Thursday, February 11, 2010

A 66 yo white female presented to the urgent care with 10 days of of increasing pruritus (itchy skin all over), yellowing skin and white part's of eyes, and pale stool. She is admitted to the hospital because of jaundice. The patient has felt fine and her only complaint is being itchy. She has no past medical history and has never been hospitalized in the past. She has never had any history of gallstones, hepatitis or cirrhosis. She had never smoked and rarely drinks alcohol. Physical exam is essentially normal except for discoloration of skin and scleral icterus. She had no abdominal pain on exam. She had tons of labs done but I'm just including LFT's:

Results Units Reference Range

TOTAL BILI 7.2 H mg/dL .2-1.2

DIRECT BILI 4.8 H mg/dL .0-.3

ALBUMIN 3.1 g/dL 3.1-4.7


ALT (SGPT) 305 HH IU/L 4-42

AST (SGOT) 257 H IU/L 10-39

TOTAL PROTEIN 7.3 g/dL 6.0-8.0
Which of the following diagnoses is most probable and which, if present, has the worst/best prognosis?
A. Choledocholithiasis
B. Pancreatic cancer
C. Klatskin tumor
D. Liver cirrhosis due to a combination of hep B and C
E. Gallbladder cancer


  1. A and D could probably be ruled out because she has not had pain or chronic illness. It is probably some type of cancer (B, C or E). Gallbladder cancer may be the least lethal of the 3 but I would not want any of them!

    I'll vote for C.

  2. This pt really grew on me. She was the nicest lady and was always so happy when I came in to exam her. She had to wait all weekend because the ultrasound and ERCP that she needed weren't available until Mon. The pancreas and gallbladder both looked fine and no stones in the bile duct. The bile duct had some narrowing which they took a biopsy of and then placed a stent. The results came back for answer C - Klatskin tumor. This cancer has a horrible prognosis and it was so sad after she had been so hopeful for good news. This was an interesting case. She will be seeing Hem/Onc this week to see if she could benefit for chemo/radiation.

  3. Wow. I'm so sad for her. I'm amazed with your prognosis, Mom. I hope the treatments will work out.