1. Painless Jaundice Randal Zhou M4

2. 58 yo asian man presents w  Jaundice x 2 months, upper abd discomfort, anorexia and pruritis  Physical: jaundiced, icteric, pronounced hepatomegaly with smooth nontender liver, no ascites

3. Labs  CBC – Hg 9.9  AST/ALT – mildly elevated  Alk phos and ggt – marked incr  INR – 1.1  Bili – 37  CEA, AFP – normal

4. DDX  Cholangiocarcinoma  Pancreatic cancer  Primary duo cancer  Choledocholithiasis  Cholangitis  Benign stricture  Short segment, regular margin, symmetric, no ductal enhancement, no LN enlargment, no mass  Liver mets  HCC

5. US  1 st line in pts with obstructive jaundice  Most common site of biliary adenocarcinoma is at or near the confluence of R/L hepatic ducts – Klatskin tumors  Notice how ill-defined the tumor is.

6. CT  Useful in diagnosing level of obstruction  Difficult to identify mass  Regions of thickening of the periductal parenchyma w altered caliber of involved duct.  Intrahepatic biliary dilatation.

8.  ERCP demonstrated marked dilated CBD with a 2cm stricture of CBD involving bifucation of R/L intrahepatics  Sphincterotomy performed  Stents placed across strictures  CHD brushings revealed atypical cells concerning for cholangiocarcinoma

9. ERCP  Superiority of ERCP to MRCP  Right demonstrates shouldering at the hilum and multiple strictures  Staging done is based on mass effect, irregular margins, and abrupt tapering.

10. MRCP  Evaluation of biliary tree  MRCP limitations include spatial resolution and inability to evaluate secondary to ducts

11. MRI  Adds little to US and CT in est dx  Isointense or slightly hyperintense areas on T2 images are due to the fibrous content of these tumors  Hyperintense areas on T2-weighted images are due to mucous secretion within the lesion

12. MRI  Planning tx, assessing for resectability  Unresectable when:  Bilateral extension  Secondary ducts  Hepatic parenchyma  Hepatic artery or PV  Occlusion of main PV  N2 nodes (around pancreas)  Distant mets  Most challenging in patients with Klatskin tumors.  50% with Klatskins that are determined to be resectable preoperatively have unresectable disease intraoperatively.

13. References  http://www.ultrasoundcases.info/Test-Yourself- Case.aspx?test=7307&cat=156&group=63&page=28&sho w=1 http://www.ultrasoundcases.info/Test-Yourself- Case.aspx?test=7307&cat=156&group=63&page=28&sho w=1  http://emedicine.medscape.com/article/189843- workup#a0722 http://emedicine.medscape.com/article/189843- workup#a0722  http://radiopaedia.org/articles/cholangiocarcinoma http://radiopaedia.org/articles/cholangiocarcinoma  http://www.radiologyassistant.nl/en/p49e17de25294d/bilia ry-ducts-pathology.html http://www.radiologyassistant.nl/en/p49e17de25294d/bilia ry-ducts-pathology.html  http://emedicine.medscape.com/article/365065- overview#a2 http://emedicine.medscape.com/article/365065- overview#a2