Metastatic Cholangiocarinoma Masquerading as Mesenteric Ischemia

Abstract

Purpose: Perihilar Cholangiocarcinoma represents 60–80% of cholangiocarcinomas. Obstructive jaundice is the presentation in 90% of patients. Other symptoms include weight loss, anorexia, acholic stools, fatigue and abdominal pain. Methods: 60 year old male presented with postprandial abdominal pain, sitophobia and 30 lb weight loss over 2 months. The pain was constant periumbilical worsened with eating. Abdomen was tender without peritoneal findings. With mesenteric ischemia in the differential a CT was performed. Mesenteric vessels were patent but small bowel and colon were diffusely thickened and mild left intrahepatic ductal dilation was noted. Surgical evaluation and review of CT suggested mesenteric ischemia was less likely. Enteroscopy and colonoscopy with ileoscopy and biopsies were negative. Liver enzymes were normal except alkaline phosphatase 185, AST 52 and ALT 104. ERCP to evaluate biliary dilation revealed mild narrowing of medial branch of right intrahepatic and tight stricture at take off of left intrahepatic. Stent was placed across the stricture. Brushings were negative. Cholangiocarcinoma was suspected when the CA 19–9 of 2000 U/mL returned in conjunction with the ERCP findings. Although CT scan did not suggest metastatic disease a CT PET scan demonstrated metastasis to the right lobe, peritoneum, mesentery and bowel. Biopsy of porta hepatis using biliary stent as landmark was consistent with adenocarcinoma of pancreatic or biliary origin (CK19 +). The patient opted for hospice care succumbing 2 months later. Results: Perihilar Cholangiocarinoma typically presents with obstructive jaundice. This patient presented with abdominal pain, sitophobia and weight loss, more consistent with mesenteric ischemia. Despite normal bilirubin, evaluation of intrahepatic duct dilation with CA 19–9, cholangiography and biopsy was needed for diagnosis. CT PET imaging accurately staged disease where CT failed. In elderly patients with negative work up for mesenteric ischemia biliary dilation should be investigated. Cholangiocarcinoma with metastasis to bowel and peritoneum can present with pain similar to mesenteric ischemia from meal stimulated increase in bile flow and/or obstruction.[figure1]Figure