"Dark Urine"

Dr. Liu presented an interesting outpatient case of an elderly woman with subacute dark colored urine, vague abdominal pain, and unintentional weight loss who was found to have lab evidence of cholestasis and was eventually diagnosed with cholangiocarcinoma.

Learning Points:

1) Cholestatic pattern of liver test abnormalities includes a disproportionate elevation in the alkaline phosphatase compared with serum aminotransferases and elevated serum bilirubin. Obtaining a GGT can help determine the source of the elevated alkaline phosphatase.

2) Biliary obstruction can be divided in extrahepatic (choledocholithiasis, malignant obstruction, biliary strictures, infections) or intrahepatic (drug/toxins, PBC, PSC, infiltrative diseases, metastatic carcinoma to the liver, amoung others).

3) Although obtaining a RUQ ultrasound would be an appropriate next step in the diagnostic algorithm of a patient with cholestasis, the clinical history of our patient was concerning enough for malignancy that a CT of the abdomen was obtained. It is important to consider your pre-test probability of disease when choosing your diagnostic study of choice.

Dr. Liu reviewed a systemic review and meta-analysis reviewing the use of adjuvant therapy in the treatment of biliary tract cancer. His take-home points included that there is insufficient data analyzing the effect of adjuvant therapy for surgically-resected, node(-) cholangiocarcinoma, but that it is generally helpful for localized, advanced cholangiocarcinoma.

Horgan AM, Amir E, Walter T, Know JJ. Adjuvant therapy in the treatment of biliary tract cancer: a systemic review and meta-analysis. J Clin Oncol 2012; 30:1934.