KLATSKIN TUMORA LESS FREQUENT CAUSE OF JAUNDICE

Ioana Tudor1, Roxana Dantes1, Rodica Pavelescu1, Diana Lupu1, Mara Jidveian1, F. Grama2, D. Cristian2, D. Isacoff1, I. Bruckner1

1Internal Medicine Department - ‘’Coltea’’ Clinical Hospital – Bucharest, Romania, 2General Surgical Department - ‘’Coltea’’ Clinical Hospital – Bucharest, Romania

IntroductionKlatskin tumor is a sporadically occurring cholangiocarcinoma thatmay be seen in patients with primary sclerosing cholangitis,ulcerative colitis, or parasitic infestation. It is characteristicallyslow growing and locally invasive, and it metastasizes morereadily to lymph nodes than systemically, although intrahepatic andperitoneal metastases are not uncommon.Bismuth-Corlette Clasiffication:

Incidence● 2–4/100,000 per year● less than 2% of all human malignancies● male-to-female ratio is 1:2.5 in patients in their 60s and 70s

and 1:15 in patients younger than 40 years.● more than 95% of these tumors are ductal adenocarcinomas

CASE STUDY67 y.o. maleMarch, 2010: anorexia, jaundice and dark urine sudden onset 5 days before admission weight loss (6 kg in 10 days)BG: HypertensionMedication: Perindopril 10 mg p.o o.d Metoprolol 50 mg p.o o.d Indapamid 1.5 mg p.o o.dPhysical examination: - alert, stable vitals, BMI 29.2 kg/m2

- jaundice, hepatomegaly - no palpable masses or adenopathy.

Tests

Abdominal Ultrasound

Diferential diagnosis:● Biliary calculi

● Carcinoma of the pancreatic head

● Periampular Carcinoma

● Cholangiocarcinoma

● Extrinsec compression (hilar adenopathy)Next step: ERCP and MRCP

Diagnosis: KLATSKIN TUMOR TYPE 1 STAGE 4

Treatment: ERCP stenting, chimiotherapty and radiotherapy

Evolution, complications November, 2010: Stenosis of the stent which needed restenting.December, 2010: Antral stenosis secondary to extrinseccompression, requiring gastro-enteric anastomosis.April, 2011: Relapse of jaundice. OGD and MRI: doudenalobstruction by tumor extension, multiple hepatic abscesses;cholangitis, sepsis; death.

ConclusionsCholangiocarcinoma represents a rare malignancy. Withoutintervention, death due to progressive jaundice is inevitable. The goalsof therapy are resection of all disease and relief of biliary obstruction.At present, there is no effective nonsurgical therapy, a completeresection with a negative histologic margin appears to be associatedwith improved survival. Prognosis is very poor with an overall survivalrate of only 6–8 months.

References1. Guidelines for the diagnosis and treatment of cholangiocarcinoma: consensus document - S A Khan, B R

Davidson, R Goldin, S P Pereira, W M C Rosenberg, S D Taylor-Robinson, A V Thillainayagam, H C Thomas.2. Sonographic Diagnosis of Klatskin Tumors – Mahan et al.3. ERCP and endoscopic endoprosthesis insertion in patients with Klatskin tumors - LIU C.-L.; LO C.-M.; LAI E. C.

S.; FAN S.-T.