Benign neoplasm of distal common bile duct – Managed by whipple’s procedure and intranodal lymphangiography with lipidol embolization

Neoplasm of distal common bile duct managed by Whipple’s procedure and intranodal lymphangiography with lipidol embolization

Mohan Krishna^1*, Deepa. S², Subathra Devi. M³, Mahalakshmi⁴

¹Staff Nurse, IMCU, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²ANS, Critical care, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu.

³Nurse Educator Kauvery Hospital, Cantonment, Trichy, Tamil Nadu.

⁴Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence

Abstract

A 68-year-old male with a past medical history of diabetic mellitus, hypothyroidism and obstructive jaundice presented with complaints of jaundice, clay-coloured stools, weight loss, constipation, USG abdomen showed loculated fluid collection located at sub hepatic region obstructing at the distal common bile duct regioṇ. The patient underwent Whipple’s procedure followed by Intranodal lymphangiography with lipiodol embolization. The patient developed decreased drainage, followed by breathing difficulty, then shifted to the critical care unit, The patient went into cardiac arrest and was revived, followed by ventilator support, inotropes, nutrition support, intensive care, then weaned and discharged to the ward.

Key words: Diabetic Mellitus; USG Abdomen; Jaundice

Introduction

Distal common bile duct tumour is a life-threatening condition that results in jaundice and liver dysfunction. Early diagnostic and surgical intervention are needed to improve survival and avoid further complications.

Case presentation

A case of a 68 years old male patient came with complaints of yellowish discoloration of skin and eyes for two months, clay-coloured stools for three days, gradual weight loss, and constipation, with history of native treatment.

Relevant clinical findings

Social History: There is no significant usage of tobacco and alcohol.

Allergies: There is no history of any allergies to medicines or the environment.

Past medical history: There is a history of known hypothyroidism for the past two years, and diabetes mellitus for the past seven years, Obstructive jaundice was recently diagnosed.

Past surgical history: The patient had undergone endoscopic retrograde cholangiopancreatography with CBD stenting a month ago.

Physical examination

On arrival the patient was conscious and oriented afebrile and icteric.

Patient GCS	E4 V5 M6
Pupils	Bilateral 2.5mmRTL
Pulse rate	72/min
Blood Pressure	130/80mmHg
SpO2	98% with RA
Temp	98.6 F
Respiratory rate	BAE (+), bilateral NVBS (+)
CNS	NFND

Relevant Investigation

Markable Investigation

S.no	Investigation name	Result
1.	Haemoglobin	9.8-11.6 g/dl
2.	WBC	11020-17110 cell/cumm
3.	Platelet	248000-143000 cells/cumm
4.	Potassium	4.5-3.4 mmol/l
5.	Urea	29-37mg/dl
6.	Creatine	0.5-0.5 mg/dl
7.	Total Bilirubin	1.6-0.7

USG done on 3/5/2026

Local fluid collection in hepatic region. Mild free fluid in paracolic gutter, bilateral moderate fluid effusion
USG guided (right side) pigtail catheter drainage done on 01.06.2026
All aseptic precautions under USG guidance, Right 10F pigtail was inserted in right pleural space. Procedure un eventful. Post procedure patients are hemodynamically stable.

USG guided (left side) pigtail catheter drainage done on 01.06.2026

Under ASP, under USG guidance, 10Fr pigtail placed in left pleural pigtail placed and about 500ml of fluid drained. Procedure uneventful

USG bed side done on 01.06.2026

Loculated fluid collection in sub hepatic space. Moderate ascites. Bilateral moderate pleural effusion.

Doppler one side (right) done on 17.06.2026

No evidence of Deep venous thrombosis of the right lower limb.

Doppler one side (left) done on 17.06.2026

No evidence of deep venous thrombosis of the left lower limb.

USG small parts done on 17.06.2026

Normal study

CT abdomen plain on 28/05/2026

Diagnosis

Distal CBD Tumour
Post ERCP + CBD Stenting Status

Medical and Surgical Management

The patient presented with obstructive jaundice due to a periampullary/distal CBD growth, for which ERCP with CBD stenting was performed on 15/04/2026 for symptomatic relief. PET-CT revealed an operable primary tumour with regional lymph nodes.

The patient underwent pylorus-preserving Whipple’s procedure with extended lymphadenectomy. Histopathological examination confirmed periampullary adenocarcinoma (pT3N2), with 5/21 lymph nodes positive, including aortocaval and coeliac nodes, positive lymphovascular invasion, no perineural invasion, and all surgical margins negative.

Postoperatively, the patient received IV antibiotics, analgesics, octreotide, PPIs, and albumin infusion. Peritoneal fluid culture grew into a multidrug-resistant organism, and antibiotics were modified according to culture and sensitivity results.

On postoperative day 5, increased chylous drain output was managed with Medium-Chain Triglyceride (MCT) feeds, central venous access, and Total Parenteral Nutrition (TPN). As the output persisted, selective cisterna chyli embolisation was performed by interventional radiology, resulting in reduced drain output.

However, 48 hours later, the patient developed respiratory distress with bilateral pleural collections and subsequently suffered cardiac arrest in the IMCU, suspected to be due to lipiodol-induced pulmonary embolism. Return of spontaneous circulation was achieved after 10 cycles of CPR, followed by ventilator support and inotropic therapy.

Bilateral ultrasound-guided pigtail drains were inserted, draining chylous fluid suggestive of chylothorax. Albumin infusion and TPN were continued.

Nursing Management

Nursing care was planned using a multi-Disciplinary, evidence based approach with emphasis on haemodynamic stabilization, respiratory support, prevention of complications and promotion of recovery.

Comprehensive Assessment

Head to toe assessment was performed regularly.
Monitored vitals and GCS regularly.
Monitored pain and intake and output hourly
Ventilator parameters and peripheral perfusions were closely monitored.
Laboratory investigations including CBC, ABG, Electrolytes, RFT, Coagulation profile were reviewed to Identify Early Clinical Deterioration.

Mechanical and Airway Management

Regularly checked ETT position and cuff pressure
Monitored ventilator settings with intensivist.
Performed sterile suctioning, oral hygiene as per protocol to prevent VAP.

Pain Assessment and Comfort Measures

Assessed pain using validated tools (CPOT)
Administered prescribed analgesics and response.
Provided 2^nd hourly position, pressure relief and supportive care.

Postoperative Abdominal Care

Monitored surgical drains amount.
Assessed for infection, bleeding, abnormal drainage at surgical site.
Assessed for abdomen distension and other signs.

Infection control

Maintained aseptic techniques for all procedures and wound care.
Maintained CVC line, urinary catheter and other invasive devices as per protocol.
Followed Hand hygiene and Standard precautions.
Monitored for fever, Inflammatory markers, wound infection, catheter related infections and sepsis.

Outcome

The patient gradually improved and was successfully weaned off ventilator and inotropic support. RT feeds were initiated and tolerated, followed by swallow assessment and gradual introduction of oral diet along with RT feeds. Anasarca was managed with albumin and a high-protein diet. The patient showed significant clinical improvement, ambulated well, and was discharged in a stable condition with advice for home nursing care, a high-protein diet, continuation of prescribed feeds, and physiotherapy.

Discharge medications

S.No	Drug Name	Strength	Frequency			Days
			M	An	N
1	Tab. Oflin	200mg	1	0	1	3 Days
2	Tab. Pantocid	40mg	1	0	1	10 Days
3	Tab. One Up Gold		0	1	0	10 Days
4	Tab. Addna	1gm	1	1	1	5 Days
5	Tab. Nodosis Gst	500mg	1	1	1	To Continue
6	Tab. Thyroxine	100mcg	1	0	0	To Continue
7	Tab. Lasilactone	50mg	2-Jan	2-Jan	0	To Continue
8	Tab. Rifagut	550mg	1	0	1	5 Days
9	Sac. Econorm		0	1	0	5 Days
10	Sac. Addphos		1	1	1	5 Days
11	Syp. Kcl	15ml	1	1	1	5 Days
12	Ensure High Protein Power	2 Scoops	1	1	1	To Continue

Discussion

The patient underwent Whipple’s surgery for periampullary adenocarcinoma.The postoperative period was complicated by infection, chyle leak,chylthorax, and cardiac arrest. Prompt CPR, Ventilator support, drainage, antibiotics, and nutritional support helped the patient recover. Gradual feeding, albumin infusion, and physiotherapy improved the patient’s condition. This case highlights the importance of early identification

Conclusion

This case concludes that the care of the patient with neoplasm over a common bile duct with surgical intervention and intensive care played a vital role in the recovery of the patient from the arrest and revival of life. It includes hemodynamic stability, nutrition support, preventing post-operative complications and multidisciplinary care that result in clinical improvement of the patient outcomes.

Benign neoplasm of distal common bile duct – Managed by whipple’s procedure and intranodal lymphangiography with lipidol embolization

Neoplasm of distal common bile duct managed by Whipple’s procedure and intranodal lymphangiography with lipidol embolization

Mohan Krishna1*, Deepa. S2, Subathra Devi. M3, Mahalakshmi4

Nightingale Journals

Mohan Krishna^1*, Deepa. S², Subathra Devi. M³, Mahalakshmi⁴