painless jaundice randal zhou m4. 58 yo asian man presents w jaundice x 2 months, upper abd...
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Painless Jaundice
Randal Zhou M4
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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
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Labs CBC – Hg 9.9 AST/ALT – mildly elevated Alk phos and ggt – marked incr INR – 1.1 Bili – 37 CEA, AFP – normal
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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
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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.
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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.
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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
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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.
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MRCP
Evaluation of biliary tree
MRCP limitations include spatial resolution and inability to evaluate secondary to ducts
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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
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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.
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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