Spyridon Zouridis, MD1, Muhammad Farhan Ashraf, MD1, Hadi Minhas, MD1, Christopher Ashley, MD, MPH, FACG2 1Albany Medical Center, Albany, NY; 2Stratton Veteran Affairs Medical Center, Albany, NY
Introduction: Cholestatic liver injury is commonly seen in the inpatient setting. Cholangitis is a little-known presentation of underlying cholangiocarcinoma.
Case Description/Methods: A 75-year-old male patient with a history of diabetes, coronary artery disease, and chronic kidney disease was admitted with weakness and altered mental status. Exam was significant for disorientation and labs showed acute kidney injury, as well as urinary tract infection. Intravenous Fluids and Levofloxacin led to improvement in mental status and renal function. On admission labs, liver enzymes were unremarkable. However, over the course of 10 days, the alkaline phosphatase rose to a peak of 2662 along with worsening abdominal pain. Jaundice with direct hyper-bilirubinemia and elevated aminotransferases followed. Ultrasound (US) and Computed Tomography (CT) revealed cholelithiasis and possible cholecystitis, but both without biliary ductal dilatation or visualized choledocholithiasis. The viral panel, medication levels, anti-nuclear, anti-mitochondrial, anti-smooth muscle antibodies, and hepatoportal doppler ultrasound were unremarkable. An Endoscopic Retrograde Cholangiopancreatography (ERCP) was performed due to presumed cholangitis. This revealed choledocholithiasis and a single segmental common bile duct (CBD) stricture consistent with extrahepatic cholangiocarcinoma. Two stents were placed in the ventral pancreatic duct and CBD. Biliary sphincterotomy and partial stone removal were accomplished. The patient’s condition and labs improved. Repeat ERCP was planned for further diagnostic work-up, however, the patient opted for comfort measures without further procedures.
Discussion: Cholangitis in the setting of cholangiocarcinoma is a unique and rare presentation accompanying this highly lethal malignancy. Usually, patients suffering from cholangiocarcinoma present with painless jaundice, right upper quadrant abdominal pain, and weight loss. Extrahepatic biliary tree obstructive pathology caused by cholangiocarcinoma is typically detected via imaging. US and CT sensitivity for choledocholithiasis vary between 50-75% and 72-88% respectively. A high degree of clinical suspicion is required and often Magnetic Resonance Cholangiopancreatography and/or ERCP may be required to diagnose underlying cholangiocarcinoma in cholangitis.
Spyridon Zouridis indicated no relevant financial relationships.
Muhammad Farhan Ashraf indicated no relevant financial relationships.
Hadi Minhas indicated no relevant financial relationships.
Christopher Ashley indicated no relevant financial relationships.
Spyridon Zouridis, MD1, Muhammad Farhan Ashraf, MD1, Hadi Minhas, MD1, Christopher Ashley, MD, MPH, FACG2. P1159 - Cholangiocarcinoma Unmasked by Cholangitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.