painless jaundice randal zhou m4. 58 yo asian man presents w jaundice x 2 months, upper abd...

Painless Jaundice

Randal Zhou M4

58 yo asian man presents w Jaundice x 2 months, upper abd discomfort,

anorexia and pruritis

Physical: jaundiced, icteric, pronounced hepatomegaly with smooth nontender liver, no ascites

Labs CBC – Hg 9.9 AST/ALT – mildly elevated Alk phos and ggt – marked incr INR – 1.1 Bili – 37 CEA, AFP – normal

DDX Cholangiocarcinoma Pancreatic cancer Primary duo cancer Choledocholithiasis Cholangitis Benign stricture

Short segment, regular margin, symmetric, no ductal enhancement, no LN enlargment, no mass

Liver mets HCC

US 1st line in pts with obstructive jaundice Most common site of biliary adenocarcinoma

is at or near the confluence of R/L hepatic ducts – Klatskin tumors

Notice how ill-defined the tumor is.

CT

Useful in diagnosing level of obstruction

Difficult to identify mass

Regions of thickening of the periductal parenchyma w altered caliber of involved duct.

Intrahepatic biliary dilatation.

ERCP demonstrated marked dilated CBD with a 2cm stricture of CBD involving bifucation of R/L intrahepatics

Sphincterotomy performed

Stents placed across strictures

CHD brushings revealed atypical cells concerning for cholangiocarcinoma

ERCP Superiority of ERCP to MRCP Right demonstrates shouldering at the hilum

and multiple strictures Staging done is based on mass effect,

irregular margins, and abrupt tapering.

MRCP

Evaluation of biliary tree

MRCP limitations include spatial resolution and inability to evaluate secondary to ducts

MRI

Adds little to US and CT in est dx

Isointense or slightly hyperintense areas on T2 images are due to the fibrous content of these tumors

Hyperintense areas on T2-weighted images are due to mucous secretion within the lesion

MRI

Planning tx, assessing for resectability

Unresectable when: Bilateral extension

Secondary ducts Hepatic parenchyma Hepatic artery or PV

Occlusion of main PV N2 nodes (around pancreas) Distant mets

Most challenging in patients with Klatskin tumors. 50% with Klatskins that are

determined to be resectable preoperatively have unresectable disease intraoperatively.

References http://www.ultrasoundcases.info/Test-Yourself-

Case.aspx?test=7307&cat=156&group=63&page=28&show=1

http://emedicine.medscape.com/article/189843-workup#a0722

http://radiopaedia.org/articles/cholangiocarcinoma

http://www.radiologyassistant.nl/en/p49e17de25294d/biliary-ducts-pathology.html

http://emedicine.medscape.com/article/365065-overview#a2