When Lightning Strikes Twice

Excerpt

A 69-year-old woman was evaluated in a local Emergency Department with a 2-week history of worsening abdominal discomfort, decreased appetite, vomiting, jaundice, and dark urine. Her total bilirubin at that time was 7.0. An abdominal ultrasound revealed mild bilateral intrahepatic biliary ductal dilation and a heterogeneous hyperechoic lesion in the left hepatic duct. A computed tomography (CT) scan was notable for intrahepatic biliary dilatation, greater in the left lateral segment (Fig. 1). She subsequently underwent magnetic resonance imaging (MRI) which revealed left-sided intrahepatic biliary ductal dilation, abruptly terminating at the location of a lesion in the left lobe of the liver. Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting were performed. Endoscopic ultrasound documented a 3 × 2 cm mass in the common hepatic duct; fine-needle aspiration was interpreted as consistent with adenocarcinoma. Tumor markers revealed carcinoembryonic antigen (CEA) of 1 and CA 19-9 of 256. She was taken to the operating room for a left hepatic tri-segmentectomy with caudate lobectomy, Roux-en-Y hepatico-jejunostomy, as well as porta hepatis and celiac lymphadenectomy. Intraoperative findings were consistent with a tumor involving the entire left biliary system, left hepatic duct, and extending into the common hepatic duct.

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