8888888 - nishi

[ArchivalUser]

A 66-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He is otherwise asymptomatic. His total bilirubin is 22 mg/dL, with 16 mg/dL direct and 6 mg/dL indirect, and his transaminase levels are minimally elevated. His alkaline phosphatase is six times the upper limit of normal, and his hemoglobin and hematocrit are normal. A sonogram of the biliary area shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thin-walled gallbladder without stones. Except for the dilated ducts, a CT scan is unremarkable. An endoscopic retrograde cholangiopancreatography (ERCP) shows an apple core area of narrowing in the distal, intrapancreatic common duct and a normal pancreatic duct. Which of the following is the most likely diagnosis?
A. Carcinoma of the ampulla of Vater
B. Cholangiocarcinoma
C. Hepatocellular carcinoma
D. Pancreatic adenocarcinoma
E. Primary sclerosing cholangitis

[ArchivalUser]

a..........

[ArchivalUser]

e??

[ArchivalUser]

correct answer is B. This patient has obstructive jaundice, and the dilated gallbladder points to a malignant source. The unremarkable CT scan suggests a very small, but strategically located, tumor.