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Abstract: This case presents a 72-year-old male with painless jaundice without obvious cause, with cutaneous scleral jaundice with pruritus, previous ultrasound suggesting marked widening of the common bile duct and high bilirubin. After consultation, the patient underwent further hepatobiliary-pancreatic enhanced CT and tumor marker examination, suggesting a high possibility of hepatoportal bile duct cancer, and was given palliative surgical treatment.
Basic information】Male, 72 years old
Disease Type】Malignant tumor of bile duct
Hospital】The First Hospital of Jilin University
Date of consultation】January 2022
Treatment plan】ERCP stenting + PD-1 immunotherapy (karelixumab)
Treatment period】7 days of hospitalization and 3 months of outpatient follow-up
Treatment effect】The disease is under control and all indicators are improving
I. Initial consultation
An elderly male patient was seen in the outpatient clinic, with a thin body and varying degrees of yellowish skin staining, and was told through questioning that the symptoms had been coming and going for more than 10 days. The symptoms, the town hospital and the old man did an ultrasound, suggesting that the common bile duct is significantly widened, liver function suggests that the bilirubin has reached 260mmol/L, so the daughter anxious to bring him to a large hospital for further treatment. After asking about his condition, we learned that the whole course of the disease did not have obvious abdominal pain fever and other symptoms similar to cholangitis, and the patient had no history of hepatitis, so the possibility of malignant obstruction of the bile duct was considered. The patient was then advised to further examine the enhanced CT and tumor markers of liver, bile and pancreas. The results indicated that the bile duct wall in the hilar region was significantly thickened with arterial phase enhancement, suggesting the possibility of cholangiocarcinoma, but the tumor had gradually wrapped into the portal vein and supra-membranous vein area, and the index of tumor markers had also increased significantly.
II. Treatment history
The patient’s lesion has encapsulated toward the blood vessels and is not suitable for radical tumor resection. The only thing that can be done now is to improve the symptoms and unblock the bile ducts, and ERCP stenting is recommended. The expected survival of this disease may not be long because the tumor is more malignant and progresses faster, and with the current treatment results, this is the best treatment. The family members agreed to the stenting after consideration and asked for an early admission. ERCP stent implantation is the main treatment for palliative treatment of bile duct malignancy, and currently the main treatment used is self-expanding metal stent, which is used to open the obstruction and stenosis, to support and drain the bile smoothly, and to relieve the symptoms. relieve the symptoms.
III. Treatment effect
From the 2nd postoperative day to about 1 week, the patient’s bilirubin decreased significantly and gradually returned to normal, the indicators of jaundice decreased significantly, and symptoms such as skin itching and nausea were relieved. After excluding pancreatitis, cholangitis and other related complications about 1 week after surgery, he could resume eating without any obvious abnormality, and the bilirubin of the liver function decreased progressively to 100 mmol/L on rechecking. During the regular postoperative review at 3 months, the patient did not show any significant recurrence of jaundice, but in the second month, a tumor metastasis in the abdominal cavity appeared, and PD-1 (carrilizumab) was recommended and used for treatment.
IV. Notes
We are glad that the patient has recovered well after treatment, but the precautions for the patient after discharge are also very important.
1.After discharge, we should focus on observing clinical symptoms, because bile duct malignant tumor has insidious onset and early symptoms are insufficient, even after treatment, symptoms may recur, we must observe urine color and skin color.
2. If abnormalities are found, one should go to hospital for liver function bilirubin examination as early as possible to clarify the diagnosis.
3, should maintain a good treatment mentality, family members should actively cooperate, positive encouragement is the main, there is a reasonable treatment mentality, very helpful to the recovery of the disease.
4, in terms of diet, should be based on a multi-protein and multi-nutrition diet, avoid spicy and stimulating food and alcohol.
Since the patient was very cooperative and the family was very understanding, the patient recovered well, and as a doctor, I was very happy.
V. Personal insight
1, painless jaundice in the elderly needs to be taken seriously, most of this condition is different from the liver function changes in young people or infants, most are due to malignant biliary obstruction, malignant biliary obstruction is currently divided into several types depending on the location of the obstructed organ, including malignant obstruction of the hilar bile duct, malignant obstruction of the middle bile duct, malignant obstruction of the terminal bile duct.
2, the symptoms caused by this type of disease are usually early painless jaundice, accompanied by yellow sclera of the skin, the disease is relatively insidious in its onset and needs to be closely observed, and the disease progresses rapidly, if not diagnosed and treated early, it may also cause the spread and metastasis of the tumor and lose the opportunity for surgical treatment.
3.At present, surgical resection is still the main means to treat malignant biliary obstruction radically, and also the main means to achieve the best survival, however, only about 30% of patients can have the chance of surgery, and another 70% of patients have already lost the chance of surgery due to the progressive factors of tumor when they are found again. stenting, which is the main and mainstream treatment at present.
4, for early biliary painless jaundice, must be early detection and early treatment, family members must be meticulous observation and care for members of their own family, with symptoms and timely medical examination, do not take it lightly, do not delay the symptoms and condition, after the diagnosis is clear, should actively and reasonably choose the relevant treatment means, the corresponding treatment, in addition, for patients with malignant biliary obstruction must be optimistic and upbeat In addition, patients with malignant biliary obstruction must be treated with an optimistic attitude and encouraged to cooperate with the treatment.