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Dr. David
Dr. David, Board Certified MD
Category: Medical
Satisfied Customers: 44437
Experience:  Board Certified Physician
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Dear Dr My mother has the following problem. She has the

Customer Question

Dear Dr

My mother has the following problem. She has the symptoms of a ampullary cancer.She has a tumour but it’s not cancerous and she is losing weight constantly and she has constant fever.She is 65. She is currently in Pakistan.

Note that her tumour has been reported as benign by agha khan labs twice as a result of biopsy tests.A stunt has been placed in where she has tumour to allow the bile to pass through,She had severe jaundice,itching. her gall bladder was swollen. There are some stones in her gallbladder as well.
but now after placing a stunt in her intestine and two times biopsies and then a month worth of antibiotics her jaundice is gone , itching is gone , palpability of gall bladder swelling is gone and abdominal pain is gone , but fever doesn't go away.
We have done an MRCP scan of her hepatobiliary channels yesterday to find out the reason for fever despite of the use of high antibiotic.
Tomorrow a blood culture test and urine culture test will be carried out for identifying targeted antibiotics for accurate results till then she will be on paracetamol and cold sponging.
Please guide us as gastroenterologist for the best available option for her treatment, otherwise she is continuing with weight loss , fever and sometime vomiting and she cannot eat anything. We use drips to keep her going.

Thanks to God that she doesn't have a periampullary carcinoma otherwise we were doomed. She has the symptoms of a ampullary cancer but its not benign.

Please give us some advice should we do a gall bladder surgery now?
Submitted: 2 years ago.
Category: Medical
Expert:  Dr. David replied 2 years ago.

Dr. David :

This is Dr. David

Dr. David :

the biopsies could still have missed the cancer area if not done properly.

Dr. David :

how has she had the biopsies performed.

Dr. David :

the best way to do these sorts of biopsies is with endoscopic ultrasound guidance during an ERCP procedure.

Dr. David :

which is very difficult procedure and I'm not sure if it is available in Pakistan.

Customer:

dear doctor

Customer:

thank you

Dr. David :

removing the gall bladder most likely will not help much

Customer:

so what should we do dr

Dr. David :

did the MRCP show the area of abnormality around the bile stent area where the potential cancer is.

Dr. David :

sometimes after a metal stent is placed in, this can cause a lot of artifact on an MRCP procedure

Dr. David :

which can make it hard to see around where the stent was placed.

Customer:

the doctor in hospital says that they will do an open surgery to see inside and if anything serious found the doctor will remove gallbladder along with cancer area

Dr. David :

I hope they can do this.

Dr. David :

it can be tough to do surgery around the liver and bile ducts.

Customer:

the doctor said that there was infection in stent area but later he said it has been cured by antibiotics

Dr. David :

I see.

Dr. David :

I would get a copy of the MRCP procedure.

Dr. David :

I would be happy to help you interpret it.

Customer:

but she cannot eat anything

Customer:

she is loosing weight

Dr. David :

yes, I understand.

Customer:

and vomiting is there as well

Dr. David :

this is most likely due to a cholangiocarcinoma or a tumor in the liver pressing on the bile ducts.

Dr. David :

this is a tough cancer, even to treat in the USA.

Dr. David :

and will be difficult also in Pakistan as well.

Customer:

she is very weak

Customer:

and i think if the doctor do another surgery she wont survive it

Dr. David :

you are right.

Dr. David :

there is a chance she might not survive a surgery.

Customer:

operation for gallbladder is not necessary

Customer:

i think

Dr. David :

I agree.

Dr. David :

removing the gall bladder is not the problem.

Dr. David :

the problem is the tumor mass which is pressing on the bile duct.

Dr. David :

possibly in the liver.

Dr. David :

it seems like her doctors are having a hard time seeing the area.

Customer:

yes that is true

Dr. David :

in the USA we would use MRI scans of the liver and PET scans to try to see the area

Dr. David :

to target for biopsy

Dr. David :

and the possibly target the area with radiation and chemotherapy.

Dr. David :

as to not use surgery in a very frail patient.

Dr. David :

does this help?

Dr. David :

do you have other questions?

Customer:

yes Dr you are very right

Customer:

Does radiation and chemotherapy have any success rates

Customer:

can it cure the problem

Customer:

they took biopsy samples twice from all possible areas and nothing cancerous was found

Dr. David :

it depends on the cancer.

Dr. David :

but the cure rates are still very very poor.

Dr. David :

with radiation and chemotherapy .

Dr. David :

but it spares the patient of having to do another surgery.

Dr. David :

do you have any other questions?

Customer:

My question is how to reduce her pain thats what what i want to do for my mother.

Customer:

Should we ultimately do a open surgery

Customer:

to remove the cancer area

Customer:

or just stay with the radiation and chemotherapy

Customer:

should she be at home or hospital?

Dr. David :

she can have morphine for pain

Dr. David :

I would lean away from doing surgery.

Dr. David :

but it seems like the surgeons are pushing to do this to get a biopsy.

Dr. David :

I have a feeling that they will be able to get a biopsy of the area with surgery, but most likely will not be able to resect all of the area

Dr. David :

chemo radiation is fine, but that will be done without a biopsy to show the cancer.

Dr. David :

it seems that with all of her pain and inability to eat, she most likely needs to be in the hospital receiving pain medications and IV fluids

Dr. David :

if she does not wish to keep fighting this cancer, she can be comfortable with only hospice care and pain medication as an option as well

Dr. David :

I know these options are not very good, but this is a very difficult cancer in an elderly patient who is suffering substantially from most likely an aggressive liver biliary cancer which seems to be very difficult to diagnose.

Dr. David :

so this is not a good situation overall.

Dr. David :

I wish I could give you better news.

Customer:

You have been very helpful Dr

Customer:

I thank you so much

Dr. David :

you are welcome

Dr. David :

if done for now, please leave positive feedback below the chat box

Dr. David :

so I can get credit for helping you.

Dr. David :

http://www.justanswer.com/medical/expert-dr-david/

Dr. David :

is my webpage if you need to reach me again.

Dr. David :

I work in the medicine and oncology sections here at JustAnswer.

Customer:

Can I be in touch with you later

Dr. David :

thanks for using JustAnswer.com

Dr. David :

of course you can be in touch with me later.

Dr. David :

don't forget to leave positive feedback below

Dr. David :

thanks.

Customer:

Thank you Dr

Customer:

Yes I will Dr

Dr. David :

thank you.

Dr. David, Board Certified MD
Category: Medical
Satisfied Customers: 44437
Experience: Board Certified Physician
Dr. David and 5 other Medical Specialists are ready to help you
Customer: replied 2 years ago.

Please attached find further reports for your expert advise.Many thanks

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Customer: replied 2 years ago.




Addendum 07.05.14


Radiologist


Dr. Abid Ali Qureshi


M.B.B.S, F.C.P.S


Associated Professor of Radiology


The Children’s Hospital and


Institute of Child Health, Lhr


Patient Name : M/o Aftab


Patient Age : 65 Years / Female


Patient R. Date : 03.05. 2014


Patient Referred : Dr. Shah Muhammad



M R C P

 


History: Status post surgery, no details available.


Discussion: MR Cholangio-pancreatography was performed and images are displayed after Maximum Intensity Projection (MIP).


 


Gall appears distended showing thick sludge and a few stones.


Intra-hepatic biliary channels appear normal with no abnormal dilatation. Pancreatic duct show mild prominence. There is no evidence of any collection in the sub-hepatic space. There is subtle heterogeneous intensity abnormal area in the left lobe of liver.


 


There is no appreciable peri-ampullary mass on these available images. Spleen, pancreas and both kidneys are unremarkable.


 


Impression:



  • Distended gall bladder with thick sludge and a few stones.

  • Mild prominence of pancreatic duct.

  • No dilatation of intra/extra hepatic biliary channels.

  • No evidence of any collection in the subhepatic space or biloma.

  • Subtle heterogeneous intensity abnormal signals in the left lobe of liver, this may please be correlated with the sonography/CT abdomen with IV contrast.







 


Dr. Abid Ali Qureshi


M.B.B.S, FCPS


Assistant Professor Radiology


CH & ICH, Lahore.


 


 




Thank you for referral. This is a comp

Customer: replied 2 years ago.

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Customer: replied 2 years ago.

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Expert:  Dr. David replied 2 years ago.
she really should have had a culture in teh bile duct as well to check for infection in teh bile duct like an ascending cholangitis infection.

an infection in the bile duct can cause air in the biliary system.

but also putting a stent in the biliary system can cause air as well.

sounds like her surgeons want to open her up and biopsy the area

I hope she can tolerate this surgery.

Customer: replied 2 years ago.

Dear Dr David,


 


Many thanks for this.


 

Expert:  Dr. David replied 2 years ago.
you are welcome

if done for now, please leave positive rating below the chat box so I can get credit for helping you today

you can always reach me with "a question for Dr. David" if you have any other questions

here is my website if you need to reach me again:

http://www.justanswer.com/medical/expert-dr-david/

Thanks for using JustAnswers.com
Customer: replied 2 years ago.

BACTERIOLOGY-BLOOD


BLOOD CULTURE REPORT-ESCHERICHIA COLI


 


AMOXICILLIN/CLAVULAN, AMPICILLIN, AMIKACIN, AZTREONAM, IMIPENEM, PIPERACILLIN/TAZOBAC, GENTAMICIN, CEFTRIXONE, CEFUROXIME, COTRIMOXAZOLE, CEFIXIME, CIPROFLOXACIN.


 


she is currently taking piperacillin/tazobac.


 


please advise me what is the actual problem with my mother and how it could be treated. i ll very much appreciate your expertise for the poor sole

Expert:  Dr. David replied 2 years ago.
this blood culture shows that she has ecoli growing in her blood.

ecoli is a very common bacteria which comes from the bowels or colon or GI system and is infected somehow into her blood stream.

it seems like this ecoli infection is sensitive to many antibiotics

this information seems like it is from a culture and sensitivity panel.

after each of those antibiotics should be either S or R for Sensitive or Resistant. some antibiotics have become resistant to certain antibiotics. hopefully her ecoli infection is sensitive to piperacillin/tozobac which is an antibiotic combination called zosyn which is very powerful.

she should be seeing an infectious disease doctor who is a doctor who specializes in infections

good luck
Customer: replied 2 years ago.

Thanks Dr David. We have been very grateful for your timely advise and help. Now she has been on ZOSYN, RISEK and GRAVINATE. She is feeling better now and she has started eating and her vomiting and fever has stopped with ZOSYN. Would you suggest any other drug to increase her appetite? But so far the the tumour is shown to be non-malignant. But i know 90% of the cases it is cancerous. Now she has ascending cholangitis as well. Once she is a bit healthier and her RBC counts are better she is welling to carry on with the surgery. Now the doctors said that they can remove the tumour and gallbladder and clean the biliary ducts from e-coli bacteria during surgery. The patient and doctors are not inclined towards radiation and chemo. Please advise us the best way forward to treatment. Many thanks in advance

Expert:  Dr. David replied 2 years ago.
there is no "best" way to treat this disease.

her biopsies have all come back negative so far. that could be from them missing the area on biopsy.

I hope she can tolerate the surgery as well.

the gall bladder is not the problem.

most likely there is a tumor around the bile duct blocking the bile flow which needed the stent.

I am glad her ascending cholangitis is better on the zosyn.

if she has surgery, I wish her all the best.

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