Extensive Cholangiocarcinoma
Description
● Patient Profile
•Age/Sex: female, 58 years old
•Past medical history: No previous illnesses or follow-up visits with primary care
● Presenting complaints:
➣Excruciating pain in the right upper quadrant that radiates to the back (× 4 months)
➣Jaundice that becomes worse over four days
➣vomiting, nausea, and diarrhoea
➣Grey or pallid stools (acholic)
➣Blood in stool was denied.
➣Food made the pain worse, and acetaminophen and ibuprofen did not help.
➣On Admission
•Hemodynamically stable, afebrile
•No prior comorbidities
● Laboratory Findings (Table 1)
➣Hb ↓ (9.7 g/dL, macrocytic, MCV 100 fL), WBC ↑ (16.8/µL) CBC
➣Function of the liver: ALP 421 U/L Bilirubin, ALT 65, and AST 139: (Direct 10.6, Indirect 3.4 mg/dL) Total 14.0
➣Coagulation: INR 11.0 (much higher)
➣Additional labs:
•12.6 mg/dL of calcium (↑)
•Ammonia (upper limit): 72 µmol/L
•AFP 1.1 (normal), CEA 3.5 (normal), and CA 19-9 571 U/mL (↑) are tumour markers.
➣Imaging
→CT scan:
•Large, lobulated, infiltrative hypo-enhancing hepatobiliary mass
•Covering the gallbladder
•extending into segments 4B and 5 of the liver
•Around the right renal artery
•IVC and left renal vein compression
→MRI:
•mass 11 × 10.6 × 16.9 cm (medial edge of segment 6, caudate, and segments 4B & 5)
•Common bile duct obstruction (ampulla to confluence)
•Biliary dilatation caused by the cutting off of the right anterior, posterior, and left hepatic ducts
•Gallbladder, duodenum (D1–D2), hepatic colon flexure, and suprarenal IVC invasion
● Diagnosis
➣Provisional: Cholangiocarcinoma (large infiltrative hepatobiliary tumor)
➣Based on:
•Clinical (acholic stools, RUQ discomfort, and jaundice)
•Biochemistry (high CA 19-9, obstructive jaundice pattern)
•Imaging (vascular involvement, biliary blockage, big tumour)
●Discussion Points
➣Cholangiocarcinoma: Rare but most common malignant biliary tumor.
➣Subtypes: Intrahepatic, perihilar, distal → different presentations.
➣Clinical characteristics:
•Intrahepatic to constitutional (sleeplessness, sweating at night).
•Extrahepatic (perihilar/distal) → cholestatic pattern, obstructive jaundice.
➣Diagnostics:
•MRCP for localisation, CT, and MRI.
•For extrahepatic lesions, ERCP/EUS.
•markers for tumours (AFP & CEA less specific, CA 19-9 helpful).
➣Treatment:
•Surgery is the sole curative option if it is resectable.
•liver transplant in some situations.
•For incurable diseases, embolisation, radiofrequency ablation, and chemotherapy are used.
➣Prognostic factor:
•High bilirubin levels (>6 mg/dL before to surgery) are associated with a higher risk of post-operative complications, •such as liver failure, haemorrhage, and death.
•Gallbladder cancer differs from cholangiocarcinoma in that it can resemble it and has a worse 3-year survival rate.
•Overall prognosis is poor; 5-year survival is about 9%.
Protocol
● Management Decisions
➣First steps: Ceftriaxone and metronidazole intravenous antibiotics were started due to a possible biliary infection.
➣Surgical evaluation: Extensive bulk, encasing vasculature, and elevated bilirubin indicate that the patient is not a candidate for resection.
➣Options for palliative decompression taken into consideration:
Endoscopic retrograde cholangiopancreatography, or ERCP, is not appropriate.
Percutaneous transhepatic cholangiogram, or PTC drainage, is advised.
➣In the end, the patient and their family decided against intrusive surgeries.
chose palliative/hospice care.
●Issues in Management
➣ Delayed identification: The tumor's extensive involvement of the biliary system made early identification difficult because of vague symptoms and presentation, which caused the tumour to develop before being discovered.
➣ Advanced Disease at Presentation: There were few alternatives for local treatment or curative surgery because of the extensive cholangiocarcinoma in this instance.
➣ As the tumour grew, complications such as jaundice, pruritus, biliary blockage, and recurrent infections were experienced.
→ Surgical and Medical Management
➣ Multidisciplinary Approach: Because of the substantial tumour involvement and related problems, the case required collaboration across gastroenterology, oncology, surgery, and palliative care.
➣ Palliative Care: Because of the advanced stage, attention was directed on palliative measures that helped manage symptoms, such as biliary drainage for blockage and comfort care to improve quality of life.
● Nursing Problems and Interventions
➣Symptom Monitoring: Nurses rapidly informed the medical team of any changes and conducted continuous assessments for deteriorating indications of infection, liver failure, and overall deterioration.
➣Interventions for infection control included managing lines and catheters to lower the risk of sepsis, keeping an eye out for fever, and using sterile technique for all operations.
➣Skin Integrity and Comfort: To avoid breakdown and pain, regular repositioning, careful skin care for skin that is jaundiced or irritated, and pressure area control were all helpful.
➣Nutritional Support: Nurses facilitated communication with nutritionists, monitored for indications of malnutrition, and promoted consumption in accordance with dietary limitations.
➣Psychosocial Support: As part of nursing care, the patient and their family received information regarding the illness, prognosis, and available treatment alternatives, such as palliative and end-of-life care.
Notes
For more details visit 10.17161/kjm.vol17.21875