Snapshot
- A 35-year-old man with a history of primary sclerosing cholangitis presents with two weeks of jaundice, pruritus, and abdominal pain. He also has noticed that his urine is dark and stools are clay-colored. On physical exam, he has generalized jaundice and a palpable right upper quadrant mass. Lab studies are remarkable for elevated alkaline phosphatase, total bilirubin, alanine aminotransferase, aspartate aminotransferase, and CA 19-9. Magnetic resonance cholangiopancreatography reveals a contrast-enhancing intrahepatic lesion with rim enhancement.
Introduction
- Most common malignancy of bile duct
- Caused by
- thorotrast
- choledochal cyst
- May be located
- intrahepatically
- at the junction of R/L hepatic ducts
- at the ampulla
Presentation
- Symptoms
- jaundice
- pruritus
- abdominal pain
- clay-colored stool
- dark urine
- weight loss
- fever
- Physical exam
- palpable gallbladder
- Courvoisier’s sign
- palpable gallbladder
- hepatomegaly
Evaluation
- Labs
- Imaging
- often start with abdominal ultrasound or MRI/MRCP
- MRI, MRCP, or MDCT are most helpful for visualizing intrahepatic lesion
- EUS or ERCP are most helpful for visualizing extrahepatic lesions
Treatment
- Surgery
- may be curative if no lymph node, vascular, or distant metastatic spread
- few patients present at early stage
- Chemotherapy and radiation
- may be used in adjuvant, neo-adjuvant, and/or palliative settings