Presentation
Painless jaundice with elevated bilirubin and ALP.
Patient Data
Axial CT demonstrates soft tissue thickening of the GB neck. This encases the common hepatic artery. This is causing biliary obstruction at the level of the CHD and there is resultant intrahepatic biliary tree dilatation. The GB fundus is dilated. There are a few gallstones.
PTC was performed. The PTC images demonstrate a right-sided puncture and initial fluoroscopic images show a stricture at the hilum. A forceps biopsy was attempted. The stricture was crossed and overlapping metal stents placed with good result. A covering internal-external drain was left in situ.
The EUS images demonstrate the stent in situ with soft tissue thickening at the GB neck and around the stent. EUS-FNA was performed which confirmed adenocarcinoma.
Case Discussion
- Soft tissue mass at the neck with local invasion, encasement of the CHA and involving the CHD. The soft tissue thickening involves the whole thickness of the GB wall, including the mucosa.
- Although benign and malignant disease of the GB can be difficult to disambiguate, and may co-exist, the focal, transmural thickening and local invasion is characteristic of GB carcinoma.
- The EUS-FNA confirmed adenocarcinoma of HPB origin.
- The differential would include locally invasive cholangiocarcinoma, although the presence of bulky disease centered on the GB neck, would favor GB origin.
Case courtesy of Dr Jamie Franklin and Dr Ed Godfrey on behalf of BSGAR.
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