S1544 An Interesting Presentation of Cholangiocarcinoma: Esophageal Varices

Abstract

INTRODUCTION: Esophageal varices are an uncommon presentation for cholangiocarcinoma. CASE DESCRIPTION/METHODS: A 75 year old female with a past medical history of anemia presented to her primary care physician with a complaint of fatigue for two months. The patient took NSAIDs regularly, but denied any melena, hematochezia or hematemesis. Lab work confirmed iron deficiency anemia, she was referred for upper endoscopy and colonoscopy. Findings were notable for grade I varices in the lower third of the esophagus and grade I internal hemorrhoids. Given the findings of varices, she was referred for a RUQ ultrasound with findings of cirrhosis without evidence of portal hypertension. The patient had no history of alcohol abuse or viral hepatitis, so these findings were concerning for a diagnosis of NASH. The patient was hospitalized after developing jaundice, abdominal distension and a 15-pound weight loss with associated clay colored stools and dark urine. At the time of admission, her total bilirubin was 22. MRI of the abdomen revealed intrahepatic and extrahepatic bile duct dilation with abrupt narrowing suspicious for stricture. Other findings included cirrhosis, esophageal varices, mild ascites, and mild splenomegaly. The patient underwent ERCP with findings of moderate dilation of the upper and middle third of the main bile duct, left and right hepatic ducts, all intrahepatic branches and the common hepatic duct. A biliary sphincterotomy was performed and 1 stent placed. Brushings of the common bile duct were notable for cholangiocarcinoma. A subsequent PET scan demonstrated mild avidity in the area of the CBD but no discrete lesion and no metastatic disease. DISCUSSION: Cancer arising from the perihilar region accounts for 60-70% of extrahepatic cholangiocarcinomas and are further classified according to the pattern of involvement of the hepatic ducts. Tumors involving the hepatic duct bifurcation, hilar cholangiocarcinomas, are collectively called Klatskin tumors. Patients with extrahepatic cholangiocarcinomas become symptomatic when there is obstruction of the biliary drainage system. Typical presenting symptoms include dark urine, jaundice, clay colored stools, weight loss, and abdominal pain. Small extrahepatic bile duct cancers may not be visualized on imaging, but an obstructing malignant lesion is suggested by ductal dilation in the absence of stones. Proximal lesions cause dilation of just the intrahepatic ducts, while distal lesions cause dilations of both the intrahepatic and extrahepatic ducts.Figure 1.: Grade I Esophageal Varices.Figure 2.: Esophageal varices in the lower third of the esophagus.Figure 3.: Common Bile Duct Dilation on MRI.