Abstract
Case ReportG.G., a 78-year-old Caucasian male was presented to ourattention complaining of continuous upper abdominal pain,jaundice, and melena. The patient referred to us that thesymptoms started 3 days before.His previous medical history comprised left superior lunglobectomy 11 years before for a non small-cell carcinoma(pT3N0M0), atypical hepatic resection for well-differentiatedhepatocellularcarcinoma(HCC)7yearsbefore,aprostaticadenocarcinoma(pT2aN0M0GS3-4)3yearsbefore, treated by radical prostatectomy with followingradiotherapy, and sigmoid resection for colic adenocar-cinoma (pT3N0M0 G2) 2 years later. In addition, hewas in anticoagulant therapy for chronic atrial fibrilla-tion and a pacemaker has been placed for an atrial-ventricular complete blockage.Tumor markers showed normal values (alfa-phetoprotein,carcinoembryonic antigen (CEA), and carbohydrate antigen19.9 (CA 19.9)) and hepatitis serology (HBVand HCV) wasnegative. Liver function tests were as follow, total bilirubin2.90 mg/dL, unconjugated bilirubin 0.41 mg/dL, gamma-GT1,335 UI/L, alkaline phosphatase 631 UI/L, glutamic oxalo-acetic transaminase (GOT) 46UI/L,glutamic-pyruvictransaminase (GPT) 55 UI/L. Blood cell counts showed Hb12.5 g/dL, WBC 6.000, RBC 4.800.000, and platelet (PLT)244.000.ACTscanoftheabdomenshowedamainbiliaryduct dilated up to 11 mm with elongated morphologyand lobulated profiles with presence of a solid tissueinside. It appeared as a lateral wall thickening with adiameter of 2.4×1.5 cm and extended longitudinally for2.5 cm determining an apparent luminal stricture. This tissuehad an early and intense contrast enhancement in the arterialphase with mild wash-out in the balance phase. CT of thethorax was negative.On the base of CT, we decided to perform endoscopicretrograde cholangiopancreatogram (ERCP) and ultrasoundendoscopy: ERCP showed a dilated biliary tract with a clotin the medial and distal third. The clot was removed afterpapillosphinterectomy. The underlying mucosa was macro-scopically normal. Ultrasound endoscopy demonstrated ahypoecoic lesion at the middle third of the main bileduct. It had an ovular shape (length 23 mm, thickness10 mm) and was vascularized at the power-dopplerexamination: the suspect of origin from the cystic duct’sstump rose. The main bile duct was infiltrated andcompressed and it had a slight increase in size up tothe hepatic hilum. A minimal dilation of intrahepaticduct was also described. The distal portion of common bileduct had a regular gage with walls with binary mor-phology as sludge deposition and aerobilia. At the he-patic hilum, a1-cmlymphnodewithpathologicmorphologywas identified.On the basis of imaging and laboratory findings, the diag-nosis of “upper biliary tract tumor” was done and an explor-ative laparotomy was planned. The liver had a cholestaticappearance. An intraoperative ultrasound exploration
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