History
A 68-year-old lady with a history of hypertension and hypothyroidism presents to the accident and emergency department with a 2-day history of right upper quadrant pain and jaundice. There is no recent travel history.
•Afebrile, pulse 70 bpm, BP 120/65mmHg, SaO2 98-100% on RA.
•Hydration is satisfactory.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•Her chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with mild right upper quadrant tenderness and no other peritoneal signs.
•No signs of oedema.
Investigations
•CBC:
–WBC 3.5 x 109/L;
–haemoglobin 9.9g/dL;
–platelets 275 x 109/L.
•ALP 661 IU/L.
•Bilirubin 18μmol/L.
•ALT 53 IU/L.
•GGT 1127 IU/L.
•International Normalised Ratio (INR) 1.62.
•Amylase normal.
•CRP normal.
•Anti-HAV IgM, HBsAg, anti-HCV, anti-HEV IgM negative.
What is your differential diagnosis?
•Acute cholangitis.
•Mirizzi syndrome.
•Malignant obstruction.
What further investigations would you arrange?
Imaging studies, i.e. ultrasonography, computed tomography, are required (Figure 9.1).
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Please describe what you see
A coronal CT scan of the abdomen with contrast. The common bile duct is moderately dilated measuring 1.3cm at the mid portion. It shows an abrupt change of calibre at the pancreatic head level. There is also suspicious diffuse ductal wall thickening at the distal common bile duct. There are no definite intraductal filling defects.
Does this narrow your differential diagnosis?
The most compatible diagnosis is cholangiocarcinoma of the common bile duct.
How would you treat this patient?
A Whipple operation (or pylorus-preserving pancreaticoduodenectomy) for curative resection.
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