Pancreatic ductal adenocarcinoma with atypical biliary obstruction secondary to tension pneumobilia: a case report

Most patients diagnosed with pancreatic cancer present with constitutional syndrome, abdominal pain, and/or jaundice. Jaundice is typically due to tumor-induced biliary obstruction. However, as we will illustrate in our clinical case, rare obstructive mechanisms can sometimes occur. We present the case of a 63-year-old woman diagnosed with borderline resectable ductal adenocarcinoma of the pancreatic head. The clinical presentation included obstructive jaundice and altered liver function tests. During the neoadjuvant therapy preparation and despite prior adequate biliary stenting via endoscopic retrograde cholangiopancreatography (ERCP), the patient experienced a new episode of progressive hyperbilirubinemia in the absence of obstructive biliary dilatation or stent dysfunction. Following investigations, this was attributed to functional obstruction secondary to trapped tension pneumobilia visible on cross-sectional imaging. Following multidisciplinary team discussion, the patient underwent a percutaneous cholecystostomy with drainage of the trapped air. This procedure successfully achieved subsequent bilirubin normalization, and the patient was able to continue successfully neoadjuvant mFOLFIRINOX chemotherapy, followed by pancreaticoduodenectomy (Whipple procedure) with curative intent. She remains cancer-free. This case highlights the importance of considering differential diagnoses in biliary obstruction in patients with patent biliary stents, as well as the relevance of a multidisciplinary approach in borderline resectable pancreatic tumors.