A primary Cholangiocarcinoma

An 80 years old female patient was admitted in our hospital for severe rib pain located at the Rt side of the thoracic cage.

She also complained of nausea, anorexia and malaise, alternating diarrhea and constipation, on top of some dry cough.

There was a urinalysis where proteins were positive, but kidney function tests were negative.

Malaria slide was positive and we have treated with Coartem. Blood sugar was normal.

The patient is chronically on thyroxin because of a sub-clinical hypothyroidism, and on allopurinol because of tendency to high levels of uric acid.

The first chest X-Ray we performed was suggestive of bronchitis.

We have therefore requested a second X-Ray with oblique view of the chest, in order to study the ribs better: the report indicated marked osteopenia of the ribs with a nodule of the Lt upper zone. There was also a Rt hilar lymphonode.

The radiologist suggested CT scan of the chest to understand better the nature of the masses.

CT scan of the chest has just confirmed the features of chronic bronchitis, but has seen possible metastatic lesions in the liver.

An abdominal U/S followed, and liver function tests were requested: the sonography has indicated a hepatomegaly with multiple hyperechogenic round masses in the liver parenchyma. There was no ascites.

The liver function tests were slightly elevated. Cholesterol levels were also checked and they were extremely low as in malignant conditions (33 mg/dl).

We have therefore proceeded to liver biopsy. The report was the following: “metastatic mucin secreting adenocarcinoma. Rule out primary from stomach, pancreas, etc”.

Next step has therefore been to perform a gastroscopy and a colonscopy: both were negative for malignancy.

Thus, we have requested a CT scan of the abdomen, to investigate pancreas, peritoneum and genital system: also the CT scan abdomen was normal, apart from the liver metastasis, which were confirmed again.

Meanwhile the patient has become more and more jaundiced and ascites has developed quite quickly. We have therefore collected ascitic fluid under U/S guidance, and sent it for cytology: the report was indicating a metastatic adenocarcinoma, with features highly suggestive of cholangiocarcinoma as primary.

The patient is now on conservative management with i.v. fluids, and on pain control with pethidine and promethazine.

Her condition is worsening steadily and the patient has now entered into a state on hepatic coma.

Dr Giuseppe Gaido