S3344 A Tight Squeeze: A Case of Metastatic Poorly Differentiated Gastric Adenocarcinoma Presenting as Malignant Biliary Strictures After a Recent Laparoscopic Cholecystectomy

Abstract

INTRODUCTION: Biliary strictures are subdivided into benign and malignant etiologies. Benign strictures often result from an array of causes including chronic or autoimmune pancreatitis, Mirizzi syndrome, and iatrogenic causes, including post-cholecystectomy strictures. Malignant strictures are often seen as a result of cholangiocarcinoma or pancreatic adenocarcinoma. Gastric adenocarcinoma is an exceedingly rare cause of biliary strictures, with resultant obstruction estimated in 1.3-2.3% of cases. Differentiating between these stricture types is of the utmost importance given vast differences in management. This case represents a diagnostic challenge in a patient presenting with biliary strictures after a recent laparoscopic cholecystectomy who was found to have metastatic gastric adenocarcinoma. CASE DESCRIPTION/METHODS: A 32-year-old female with a past medical history significant for a laparoscopic cholecystectomy four months prior to admission presented with subacute fatigue, jaundice, and dark urine. Initial laboratory values were notable for a direct pre-dominant hyperbilirubinemia. An MRCP showed stricturing at the confluence of the biliary ductal system, moderate ascites, and enlarged para-aortic/retroperitoneal nodes that were visualized four months prior. Initial provider concerns included post-cholecystectomy complications; however, the persistent lymphadenopathy remained a cause for concern. An ERCP demonstrated erythematous mucosa throughout the stomach and severe biliary strictures in the entire main bile duct, with a thickened gastric fold biopsy revealing poorly differentiated gastric adenocarcinoma (surgical pathology from her recent cholecystectomy demonstrated only acute and chronic calculous cholecystitis). Her hospital course was complicated by peritoneal carcinomatosis, peritonitis, recurrent gastric outlet obstructions, and enteral and biliary stent placement. Palliative chemotherapy was initiated in the inpatient setting prior to discharge. DISCUSSION: Given the temporal relationship of the patient’s symptoms to her recent cholecystectomy, initial concerns involved post-cholecystectomy complications such as benign biliary strictures. However, the importance of the patient’s persistent lymphadenopathy was noted and additional procedures were pursued, leading to the diagnosis of malignancy as the cause of the patient’s strictures. Determining the etiology of the patient’s biliary stricture was of paramount importance to ensure the expedient delivery of chemotherapy.