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A 72 year old male was admitted for recurrent right upper abdominal pain, intermittent fever, and 12 kg weight loss over a period of six months. Some liver enzymes were elevated (that is, alkaline phosphatase 10.14 µmol/l/s (norm 1.77–4.4), gamma glutamyl transferase 7.81 µmol/l/s (0.18–0.83)). CA 19-9 was within the normal range. Abdominal ultrasound revealed cholestasis, a thickened gall bladder wall, and suspected bile duct stones. Endoscopic retrograde cholangiography showed a proximal common bile duct and hilar stenosis, highly suspicious of gall bladder or bile duct cancer. Biopsies were taken showing dysplastic epithelium. Contrast enhanced ultrasound, magnetic resonance imaging, and computed tomography scanning were performed, revealing a hilar infiltration (34 mm) and a thickened gall bladder wall compatible with gall bladder cancer (fig 1A–C). Positron emission tomography (PET) with [18F]fluoro-2-deoxy-D-glucose (FDG-PET) identified two metabolically active areas in the region of the gall bladder and the hilus (fig 1D). Taken together, a diagnosis of gall bladder cancer was made. Due to comorbidities and local tumour extension, the patient was treated with palliative insertion of plastic bile duct stents.
What is the most probable clinical course of the patient?
See page 1664 for answer
This case is submitted by:
Robin Spiller, Editor
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