Wednesday, August 5, 2009

Darth Vater

(Even though the case is titled Darth Vater, it does not have to do with the ampulla itself, I just liked the title).

A 50 year old man with known untreated choledochal cysts presents with subjective fever, weight loss, and pruritis. The onset is unclear; it has been gradual over the last few months. He also has a dull ache in the right upper quadrant of the abdomen. You notice he is clearly jaundiced and when you ask, you find out he has clay-colored stools and dark urine. The rest of your physical exam is notable for hepatomegaly and a palpable gallbladder.

Laboratory results show an elevated total and direct bilirubin, alkaline phosphatase, 5'-nucleosidase, and gamma-glutamyltransferase. AST, ALT, and coags are normal. Here's a CT:

This is the finding on ERCP, showing common bile duct stricture and dilation of the proximal common bile duct:

Challenge: What's your diagnosis?

Related Questions:
1. What "sign" is the palpable gallbladder?

First image shown under GNU Free Documentation License, second image is in the public domain.

1 comment:

Craig Chen said...

Darth Vater

This is a cholangiocarcinoma, a cancer arising from the epithelial cells of the bile ducts. The other big risk factors not described here include primary sclerosing cholangitis, parasitic infection, cholelithiasis, hepatolithiasis, and toxins. The palpable gallbladder is Courvoisier's sign due to obstruction distal to the take-off of the cystic duct. The DDX includes pancreatic malignancy, choledocholithiasis, benign bile duct structures (postoperative), sclerosing cholangitis, and pancreatitis.

Sources: UpToDate; Wikipedia.