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An Unusual Case of Obstructive Jaundice
Electronic Clinical Challenges and Images in GI An Unusual Case of Obstructive Jaundice Chien-Chih Tung, Ming-Chu Chang, and Yu-Ting Chang Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
Question: A 68-year-old woman presented with a 2-month history of abdominal fullness, weight loss of about 6 kg, and jaundice. She had been diagnosed with skin melanoma on the right toe and underwent operative excision about 10 years earlier. She then kept regular follow-up and no recurrence was found during the latest whole body positron emission tomography scan about 1 year ago. On physical examination, she had icteric sclera and slight tenderness over epigastric area. Laboratory investigations revealed total serum bilirubin of 7.31 mg/dL with a direct fraction of 62%, elevated serum glutamic-oxaloacetic transaminase (111 U/L), serum glutamic-pyruvic transaminase (157 U/L), alkaline phosphatase (604 U/L), and ã-glutamyl transpeptidase (245 U/L). Serologic tumor markers including alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19⫺9 were within normal limits. On computed tomography (Figure A), a 2.8 ⫻ 1.5-cm mass lesion was seen in the bifurcation of common hepatic duct, which caused dilatation of bilateral intrahepatic ducts. Endoscopic retrograde cholangiopancreatography (Figure B) with brushing cytology from the filling defect showed the pathology result (Figure C). What is your diagnosis and further management? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2011 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.04.063
GASTROENTEROLOGY 2011;141:e12– e13
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 4: Metastatic Melanoma Brushing cytology showed degenerative cancer cells with relatively poor cohesiveness, which was compatible with the metastatic melanoma. She received operation of common bile duct and Roux-en-Y hepatojejunostomy. Microscopically, the tumor cells are positive for S100 and HMB-45 on immunohistochemistry, and the liver tissue around hilum demonstrated no evidence of malignancy. The patient recovered well about 2 weeks after the surgery. The incidence of melanoma increased 15-fold in the last 50 years.1 Melanoma can metastasize to any organs; however, a metastatic melanoma in the biliary tract is relatively rare. Contrast-enhanced imaging can detect the lesion, but tissue proof is the only way to make definite diagnosis. The average 2-year survival after distant visceral metastasis is about 1%–2%.2 There is no standard treatment for this condition. However, in highly selected patients with isolated metastases, operative resection can result in 5-year survival rates of up to 25%.3 References 1. Johnson TM, Dolan OM, Hamilton TA, et al: Clinical and histologic trends of melanoma. J Am Acad Dermatol 1998;38:681– 686. 2. Balch CM. Cutaneous melanoma: Prognosis and treatment results worldwide. Semin Surg Oncol 1992;8:400 – 414. 3. Morton DL, Essner R, Balch C. Surgical excision of distant metastases. In: Balch C, Houghton A, Sober A, et l, eds. Cutaneous melanoma. 4th ed. St. Louis: Quality Medical Publishing; 2003:547–572. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
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Question: A 68-year-old woman presented with a 2-month history of abdominal fullness, weight loss of about 6 kg, and jaundice. She had been diagnosed with skin melanoma on the right toe and underwent operative excision about 10 years earlier. She then kept regular follow-up and no recurrence was found during the latest whole body positron emission tomography scan about 1 year ago. On physical examination, she had icteric sclera and slight tenderness over epigastric area. Laboratory investigations revealed total serum bilirubin of 7.31 mg/dL with a direct fraction of 62%, elevated serum glutamic-oxaloacetic transaminase (111 U/L), serum glutamic-pyruvic transaminase (157 U/L), alkaline phosphatase (604 U/L), and ã-glutamyl transpeptidase (245 U/L). Serologic tumor markers including alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19⫺9 were within normal limits. On computed tomography (Figure A), a 2.8 ⫻ 1.5-cm mass lesion was seen in the bifurcation of common hepatic duct, which caused dilatation of bilateral intrahepatic ducts. Endoscopic retrograde cholangiopancreatography (Figure B) with brushing cytology from the filling defect showed the pathology result (Figure C). What is your diagnosis and further management? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2011 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.04.063
GASTROENTEROLOGY 2011;141:e12– e13
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 4: Metastatic Melanoma Brushing cytology showed degenerative cancer cells with relatively poor cohesiveness, which was compatible with the metastatic melanoma. She received operation of common bile duct and Roux-en-Y hepatojejunostomy. Microscopically, the tumor cells are positive for S100 and HMB-45 on immunohistochemistry, and the liver tissue around hilum demonstrated no evidence of malignancy. The patient recovered well about 2 weeks after the surgery. The incidence of melanoma increased 15-fold in the last 50 years.1 Melanoma can metastasize to any organs; however, a metastatic melanoma in the biliary tract is relatively rare. Contrast-enhanced imaging can detect the lesion, but tissue proof is the only way to make definite diagnosis. The average 2-year survival after distant visceral metastasis is about 1%–2%.2 There is no standard treatment for this condition. However, in highly selected patients with isolated metastases, operative resection can result in 5-year survival rates of up to 25%.3 References 1. Johnson TM, Dolan OM, Hamilton TA, et al: Clinical and histologic trends of melanoma. J Am Acad Dermatol 1998;38:681– 686. 2. Balch CM. Cutaneous melanoma: Prognosis and treatment results worldwide. Semin Surg Oncol 1992;8:400 – 414. 3. Morton DL, Essner R, Balch C. Surgical excision of distant metastases. In: Balch C, Houghton A, Sober A, et l, eds. Cutaneous melanoma. 4th ed. St. Louis: Quality Medical Publishing; 2003:547–572. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
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