mg/dL

Bilirubin direk 0.38 < 0.25 mg/dL
Bilirubin 0.20 < 0.75 mg/dL
indirek
AST 73 0-32 U/L
ALT 42 0-33 U/L
Albumin 2.20 2.36 2.7 1.96 3.5-5.5 g/dL
albumin hematemesis

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Imunoserology 12/6 Reference
Procalcitonin > 100 ng/mL < 0,5 low risk of sepsis
HbsAg Non reactive COI< 0.9 non reactive
COI: 0.431
Anti HCV Non reactive COI< 0.9 non reactive
COI: 0.080
CEA 2.44 < 5.0 ng/mL
Ca 19-9 36.58 <27 U/mL

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Clinical Chemistry 17/6 Reference

Urea 23.5 16.6-48.5 mg/dL

Creatinine 0.80 <1.2 mg/dL

eGFR 97.551 mL/menit/ 1.73 m2

RBG 99 <200 mg/dL

Calcium 7.9 7.6-11 mg/dL
Phospor 3.7 2.7-4.5 mg/dL

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Serum Electrolyte 12/06 Reference

Na 135 136-145 mmol/L

K 2.56 3.5-5 mmol/L

Cl 102 98-106 mmol/L

Antigen 12/6 Reference

Rapid test Antigen SARS- Negatif Negatif
CoV2

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 Blood Gas Analysis
12/6/22 Reference Range
pH 7,31 7,35-7,45
pCO2 33,9 35-45
pO2 43,5 80-100
Bikarbonat 17,1 21-28
(HCO3)
Base Excess -9,4 (-3)-(+3)

O2 Saturation 75,2 >95

Hb 8,6
Suhu 37,0

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Conclusion: metabolic acidosis dd/ vein sample
CXR 19/6/22 → Normal
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▪Carcinoma caput
pancreas with
peripancreatic mass
▪Multiple nodul ec. Susp.
Inflamation

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▪ IVFD PZ: D10 1:1
▪ Inj. Lansoprazol 1x1 iv
▪ Inj. Tranexamic acid 3x1 iv
▪ Inj. Ceftriaxone 2x1 iv
▪ Inj. Santagesik 3x1 iv
▪ Inj. Ondancetron 3x 8 mg iv

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▪ The laboratory results showed: normochromic normocytic anemia,
thrombocytopenia and increased RDW, acidosis metabolic,
increased AST and ALT, hypoalbuminemia, hyponatremia,
hypokalemia, with high procalcitonin and Ca 19-9.
▪ Radiology results: normal
▪ History taking, physical examination and other examination
showed:
1. Ca caput pancreas
2. Hypoalbuminemia d.t liver insufficiency DD hypercatabolic
state
3. Sepsis d.t pancreatic cancer DD susp. UTI
4. Normochromic anisocytosis Anemia dt chronic disease
(malignancy)
5. Electrolyte imbalance dt low intake DD metabolic acidosis 15
▪ Performing: blood smear, reticulocyte, amylase, lipase,
ascites fluid analysis, total protein, globulin, ALP, GGT, AFP,
blood culture, lactic acid, urinalisis
▪ Monitoring: CBC, albumin, AST/ALT, ureum, creatinine,
bilirubin TDI, AST/ALT, electrolyte serum, FH, CEA, Ca 19-9,
BGA, SOFA score, CXR,Vital sign

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Establishment of
diagnosis

High Ca 19-9 in this

patient
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Establishment of
diagnosis

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 • Establishment of
1 the diagnosis

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  Pancreatic cancer is the fourth leading cause of cancer deaths,
being responsible for about 7% of all cancer-related deaths.
 Approximately 75% of all pancreatic carcinomas occur within
the head or neck of the pancreas, 15-20% occur in the body of the
pancreas, and 5-10% occur in the tail.
 The relative 1-year survival rate for pancreatic cancer is only 28%,
and the overall 5-year survival is 7%
 Pancreatic cancer is notoriously difficult to diagnose in its early
stages.
 At the time of diagnosis, 52% of all patients have distant disease
and 26% have regional spread.
McGuigan, Andrew, et al. "Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes." World journal of gastroenterology 24.43 (2018): 4846.
https://emedicine.medscape.com/article/280605-overview
 ▪ Anorexia, malaise, nausea,
fatigue, diarrhea
▪ Significant weight loss:
Characteristic feature of
pancreatic cancer
▪ Midepigastric pain: Common
symptom of pancreatic cancer,
sometimes with radiation of the
pain to the midback or lower-
back region
https://emedicine.medscape.com/article/280605-overview
▪ Painless obstructive jaundice:
Most characteristic sign of
cancer of head of the pancreas
▪ Developing, advanced intra-
abdominal disease: Presence
of ascites, a palpable
abdominal mass,
hepatomegaly from liver
metastases, or splenomegaly
from portal vein obstruction
▪ Ascites may result, and this
has an ominous prognosis.
 NON-MODIFIABLE RISK FACTORS: MODIFIABLE RISK FACTORS:
1. Age: 90% of newly diagnosed patients are a. Smoking
aged over 55 years of age, with the b. Alcohol
majority in their 7th and 8th decade of life c. Chronic pancreatitis
2. Sex: Male : female = 4:1 d. Obesity
3. Ethinicity e. Dietary factor
4. Blood group
5. Gut microbiota
6. Family history and genetic susceptibility
7. Diabetes mellitus

McGuigan, Andrew, et al. "Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes." World journal of gastroenterology 24.43 (2018): 4846.
- CBC : a mild normochromic anemia, Thrombocytosis
- Hepatobiliary tests: Patients with obstructive jaundice show significant
elevations in bilirubin (conjugated and total), ALP, GGT, and, to a lesser
extent, AST and ALT
- Serum amylase and/or lipase levels: Elevated in less than 50% of patients
with resectable pancreatic cancers and in only 25% of patients with
unresectable tumors
- Patients with advanced pancreatic cancers and weight loss may also have
general laboratory evidence of malnutrition (eg, low serum albumin or
cholesterol level).
- Tumor markers such as CA 19-9 antigen and CEA: 75-85% have elevated CA
19-9 levels; 40-45% have elevated CEA levels
https://emedicine.medscape.com/article/280605-guidelines#g1
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▪ Female, 59 years
▪ Anamnesis : anorexia, - Carcinoma caput pancreas
weight loss, decrease - Electrolyte imbalance dt low intake DD
appetite metabolic acidosis
▪ Lab. Findings:
Normochromic anisocytosis
anemia, thrombocytopenia,
increased AST/ALT, high • Performing: amylase, lipase, ascites fluid
procalcitonin, high Ca 19-9, analysis, SAAG, total protein, globulin,
hyponatremia,hypokalemia ALP, GGT, AFP, SPE (if needed),
hypoalbuminemia, BGA: • Monitoring: CBC, albumin, AST/ALT,
metabolic acidosis bilirubin TDI, AST/ALT, SE, BGA
▪ Thorax Xray: normal
▪ Abdominal CT-Scan: ca
caput pancreas
▪ Sepsis is defined as life-threatening organ dysfunction caused
by a dysregulated host response to infection.
▪ Organ dysfunction can be identified as an acute change in total
SOFA score ≥2 points consequent to the infection.
▪ Septic shock can be defined with a clinical construct of sepsis
with persisting hypotension requiring vasopressors to maintain
MAP≥65mmHg and having a serum lactate level>2mmol/L
(18mg/dL) despite adequate volume resuscitation.

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 Sofa score: 3

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▪ Patients with pancreatic cancer were found to have the
highest incidence of sepsis, even greater than for leukemia.
▪ Cancer patients may be immunocompromised due to multiple
factors such as chemotherapy, radiotherapy, impairment of
normal leukocyte function, or use of corticosteroids
▪ For patients with pancreatic cancer, tumor growth causing
obstruction of the bile duct is a common, yet troubling
occurrence, leading to potential serious complications
including severe infections.

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▪ UTIs are rare in adult younger than 50 years but increase in
incidence thereafter.
▪ Dysuria is the most frequent chief complaint in adult with UTI.
The combination of dysuria, urinary frequency, and urinary
urgency is about 75% predictive for UTI
▪ Causes of adult → UTIs include prostatitis, epididymitis, orchitis,
pyelonephritis, cystitis, urethritis, and urinary catheters.
▪ Routine laboratory studies include urine studies, such as
urinalysis, Gram staining, and urine culture.

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Score: 2
▪ Female, 59 years
▪ Anamnesis : anorexia,
weight loss, decrease - Sepsis dt pancreatic cancer DD susp. UTI
appetite,
▪ Lab. Findings:
Normochromic anisocytosis
anemia, thrombocytopenia,
high procalcitonin, SOFA
score: 6 • Performing: lactic acid, urine culture, blood
culture (if needed)
▪ Thorax Xray: normal
• Monitoring: Vital sign, GCS, SOFA score,
▪ Abdominal CT-Scan: Ca CBC, albumin, AST/ALT, bilirubin TDI,
caput pancreas
creatinine, procalcitonin
 Female, 59 y.o
▪ Hypoalbuminaemia may be a result of decreased production (rare) of
albumin or increased loss of albumin via the kidneys, gastrointestinal (GI)
tract, skin, or extravascular space or increased catabolism of albumin or a
combination of 2 or more of these mechanisms. Hypoalbuminemia. Gounden V, et al. StatPearls Publishing. Europe PMC Plus. 2018

Low intake • Low intake (nausea,

vomitting)
Hypoalbuminemia
et causa:
Increased • Infection, cancer
catabolism
▪ Female, 59 years Diagnosis:
▪ Lab findings: • Hypoalbuminemia d.t liver
- Hypoalbuminemia insufficiency DD hypercatabolic
- Increased AST/ALT state
- SOFA score: 6

Plan
• Suggest : total protein, globulin,
ALP/GGT, bilirubin
• Monitoring: CBC, AST/ALT,
albumin, SOFA score

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• Normocytic normochromic
anemia is the type of
anemia in which the
circulating red blood cells
(RBCs) are the same size
(normocytic) and have a
normal red color
(normochromic).
• Most of the normochromic,
normocytic anemias are a
consequence of other
diseases; a minority
reflects a primary disorder
of the blood.

• Suggestion : peripheral blood

smear, reticulocyte
Yilmaz G, Shaikh H. Normochromic Normocytic Anemia. 2022 Mar 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID:
• Monitoring : CBCkaryotyping 33351438.
 • High Ca 19-9 in
this patient
2

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 - CA19-9 is the most commonly used and best validated serum
tumor marker for pancreatic cancer diagnosis in symptomatic
patients and for monitoring therapy in patients with pancreatic
adenocarcinoma.
- Normally synthesized by normal human pancreatic and biliary
ductal cells and by gastric, colon, endometrial and salivary
epithelia.
- CA 19-9 is present in small amounts in serum

• McGuigan, Andrew, et al. "Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes." World journal of gastroenterology 24.43 (2018): 4846.
• Lin, Y. C., Lee, P. H., Yao, Y. T., Hsiao, J. K., Sheu, J. C., & Chen, C. H. (2007). Alpha-fetoprotein-producing pancreatic acinar cell carcinoma. Journal of the Formosan
Medical Association, 106(8), 669-672.
 Serum cancer antigen 19-9 (CA 19-9) is the only marker
approved by the United States Food and Drug Administration
for use in the routine management of pancreatic cancer
However, CA19-9 is not an ideal marker since its sensitivity is
only 87% and specificity only 86% for pancreatic cancers when
the upper normal limit is set to 37 U/mL.
CA 19-9 is not recommended for use as a screening test for
pancreatic cancer and is only appropriate to monitor response
to treatment and as a marker of recurrent disease

• McGuigan, Andrew, et al. "Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes." World journal of gastroenterology 24.43 (2018): 4846.
• Lin, Y. C., Lee, P. H., Yao, Y. T., Hsiao, J. K., Sheu, J. C., & Chen, C. H. (2007). Alpha-fetoprotein-producing pancreatic acinar cell carcinoma. Journal of the Formosan
Medical Association, 106(8), 669-672.
The diagnostic utility of CA 19.9 presents important limitations
above all related to a low sensitivity in symptomatic patients
and a low PPV. In particular for the following:
1. Lacking in CA 19-9 sensitivity for early or small-diameter
pancreatic cancers. Because of serum CA 19-9 concentration
is highly correlated to the tumor size in most, if not in all,
patients with pancreatic cancer, just 50 % of patients with
pancreatic cancers less than 3 cm in diameter presents
elevated levels of CA 19-9, thus it is difficult to use CA 19-9 as
a marker for early diagnosis of pancreatic cancer
2. Poor correlation between the degree of cell differentiation of
the tumor and the serum level of CA 19-9. Poorly
differentiated pancreatic cancers appear to express less CA
19-9 than either moderately or well differentiated cancers.
3. Impossibility to detect CA 19-9 in subjects that have a
fucosyltransferase deficiency, approximately of 5–10 % of the
Caucasian population, who cannot synthesize the Ca-19-9
epitope. Therefore, in these genotypically Lewis a–b– patients,
false negative results for CA 19-9 serum levels can be
obtained even in the presence of advanced pancreatic cancer.
- Ithas been discussed patient with carcinoma caput
pancreas + hypoalbuminemia+ electrolyte imbalance
- CA 19-9 is the most commonly used and best
validated serum tumor marker for pancreatic cancer.
- High CA 19-9 level in this patient due to her
pancreatic cancer
▪ Performing: blood smear, reticulocyte, amylase,
lipase, ascites fluid analysis, total protein, globulin,
ALP, GGT, AFP, HbA1c, urinalysis, urine culture, blood
culture, lactic acid, SPE (if needed)
▪ Monitoring: CBC, albumin, AST/ALT, bilirubin TDI,
AST/ALT, electrolyte serum, FH, CEA, Ca 19-9, BGA,
SOFA score, CXR, GCS,Vital sign
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PCCL PL IDx PDx
1. Female/59 years Normocromic Normocromic Blood smear,
Anisocytosis Anisocytosis Reticulocyt
Physical Examination Anemia Anemia
- Anemic conjunctiva d.t: Monitoring:
1. Chronic CBC
Laboratory disease
- Hb ↓ 2. Acute blood
- HCT ↓
- MCV N, MCH N loss
- High RDW

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PCCL PL IDx PDx
2. Female/ 59 y.o Electrolyte Electrolyte Urine electrolyte
imbalance imbalance
Laboratory d.t low Monitoring:
- Hyponatremia intake DD - SE
- Hypokalemia metabolic - BGA
- BGA: metabolic acidosis acidosis

Anamnesis
• Low intake

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PCCL PL Idx PDx
3. woman/ 59 years Hypoalbumin Hypoalbumin Total Protein
emia emia Globulin
Laboratory: dt liver ALP/GGT
Hypoalbuminemia insufficiency bilirubin T/D/I
↑AST and ALT DD
hypercataboli
c state Monitoring:
CBC
Albumin
ALT
AST

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PCCL PL IDx PDx
4. Female/54 years Sepsis Sepsis d.t − Urinalysis
1. Pancreatic − Blood culture and
Laboratory: cancer sensitivity test
- Elevated Procalcitonin 2. Susp. UTI
- Hypoalbuminemia Monitoring:
- SOFA score 6 CBC
Procalcitonin
CRP
SOFA score
Thorax photo

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PCCL PL IDx PDx
7. Female/ 59 y.o ca caput ca caput - Ascites fluid
pancreas pancreas analysis
Laboratory - Amylase, lipase
• NN Anemia - Fecal analysis
• ↑AST and ALT 2-3x ULN - Total protein,
• Hypoalbuminemia globulin, ALP, GGT
• ↑ CA 19-9 - AFP
- Normal thrombocyte → Monitoring:
thrombocytopenia - GCS
- Vital sign
- SOFA score: 6
- Urine output
- CBC
- Bilirubin T/D/I
- AST, ALT
- Albumin
- CEA, CA 19-9
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PCCL PL IDx PDx
7. Female/ 59 y.o ca caput pancreas ca caput - Ascites fluid analysis
- Amylase, lipase
pancreas - Fecal analysis
Physical Examination - Total protein, globulin,
-Anemic conjunctiva ALP, GGT
-shifting dullness (+) - AFP
Anamnesis Monitoring:
- GCS
- weakness - Vital sign
- Abdominal pain - Urine output
- ↓appetite, ↓ body weight - CBC
- Bilirubin T/D/I
- AST, ALT
Abdominal CT scan:
- Albumin
- Carcinoma caput pancreas, - CEA, CA 19-9

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