A 78-year-old woman had felt unwell for a few weeks. Her appetite had diminished and she had lost 5–6kg in a few months.
She was pale but not clinically anaemic but her sclerae appeared slightly yellow. On abdominal examination there were no masses palpable and no tenderness elicited.
What are the diagnosis, management and differential diagnoses?
Diagnosis and management
This woman is jaundiced. At presentation her bilirubin was 40µmol/l with alkaline phosphatase 359IU/l and ALT 33IU/l. She has generalised itching and pale stools of 24 hours duration.
She was admitted to hospital where her bilirubin was 202µmol/l and a mass visible on ultrasound was obstructing the bile duct. She underwent endoscopic retrograde cholangio-pancreatography and biopsy, and a stent insertion to relieve the obstruction.
Biopsy confirmed cholangiocarcinoma, a rare malignant tumour arising in any part of the biliary tree but most commonly in the perihilar region near the confluence of the right and left hepatic ducts. In the UK 600 new cases occur annually. Treatment is by surgery only.
Possible different diagnoses
- Carcinoma of the pancreas.
- Bile duct stricture.
- May be asymptomatic or cause biliary colic.
- Diagnosis is usually based on ultrasound.
- Risk factors include female sex, obesity and family history.
- Patients with diabetes are predisposed to severe manifestations.
Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire