Abstract
In 11 years and 3 months, 2037 patients with HCC were seen and 48 patients (2.4%) were diagnosed to have obstructive icteric type HCC. Five patients were terminally ill and were not investigated further. Forty three patients were initially investigated by endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangiogram (PTC) and classified as having obstructive icteric type 1, 2, or 3 HCC based on the cholangiographic findings. The obstruction in type 1 HCC was due to intraluminal tumour casts and/or tumour fragments obstructing the hepatic ductal confluence or common bile duct, while intraluminal blood clots, from haemobilia, filling the biliary tree was the cause in type 2 HCC. The pathology in type 3 HCC was extraluminal obstruction by extensive tumour encasement of the intra–hepatic biliary ductal system and/or extrinsic compression of the hepatic and common bile ducts by tumour(s) and/or malignant lymph nodes. At the initial ERC/PTC, 10 patients (5 resected, 50%) had obstructive icteric type 1 and 23 patients (0 resected) had obstructive icteric type 3 HCC. Of the 10 patients initially classified according to cholangiography to have obstructive icteric type 2 HCC, subsequent investigations revealed that 6 patients had type 1 HCC (4 resectable, 67%) and 4 patients had type 3 HCC (0 resectable). The classification of the obstructive icteric type HCC into types 1, 2, and 3, based on the initial cholangiographic appearances has simplified and rationalized our management strategy for this condition.
Highlights
Jaundice as a presenting symptom of hepatocellular carcinoma (HCC) occurs in 5-44% of cases [1,2,3,4]
In our study of 48 patients, we present the cholangiographic features of obstructive icteric type HCC on the initial cholangiogram and based on these cholangiographic findings we have established a management algorithm which we have found to be useful in the diagnosis and management of these patients
The description of 3 main types of cholangiographic appearances by Lee et al, emphasised the extrahepatic and intrahepatic appearances of the ductal system [6]. It is obvious from their description, that overlap of the different types of appearances occurs within a single case, giving rise to ambigious information on the biliary tree which would affect management planning
Summary
Jaundice as a presenting symptom of hepatocellular carcinoma (HCC) occurs in 5-44% of cases [1,2,3,4]. Its occurrence can be secondary to parenchymal insufficiency due to the underlying liver cirrhosis and/or parenchymal infiltration by the HCC, to obstruction of the biliary tract by intraluminal tumour cast/fragments/blood clots, to extraluminal compression of the bile ducts by the tumour or obstruction by enlarged malignant lymph nodes at the porta hepatis The majority of these icteric patients has underlying parenchymal insufficiency and a percutaneous ultrasound scan will demonstrate an underlying non-dilated biliary ductal system. Despite remarkable improvements in the diagnostic tools available for investigating obstructive jaundice, not infrequently, these cases are still misdiagnosed as cholangiocarcinoma or choledocholithiasis Prompt recognition of this type of HCC with relief, of the obstruction either by stenting or resection can lead to extended survival with good palliation and occasionally cure [6, 7, 9,10,11,12]. In our study of 48 patients, we present the cholangiographic features of obstructive icteric type HCC on the initial cholangiogram and based on these cholangiographic findings we have established a management algorithm which we have found to be useful in the diagnosis and management of these patients
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