Cholangiocarcinoma: Pruritus, Fatigue & Bile Duct Dilation

Dr. Feng presented an outpatient case today of an older male with greater than a year of pruritus, fatigue and nonspecific abdominal pain. Ultimately he was found to have a Klatskin tumor, hepatic hilar cholangiocarcinoma. This case allowed for differntial building around the common presentation on pruritus and development for an illness script of cholangiocarcinoma which can have early, yet subtle symptoms.

Ultrasound of porta hepatis with intrahepatic bile duct dilation.

Ultrasound of porta hepatis with intrahepatic bile duct dilation.

Pruritus Differential:

  • Dermatologic: xerosis (most common in the elderly), psoriasis, urticaria/hives, infestations
  • Neuropathic: brachioradial pruritus, notalgia paraesthetica, postherpetic neuralgia, MS, trigemial trophis syndrome
  • Psychogenic: neurotic excoriations, prurigo nodularis, delusions or parasitosis (more commonly seen with concurrent depression, anxiety, somataform disease)
  • Systemic: medications (opiods, BRAF inhibitors, CTLA-4 antagonists, EGFR inhibitors, HMG-CoA reductase inhibitors, HES), liver disease (cholestatic or not), HIV, CKD/uremic, hematologic (PV, anemia), HL, NHL, parasites, hyperthyroidism

Cholangiocarcinoma Review:

  • Yearly incidence: 2-4 per 100,000 patients
  • Overall 5-year survival ~10%
  • Usually not diagnosed until late stage: relatively modest symptoms until disease is advanced with up to 30% of pt.s may present with occult metastases
  • Surgery is the only potentially curative option: improves 5-year survival to ~25-40%
  • Diagnosis: CEA + Ca-19-9 in combination have 100% sensitivity and specificity if CEA >5.2 ng per ml and Ca-19-9 >180 U per ml
cholangio risk factors.JPG
cholangioa exam.JPG