DEPARTMENT OF INTERNAL MEDICINE

CASE PRESENTATION

PGI - ALAN JONES

GENERAL INFORMATION

Name: B.F
Age: 72
Sex: Female
Address: Davao City
Informant: Patient
Reliability: 85%
Date of admission: June 13, 2023
CHIEF COMPLAINT

JAUNDICE
HISTORY OF PRESENT ILLNESS

Approximately 34 days PTA, patient noted bipedal edema. No other recalled associated
symptoms such as exertional dyspnea, orthopnea and oliguria.No meds taken, no consult
was done.

Approximately 31 days PTA, now associated with icterisia by neighbour, still with persistence
of bipedal edema. No fever, no abdominal pain, no vomiting, no dysuria, no oliguria, no
dyspnea, no orthopnea, no exertional dyspnea, no chest pain and palpitations.
sought consult with previous AP due to progression of jaundice, advised work-up and
imaging but did not comply due financial constraints.
HISTORY OF PRESENT ILLNESS

In the interim patient would gradually note progression of jaundice, with increasing severity
in her icterisia. This was not associated with dark colored urine, no acholic stools noted.
Patient noted LBM and her neighbours suggested Loperamide 2 tabs OD, and Dicycloverine
OD for 5 days with relief of loose stool. No changes in stool caliber was noted during this
time.
HISTORY OF PRESENT ILLNESS

19 days PTA, sought consult with previous AP due to progression of jaundice and but noted
constipation, again advised work-up and imaging but did not comply due financial
constraints. She was prescribed w/ the following medications:
Pantoprazole 40mg tab
Essentiale Forte 300mg cap
Lactulose Syrup
Patient took the above medications but still with no relief of constipation.
HISTORY OF PRESENT ILLNESS

In the interim above symptoms progressed now associated with body malaise, decreasing
appetite and early satiety patient was noted. Patient would also have occasional episodes of
vague hypogastric discomfort, non migrating in character, PS of 6-8/10 relieved by food
intake.

Due to persistence of above symptoms patient sought consult at the OPD, work up was done
and was noted with the following findings:
CBC - Hepatitis C virus (anti-HCV) - non
● Hgb : 114 reactive
● Hct : 0.34 - Hepatitis B surface antigen (HBsAG)
● RBC : 3.49 QUANTITATIVE - non reactive
● WBC : 6.8
● N : 88 - Sodium - 130 mmol/L
● L :8 - Potassium - 2.80
● M. : 0.11 - Ast - 205 (x6)
● E : 0.01 - Alt - 101 (x1.8)
● B :0 - Albumin - 30
● Plt : 310 - Alkaline phosphatase - 626 (x4.9)
● MCV : 98 - Total bilirubin - 270 (x12)
● MCH : 33 - Direct bilirubin - 241 (x48)
● MCHC : 33 - Indirect bilirubin - 29 (x1.5)
HISTORY OF PRESENT ILLNESS

Patient was then advised admission for further work-up and management hence this case.
PAST MEDICAL HISTORY

No HPN
No DM
No known allergies
(-) CVA
(-) MI
(-) BA
(-) Previous history of PTB
FAMILY HISTORY

● No family history of DM, HPN or cancer

● No other heredofamilial illness
PERSONAL AND SOCIAL HISTORY

● Smoker - 52 pack years

● Non alcohol beverage drinker
● No herbal medications use
● Patient used to work as a secretary
REVIEW OF SYSTEMS

GENERAL : (-) fever, (-) anorexia, (-) chills, (+) undocumented weight loss

SKIN : (-) Rashes, (-) pruritus

HEAD : (-) dizziness, (-) alopecia,

EYES : (-) redness, (-) diplopia

EARS : (-) discharge, (-) tinnitus, (-) hearing loss

NOSE AND SINUS : (-) colds/sinusitis, (-) nasal congestion

THROAT : (-) sore throat, (-) hoarseness, (-) oral ulcers

NECK : (-) stiffness

RESPIRATORY : (-) orthopnea, (-) hemoptysis, (-) shortness of breath

REVIEW OF SYSTEMS

CARDIOVASCULAR : (-) chest pain, (-) palpitation

GASTROINTESTINAL : (-) nausea, (-) vomiting, (+) flatus, (+) loss of appetite

PERIPHERAL VASCULAR : (-) calf tenderness, (+) on and off bipedal edema

URINARY : (-) flank pain

MUSCULOSKELETAL : (-) joint pains, (-) aching muscles, (-) extremities weakness

NEUROLOGIC : (-) seizures, (-) memory loss, (-) changes in behavior, personality, sensory
deficits

HEMATOLOGIC : (-) easy bleeding or bruising, (-) pallor

ENDOCRINE : (-) heat/cold intolerance, (-) polyphagia, (-) polyuria

PSYCHIATRIC : (-) depression, (-) anxiety, (-) hallucinations

PHYSICAL EXAMINATION

patient was examined awake, cooperative, conversant,

coherent, NIRD, ambulatory (jaundiced)

Vital Signs
● BP : 110/70 mmHg
● HR : 79 bpm
● RR : 21 cpm
● Temp : 36.6 C
● O2 sat : 95% at room air

Anthropometrics
● Weight : 38 kg
● Height : 152 cm
● BMI : 16.4 (Underweight; WHO Guidelines)
PHYSICAL EXAMINATION

Skin: (-) pallor, (-) rashes, (-) jaundice

Head:
I: symmetrical, (-) alopecia
P: (-) tenderness, (-) masses, (-) areas of tenderness

Eyes: icteric sclerae, PERRLA

Ear:
I: (-) discharges, (-) skin tags
P: (-) tenderness tug test, (-) preauricular LA
PHYSICAL EXAMINATION

Nose and Paranasal Sinuses:

I: (-) alar flaring, (-) deformation, (-) lesions
P: (-) tenderness of frontal and maxillary sinuses

Mouth: moist lips and oral mucosa

Neck:
I: (-) tracheal deviation, (-) Jugular vein distention
P: (-) No neck masses
PHYSICAL EXAMINATION

Chest and Lungs:

I: Equal Chest Expansion, (-) retractions
P: Resonant on all lung fields
P: Equal vocal fremitus
A: clear breath sounds

Cardiac Examination:
I: Adynamic precordium
P: no heaves or thrills
A: Regular cardiac rate and rhythm, Distinct S1 and S2 heart sounds, no murmurs
PHYSICAL EXAMINATION

Abdominal Examination:
I: Globular, slightly distended abdomen
A: Normoactive bowel sounds (20’s)
P: Tympanitic on percussion on all quadrants, (+) dullness heard at approx. 10 cm from the
midsternal line.
P: (+) direct tenderness in the lower abdomen.

Extremities
Full pulses, (+) bipedal edema pitting grade 1, CRT less than 2 seconds

DRE: No Gross Lesions, no external masses, w/ good sphincter tone, no internal masses
palpated (+) light yellow stool on examining finger
PHYSICAL EXAMINATION

Neuro
GCS 15

● Awake, no loss in sensorium

● Oriented to time, place and person
● Intact short term and long term memory
● Intact cranial nerves
● motor strength (5/5 in all extremities)
PHYSICAL EXAMINATION

Neurologic
GCS 15
CN I - not assessed
CN II - no visual field loss, PERRLA
CN III, IV, VI - no preferential gaze
CN V - (+) corneal reflex
CN VII - no facial asymmetry
CN VIII - intact hearing
CNIX, X - intact gag reflex
CN XI - (-) shoulder lag, right
CN XII - no tongue deviation
ADMITTING IMPRESSION

Obstructive Jaundice Probably secondary Cholelithiasis not in Cholangitis

T/C Liver Cirrhosis probably secondary to NAFLD Child-Pugh C , FID-4 index
4.74 (Advanced Fibrosis)
Hypokalemic Ileus R/O Partial Intestinal Obstruction probably secondary to
Colonic Malignancy w/ Hepatic Metastasis vs Diverticulosis
T/C Anemia of malignancy
Hypoalbuminemia secondary to poor intake
 SALIENT FEATURES

72 YEAR OLD ALTERNATING BOWEL

FEMALE JAUNDICE HABITS WEIGHT LOSS

VAGUE HYPOGASTRIC
EARLY SATIETY BIPEDAL EDEMA PAIN

52 PACK YEAR SMOKER LOSS OF APPETITE

DIFFERENTIAL
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS

Choledocholithiasis

RULE IN RULE OUT

(+) jaundice (-) non radiating abdominal pain

(+) weight loss (-) location of the pain; in the lower abdomen
(+) Abdominal discomfort and pain instead of the RUQ
(-) constipation
(-) needs abdominal ultrasound to completely
rule out.
(-) bipedal edema
Liver cirrhosis

RULE IN RULE OUT

(+) jaundice (-) spider angiomata

(+) loss of appetite (-) palmar erythema
(+) Weight loss (-) constipation
(+) bipedal edema (-) caput medusae
(+) hepatomegaly
Primary hepatic cancer

RULE IN RULE OUT

(+) jaundice (-) cannot be ruled out without

(+) hepatomegaly abdominal ultrasound or CT
(+) abdominal pain (-) non radiating RUQ pain to the
(+) weight loss shoulder
(+) age of the patient; elderly (-) acholic stool
(+) lack of appetite (-) predisposition to the male sex
(+) bipedal edema
(+) tobacco use (smoking - 52 pack
years)
(+) constipation
Tuberculous enteritis

RULE IN RULE OUT

(+) jaundice (-) no environmental exposure to

(+) pedal edema unpasteurized milk
(+) hepatomegaly
(+) abdominal pain
(+) constipation succeeding diarrhea
(+) weight loss
(+) loss of appetite
Cholangiocarcinoma - KLATSKIN Neoplasia

RULE IN RULE OUT

(+) jaundice (-) cannot be ruled out without

(+) hepatomegaly abdominal ultrasound or CT
(+) abdominal pain (-) lymphadenopathy
(+) weight loss (-) pruritus
(+) lack of appetite (-) bipedal edema
(+) tobacco use (smoking - 52 pack (-) Courvoisier sign
years) (-) acholic stool
(+) most commonly seen in elderly
population
Colorectal cancer with hepatic metastasis

RULE IN RULE OUT

(+) jaundice (-) cannot be ruled out without abdominal

(+) hepatomegaly ultrasound or CT
(+) abdominal pain (-) hematochezia
(+) constipation
(+) weight loss
(+) tobacco use (smoking - 52 pack years)
(+) age - average age of diagnosis is 72 which
is the exact age of the patient
(+) low appetite
LATEST LABS

● Creatinine : 40.1
● EGFR : 102

RT PCR - Negative for Sars-Cov 2

PT 27.3 vs 12.3
INR 2.35
APTT 39.4 vs 29
PTPA 29.4%
IMAGING

CXR
A- PA view, good inspiratory effort
B- no bone deformities, no fractures
C- no double density sign, no cardiomegaly
D- no pneumoperitoneum, sharp
costophrenic angles
E- F- no NGT, ET tubes, clear lung fields, no
foreign objects

IMPRESSION: ATHEROSCLEROTIC
AORTA
ECG INTERPRETATION

Rate 71 bpm
Rhythm-sinus rhythm
Pr interval-0.16 normal
Axis-normal axis
Qrs complex-0.08 normal
T wave-positive deflection
QT interval-0.4 sec

Impresion : sinus rhythm

IMAGING - X-RAY ABD
X-RAY ABD

OFFICIAL IMPRESSION:

NO SIGNIFICANT ABDOMINAL FINDINGS

LEVOSCOLIOSIS AND SPONDYLOSIS DEFORMANS LUMBAR SPINE
WARD IMPRESSION

Obstructive Jaundice Probably secondary Cholelithiasis not in Cholangitis

T/C Liver Cirrhosis probably secondary to NAFLD Child-Pugh C , FID-4 index 4.74 (Advanced
Fibrosis)
Hypokalemic Ileus R/O Partial Intestinal Obstruction probably secondary to Colonic Malignancy w/
Hepatic Metastasis vs Diverticulosis
T/C Anemia of malignancy
Hypoalbuminemia secondary to poor intake
CURRENT MANAGEMENT

GENERAL PLANS
● 1L pnss at 90cc/hr
● SD: KCl Drip: 20 meqs + 100 cc PNSS at 10 cc/hr
● NPO for now then CBG q4 while on NPO
● VS q 4
● I and O q shift
PLANS AT THE ER

Jaundice:
- Cannot totally rule out hepatic cause vs Gall bladder etiology hence for ultrasound of WAB
- Will Rule out Hepatitis

Partial Intestinal Obstruction/ TC GI malignancy:

- Patient on NPO
- Hydrated w/ at 2.6 cpk
- For UTZ of WAB
- Ideally for CT Scan with contrast
- plan to do CEA and AFP
PLANS AT THE ER

T/C Hypokalamic Ileus:

- KCl drip (20 meqs + 100 cc PNSS)
- KCl tablet once diet is resumed
- Repeat S. K post 1 cycle KCl drip

T/c Cirrhosis:
- vitamin K supplementation
- Hepatek once diet is resume
- to Start Aminoleban 500 mg IV OD to run for 5 hours
- continue lactulose 30 cc ODHS
PLANS AT THE ER

Hypoalbuminemia:
- Once Diet is resumed plan to start supplemental milk feeding plus beneprotein, to include egg
whites per meal
MEDICATIONS
Given throughout the course of admission

- Pantoprazole 40 mg IV now then OD

- Hepatek cap 1 cap BID once diet is resumed
- KCl tabs 2 tabs TID
- Vitamin k 1 Amp+ 50cc pnss to run for 30 mins q 8 hours x 3 doses for now
- Lactulose 30cc ODHS
- Ceftrioxone 2g IVTT OD
COURSE IN THE WARDS
DAY 1 OF ADMISSION
SUBJECTIVE COMPLAINTS

1. 2 Episodes of bowel movement

2. No epigastric pain
3. Jaundiced
4. No nausea or vomiting
5. Patient had good quality of sleep. No other subjective complaints
6. Bipedal edema
7. Lack of appetite but improving compared to 2 days ago.

OBJECTIVE FINDINGS

1. Icteric sclera
2. Jaundiced skin
3. Moist lips and oral mucosa, no alar flaring, no ear discharge, no erythematous or
enlarged tonsils
4. Equal chest expansion, no retractions, clear breath sounds
5. Adynamic precordium, no heaves or thrills, no murmurs, normal rate and regular
rhythm.
6. Soft, flabby, non-tender abdomen. Normoactive bowel sounds.
7. Warm, full pulses, mild bipedal edema
8. GCS 15
VS
BP - 11/80
T - 36.7
HR - 76
RR - 22
02 - 97% at room air

ASSESSMENT

Obstructive jaundice secondary to T/C non-alcoholic liver disease Vs liver cirrhosis. R/O
Choledocholithiasis

PLAN

IVF PNSS at 90 cc/hr

For Ultrasound of whole abdomen
For serum potassium and UA
Shift pantoprazole to Tab 40mg OD
Start Ceftrioxone 2g IVTT OD
Abdominal Ultrasound (6/14)

Official impression:
1. MINIMAL ASCITES
2. DIFFUSE LIVER PARENCHYMAL DISEASE WITH HETEROGENEOUS SOLID MASS,
INTRADUCTAL BILIARY ECTASIA AND HEPATIC CYST, SEGMENT 3. TRIPHASIC CT
SCAN SUGGESTED FOR FURTHER EVALUATION.
3. SIMPLE CORTICAL RENAL CYST, LEFT
4. SONOGRAPHICALLY NORMAL PANCREAS, SPLEEN, PARA-AORTIC AREAS AND
URINARY BLADDER
 LABS

UA - 6/14

Amber, clear.
PH 6.0
Spec. grav 1.030
Glucose and protein - negative

WBC - 0.34 /HPF

RBC - 3.06 /HPF
EPI CELLS - 0.67 /HPF
CAST - 0.00 /HPF
BACTERIA - 53.05 /HPF
MUCUS THREADS - 0

K - 3.83
DAY 2 OF ADMISSION
SUBJECTIVE COMPLAINTS

1. 2 Episodes of bowel movement after meals

2. No epigastric pain
3. Jaundiced
4. No nausea or vomiting
5. Patient had good quality of sleep. No other subjective complaints

OBJECTIVE FINDINGS

1. Icteric sclera
2. Jaundiced skin
3. Moist lips and oral mucosa, no alar flaring, no ear discharge, no erythematous or
enlarged tonsils
4. Equal chest expansion, no retractions, clear breath sounds
5. Adynamic precordium, no heaves or thrills, no murmurs, normal rate and regular
rhythm.
6. Soft, flabby, non-tender abdomen. Normoactive bowel sounds.
7. Warm, full pulses, mild bipedal edema
8. GCS 15
VS
BP - 100/70
T - 36.1
HR - 72
RR - 20
02 - 96% at room air

ASSESSMENT

Obstructive jaundice secondary to T/C non-alcoholic liver disease Vs liver cirrhosis. R/O
Choledocholithiasis

PLAN

IVF PNSS at 90 cc/hr

For Biphasic abdominal CT with contrast
For FOBT and Urine gram strain
Strict compliance to antibiotics
Continue present management
CT - ABD W/ CONTRAST
 LABS

STOOL OCCULT BLOOD (6/15)

Positive
DAY 3 OF ADMISSION
SUBJECTIVE COMPLAINTS

1. 1 Episode of bowel movement

2. No epigastric pain
3. Jaundiced
4. No nausea or vomiting
5. Patient had good quality of sleep. No other subjective complaints

OBJECTIVE FINDINGS

1. Icteric sclera
2. Jaundiced skin (chest, abdomen and face)
3. Moist lips and oral mucosa, no alar flaring, no ear discharge, no erythematous or
enlarged tonsils
4. Equal chest expansion, no retractions, clear breath sounds
5. Adynamic precordium, no heaves or thrills, no murmurs, normal rate and regular
rhythm.
6. Soft, flabby, non-tender abdomen. Normoactive bowel sounds.
7. Warm, full pulses, mild bipedal edema
8. GCS 15
VS
BP - 100/70
T - 36.3
HR - 71
RR - 20
02 - 99% at room air

ASSESSMENT

Obstructive jaundice probably secondary to cholangiocarcinoma

PLANS

IVF - PNSS 1L at 90 cc/hr

Monitor vitals signs Q4H and INO Q shift

Repeat Serum Creatinine 48H post CT scan

Strict compliance to Antibiotics

Follow up on pending lab results

To continue present management and refer accordingly

 LABS

URINE GRAM STAIN

(6/16)

No organism found
DAY 4 OF ADMISSION
SUBJECTIVE COMPLAINTS

1. 1 Episode of bowel movement

2. No epigastric pain
4. No nausea or vomiting
5. Patient had good quality of sleep. No other subjective complaints

OBJECTIVE FINDINGS

1. Icteric sclera
2. Very mild Jaundiced skin (chest, Face)
3. Moist lips and oral mucosa, no alar flaring, no ear discharge, no erythematous or
enlarged tonsils
4. Equal chest expansion, no retractions, clear breath sounds
5. Adynamic precordium, no heaves or thrills, no murmurs, normal rate and regular
rhythm.
6. Soft, flabby, non-tender abdomen. Normoactive bowel sounds.
7. Warm, full pulses, mild bipedal edema
8. GCS 15
VS
BP - 120/80
T - 36.9
HR - 74
RR - 20
02 - 99% at room air

ASSESSMENT

Obstructive jaundice probably secondary to cholangiocarcinoma

PLAN

1. Switch to oral antibiotics

2. For discharge and to follow up as OPD.
 DISCUSSION
ON
BILE DUCT CANCER
WHAT IS BILE DUCT CANCER

Bile duct cancer is a rare disease in which malignant (cancer) cells form in the bile ducts. Bile
duct cancer is also called cholangiocarcinoma. There are two types of cholangiocarcinomas -

1. Intrahepatic cholangiocarcinomas
2. Extrahepatic cholangiocarcinomas
TYPES OF CHOLANGIOCARCINOMAS

Intrahepatic bile duct cancer: This type of cancer forms in the bile ducts inside the liver. Only a small
number of bile duct cancers are intrahepatic. Intrahepatic bile duct cancers are also called intrahepatic
cholangiocarcinomas.
TYPES OF CHOLANGIOCARCINOMAS

Extrahepatic bile duct cancer: This type of cancer forms in the bile ducts outside the liver. The two types of
extrahepatic bile duct cancer are perihilar bile duct cancer and distal bile duct cancer:

1. Perihilar bile duct cancer: This type of cancer is found in the area where the right and left bile ducts
exit the liver and join to form the common hepatic duct. Perihilar bile duct cancer is also called a
Klatskin tumor or perihilar cholangiocarcinoma.

2. Distal bile duct cancer: This type of cancer is found in the area where the ducts from the liver and
gallbladder join to form the common bile duct. The common bile duct passes through the pancreas and
ends in the small intestine. Distal bile duct cancer is also called extrahepatic cholangiocarcinoma.
COMMON PRESENTATION

➔ Jaundice (yellowing of the skin or whites of the eyes)

➔ Dark urine
➔ Clay colored stool - Acholic stool
➔ Pain in the abdomen - RUQ
➔ Fever
➔ Itchy skin - Pruritus
➔ Nausea and vomiting
➔ Weight loss for an unknown reason
RISK FACTORS

➔ primary sclerosing cholangitis (a progressive disease in which the bile ducts

become blocked by inflammation and scarring)
➔ chronic ulcerative colitis
➔ cysts in the bile ducts (cysts block the flow of bile and can cause swollen bile
ducts, inflammation, and infection)
➔ infection with a Chinese liver fluke
STAGING OF CHOLANGIOCARCINOMA
TUMOR SIZES EXAMPLES
Intrahepatic bile duct cancer staging

Stage 0: In stage 0 intrahepatic bile duct cancer (carcinoma in situ), abnormal cells are found in

the innermost layer of tissue lining the intrahepatic bile duct. These abnormal cells are not
actually cancer but may become cancer and spread into nearby normal tissue.

Stage I: Stage I intrahepatic bile duct cancer is divided into stages IA and IB.  

- In stage IA, cancer has formed in an intrahepatic bile duct and the tumor is 5 centimeters or

smaller. 

- In stage IB, cancer has formed in an intrahepatic bile duct and the tumor is larger than 5
centimeters.
Intrahepatic bile duct cancer staging

Stage II: In stage II intrahepatic bile duct cancer, either of the following is found: 

- the tumor has spread through the wall of an intrahepatic bile duct and into a blood vessel; or 

- more than one tumor has formed in the intrahepatic bile duct and may have spread into a
blood vessel.
Intrahepatic bile duct cancer staging

Stage III: Stage III intrahepatic bile duct cancer is divided into stages IIIA and IIIB. 

- In stage IIIA, the tumor has spread through the capsule (outer lining) of the liver. 

- In stage IIIB, cancer has spread to organs or tissues near the liver, such as

the duodenum, colon, stomach, common bile duct, abdominal wall, diaphragm, or the part of
the vena cava behind the liver, or the cancer has spread to nearby lymph nodes.  
Intrahepatic bile duct cancer staging

 Stage IV: In stage IV intrahepatic bile duct cancer, cancer has spread to other parts of the
body, such as the bone, lungs, distant lymph nodes, or tissue lining the wall of the abdomen
and most organs in the abdomen.
Perihilar bile duct cancer staging

Stage 0:
In stage 0 perihilar bile duct cancer (carcinoma in situ), abnormal cells are found in the
innermost layer of tissue lining the perihilar bile duct. These abnormal cells are not actually
cancer but may become cancer and spread into nearby normal tissue. Stage 0 is also called
high-grade dysplasia.

 Stage I:  In stage I perihilar bile duct cancer, cancer has formed in the innermost layer
of tissue lining the perihilar bile duct and has spread into the muscle layer or fibrous tissue
layer of the perihilar bile duct wall.

Stage II:  In stage II perihilar bile duct cancer, cancer has spread through the wall of
the perihilar bile duct to nearby fatty tissue or to liver tissue.
Perihilar bile duct cancer staging

Stage III: Stage III perihilar bile duct cancer is divided into stages IIIA, IIIB, and IIIC. 

- Stage IIIA: Cancer has spread to branches on one side of the hepatic artery or of the portal

vein. 

-  Stage IIIB: Cancer has spread to one or more of the following:  

● the main part of the portal vein or its branches on both sides

● the common hepatic artery
● the right hepatic duct and the left branch of the hepatic artery or of the portal vein
● the left hepatic duct and the right branch of the hepatic artery or of the portal vein

-  Stage IIIC: Cancer has spread to 1 to 3 nearby lymph nodes.

Perihilar bile duct cancer staging

Stage IV: Stage IV perihilar bile duct cancer is divided into stages IVA and IVB. 

- Stage IVA: Cancer has spread to 4 or more nearby lymph nodes.

- Stage IVB: Cancer has spread to other parts of the body, such as the liver, lung, bone,
brain, skin, distant lymph nodes, or tissue lining the wall of the abdomen and most organs in
the abdomen
Distal bile duct cancer staging

Stage 0: 

In stage 0 distal bile duct cancer (carcinoma in situ), abnormal cells are found in the

innermost layer of tissue lining the distal bile duct. These abnormal cells are not actually
cancer but may become cancer and spread into nearby normal tissue. Stage 0 is also called
high-grade dysplasia

Stage I: 

In stage I distal bile duct cancer, cancer has formed and spread fewer than 5 millimeters into
the wall of the distal bile duct
Distal bile duct cancer staging

Stage II: Stage II distal bile duct cancer is divided into stages IIA and IIB. 

- Stage IIA: Cancer has spread

● fewer than 5 millimeters into the wall of the distal bile duct and has spread to 1 to 3
nearby lymph nodes; or 
● 5 to 12 millimeters into the wall of the distal bile duct.

- Stage IIB: Cancer has spread 5 millimeters or more into the wall of the distal bile duct.
Cancer may have spread to 1 to 3 nearby lymph nodes
Distal bile duct cancer staging

Stage III: Stage III distal bile duct cancer is divided into stages IIIA and IIIB.

- Stage IIIA: Cancer has spread into the wall of the distal bile duct and to 4 or more
nearby lymph nodes.

- Stage IIIB: Cancer has spread to the large vessels that carry blood to the organs in the
abdomen. Cancer may have spread to 1 or more nearby lymph nodes.

Stage IV: In stage IV distal bile duct cancer, cancer has spread to other parts of the body,
such as the liver, lungs, or tissue lining the wall of the abdomen and most organs in the
abdomen
DIAGNOSTIC MODALITIES

➔ Liver function tests

➔ Carcinoembryonic antigen (CEA) and CA 19-9 tumor marker test
➔ Ultrasound exam:
➔ CT scan (CAT scan):
➔ Magnetic resonance imaging (MRI):
➔ Magnetic resonance cholangiopancreatography (MRCP):
DIAGNOSTIC MODALITIES

BIOPSY

➔ Laparoscopy:

➔ Percutaneous transhepatic cholangiography (PTC):

➔ Endoscopic retrograde cholangiopancreatography (ERCP)

➔ Endoscopic ultrasound (EUS)
TREATMENT OF CHOLANGIOCARCINOMA
 TREATMENT OPTIONS

SURGERY RADIATION CHEMO TRANSPLANT

TARGETED IMMUNOTHERAPY EXPERIMENTAL

SURGICAL OPTIONS
 Main surgical options

1. Removal of the bile duct

2. Partial hepatectomy
3. Whipple procedure

Palliative surgical options

1. Biliary bi-pass
2. Endoscopic stent placement
3. Percutaneous transhepatic biliary drainage
RADIATION THERAPY
1. External radiotherapy
w/ or w/o hyperthermia therapy or radiosensitizers

2. Internal radiotherapy
CHEMOTHERAPY
1. Systemic chemotherapy
- Gemcitabine and Cisplatin
- Capecitabine and Oxaliplatin (XELOX)
- Gemcitabine and Oxaliplatin (GEMOX)
- Gemcitabine and Capecitabine

2. Internal radiotherapy
TARGETED THERAPY
The following targeted therapies are being studied in patients with bile duct cancer
that is locally advanced and cannot be removed by surgery or has spread to other
parts of the body:

1. ivosidenib
2. pemigatinib
3. infigratinib
IMMUNOTHERAPY
Immune checkpoint inhibitor therapy is a type of immunotherapy. The following
immune checkpoint inhibitor are used to treat bile duct cancer:

1. pembrolizumab
2. durvalumab