QUESTION

A 76-year-old woman presented to the emergency department with 2-week history of epigastric discomfort, obstructive jaundice and gastric outlet symptoms. She denied fever but had loss of weight and appetite. She was clinically cachexic with jaundice but no signs of chronic liver disease. There was a palpable gallbladder with positive succussion splash. No supraclavicular lymph node felt. She was biochemically obstructed with total bilirubin of 290 and direct bilirubin of 230. Liver transaminases were within normal range. Tumour markers namely CA 19-9 was 120 U/mL (<37) and CEA was 2.1 ng/mL (<5). The hepatitis screening was non-reactive. Spot the radiological diagnosis and briefly how to manage?

ANSWER

Computed tomography scan of the abdomen and pelvis showed a massively dilated common bile duct, intrahepatic duct, gallbladder, and stomach. These conditions can develop in head of pancreas tumour which includes pancreatic cancer, distal cholangiocarcinoma, valerian tumour, and duodenal carcinoma. Provisional diagnosis was distal cholangiocarcinoma by looking at the imaging picture and raised tumour marker. Biliary decompression via endoscopic retrograde cholangiopancreaticoduodenoscopy (ERCP) or percutaneous transbiliary drainage (PTBD) is required for initial treatment. The definitive surgery is whipple’s procedure or pylorus preserving pancreaticoduodenectomy for a localized disease, meanwhile metallic stenting for palliative intent.