A 42-year-old man was admitted to the Johns Hopkins Hospital with right upper quadrant abdominal pain and scleral icterus of 3 weeks duration. The pain was described as aching and cramping in quality that typically occurred after meals. He had no vomiting or diarrhea but did note acholic stools and had more recently developed diffuse pruritus. There was a 20-pound unintentional weight loss, and he felt significantly more fatigued and weaker than usual. He reported no home medications.
Presentation
The patient’s maximum temperature during the first 24 hours of admission was 37.8°C (100.0°F). He was normotensive. Examination was notable for scleral icterus together with jaundice present under the tongue. Heart and lung sounds were normal. There was tenderness in the right upper quadrant on deep palpation with a liver edge palpable 2 cm below the costal margin. The spleen was not palpable. Courvoisier sign was absent.
Admission laboratory data revealed a white blood cell count of 10.3 × 103 cell/mm3, thrombocytosis with a platelet count of 483 K/mm3, and a normocytic anemia with hemoglobin of 9.6 g/dL and hematocrit of 28.0%. Mean corpuscular volume was 85 fL, and red blood cell distribution width was elevated at 18.2%. He was hyponatremic with a serum sodium of 124 mEq/L, low chloride of 89 mEq/L, and lower limit normal bicarbonate value of 21 mEq/L. Liver function test results were notably abnormal, with a markedly elevated alkaline phosphatase of 1360 U/L, aspartate aminotransferase of 178 U/L, alanine aminotransferase of 188 U/L, and total bilirubin of 20.8 mg/dL. The patient’s international normalized ratio was 1.7 with a normal partial thromboplastin time. Urinalysis was notable for large bilirubinuria without hematuria or pyuria.
Next, computed tomography scan of the abdomen with intravenous contrast was pursued, which demonstrated a 6.7 × 5.9-cm low-attenuation mass in the hepatic hilum just cranial to the pancreatic head, associated with extensive intrahepatic biliary duct dilatation (Figure 1). A rounded low-attenuation mass of the medial right hepatic lobe and multiple low-attenuation lesions of the spleen were observed, both suggestive of metastases (Figure 2). A distinct mass arising from the pancreatic head or an intrinsic biliary duct mass lesion was absent.
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-Kathleen Tompkins, MD, Genevieve M. Crane, MD, PhD, Stefan L. Zimmerman, MD, Allan C. Gelber, MD
This article originally appeared in the February 2017 issue of The American Journal of Medicine.
