1. Clinicopathological Conference CPC #1 September 8, 2009

2. Patient 62 year old male DM II COPD Chronic Hepatitis B with mild fibrosis – U/S 4 months ago no mass HTN Active Smoker

3. HPI 4 weeks fatigue 10/10 RUQ pain – radiated to the back Jaundice Light/clay colored stools Nausea Dark urine

4. At Risk Hepatoma (3-4% risk per year) – Hepatitis B Severe Infection – DM, COPD and Cirrhosis FHF with appropriate trigger Cancer risk – prostate, colorectal, lung

5. Extrahepatic Malignant – Cholangiocarcinoma – Pancreatic cancer – Gallbladder cancer – Ampullary cancer – Malignant involvement of the porta hepatis lymph nodes – Hepatoma Benign – Choledocholithiasis – Primary sclerosing cholangitis – Chronic pancreatitis – AIDS cholangiopathy – Stricture (benign)

6. Differential Diagnosis Hepatocellular Carcinoma – Correct Host – Fibrolamellar variant (nl AFP) – Pulmonary lesions Cholangiocarcinoma – Ductal dilatation – Elevated CA 19-9

7. Key points Non-enhancing lesion on CT scan Normal ultrasound 4 months ago Normal AFP

8. Cholangiocarcinoma Adnocarcinoma of the epithelial cells of the biliary tract 2-3,000 cases per year Associated with primary sclerosing choangitis and chronic inflammation Risk factors – parasitic liver infection (liver flukes) Congenital liver abnormalities

9. Diagnosis Metastatic cholangiocarcinoma triggering fulminant hepatic failure in a patient with ETOH/Hep B cirrhosis