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 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 11  |  Page : 3748-3751  

Atypical presentation of intrahepatic cholangiocarcinoma---Fever and ascites in a postpartum lady


1 Department of Medicine, Christian Medical College and Hospital, Vellore, India
2 Department of General Pathology, Christian Medical College and Hospital, Vellore, India

Date of Submission08-Sep-2019
Date of Decision16-Sep-2019
Date of Acceptance26-Sep-2019
Date of Web Publication15-Nov-2019

Correspondence Address:
Dr. Sohini Das
Department of Medicine Unit 5, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_748_19

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  Abstract 


Intrahepatic cholangiocarcinoma is an uncommon malignancy which usually occurs in the 7th decade. Here we present a postpartum patient with fever, hepatomegaly, and ascites, who was diagnosed to have metastatic intrahepatic cholangiocarcinoma.

Keywords: Cholangiocarcinoma, jaundice in pregnancy, pregnancy associated cancer


How to cite this article:
Das S, Job M, Kodiatte T, Iyadurai R. Atypical presentation of intrahepatic cholangiocarcinoma---Fever and ascites in a postpartum lady. J Family Med Prim Care 2019;8:3748-51

How to cite this URL:
Das S, Job M, Kodiatte T, Iyadurai R. Atypical presentation of intrahepatic cholangiocarcinoma---Fever and ascites in a postpartum lady. J Family Med Prim Care [serial online] 2019 [cited 2019 Dec 11];8:3748-51. Available from: http://www.jfmpc.com/text.asp?2019/8/11/3748/270946



[TAG:2]Introduction[/TAG:2]

Cholangiocarcinoma accounts for 3% of gastrointestinal malignancies.[1],[2] Median age of presentation is the 7th decade.[2] Occurrence of cholangiocarcinoma in a pregnant patient is uncommon, with few reported cases.[3],[4],[5],[6],[7] Here we present a postpartum patient with cholangiocarcinoma.

[TAG:2]Case Presentation[/TAG:2]

A 28-year-old lady presented with 1 week of high-grade fever on postpartum day 10. She had right upper abdominal pain and jaundice from week 20 of gestation. She had postprandial vomiting throughout pregnancy. She underwent regular antenatal checkups and fetal ultrasound scans during this pregnancy. Provisional diagnosis of acute fatty liver of pregnancy (AFLP) was made by her treating physician. She delivered via normal vaginal delivery at week 33. Abdominal distention, initially attributed to pregnancy, worsened after delivery. There was no loss of weight, melena, pruritus, or pale stools. She denied history of smoking, diabetes mellitus, hypertension, and malignancy in family members. Due to worsening symptoms she was referred to our hospital for evaluation.

On examination, her pulse rate was 122/min and temperature 101F. Systemic examination revealed a hard liver palpable 12 cm below the right costal margin. Shifting dullness was present. Pelvic examination was normal.

Differential diagnoses considered were infectious causes (liver abscess, malaria, endometritis) and non-infectious etiologies (Budd Chiari syndrome, AFLP). Neoplastic etiology was also considered due to chronic history of jaundice and abdominal pain. Blood investigations have been mentioned in [Table 1]. Ascitic fluid analysis revealed 240 cells/ml (neutrophils-24%, lymphocytes-76%), albumin and protein of 1.4 g/dl and 3.1 g/dl, respectively. Blood, urine, and ascitic fluid cultures did not reveal growth. Computed tomography (CT) scan showed hepatomegaly with multiple liver lesions, largest being 13 × 10 × 8 cm. Multiple lung nodules, enlarged lesser omental, para-aortic, aortocaval lymph nodes, and lytic lesion in the first lumbar vertebra were noted.
Table 1: Relevant laboratory investigations

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Ultrasound-guided biopsy of the largest liver lesion was done. This was reported as cholangiocarcinoma [Figure 1]. Our final diagnosis was metastatic intrahepatic cholangiocarcinoma. Our patient was initiated on palliative chemotherapy with capecitabine and opted for follow-up at another center.
Figure 1: Photomicrograph depicting infiltrating malignant tumor glands (black arrow) of cholangiocarcinoma (400×, H and E)

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[TAG:2]Discussion[/TAG:2]

Common causes of postpartum fever include endometritis, urinary tract infection, mastitis, and perineal/episiotomy site infections.[8],[9] Cholangiocarcinoma presenting as postpartum fever is rare.[10]

Risk factors for cholangiocarcinoma include primary sclerosing cholangitis, hepatobiliary flukes, bile duct cystic disorders, cirrhosis, diabetes mellitus, and obesity.[11],[12],[13],[14],[15],[16] Our patient was a 28-year-old female without any risk factors for cholangiocarcinoma.

In our patient, ascitic fluid analysis was consistent with malignant ascites (low-serum ascites albumin gradient, high-ascitic fluid protein). Fever, though uncommon, has been reported in other cases of cholangiocarcinoma.[17],[18]

Abdominal pain and jaundice are common symptoms of cholangiocarcinoma.[19] Clinical presentation of cholangiocarcinoma can mimic that of AFLP and HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) [Table 2].[4],[6]
Table 2: Cholangiocarcinoma diagnosed in pregnancy/postpartum period

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In our patient, pregnancy could have masked hepatomegaly and ascites and led to delay in establishing diagnosis.

Antenatal ultrasound scans focus on fetal parameters and may not detect maternal visceral abnormalities. CT scans are contraindicated in pregnancy. Tumor markers like alpha-fetoprotein and alkaline phosphatase are elevated in normal pregnancies. Weight loss due to malignancy may not occur in a pregnant patient. Vomiting due to other causes may be attributed to pregnancy. The above factors lead to difficulty in diagnosis of malignancy in a pregnant patient.

A significant proportion of antenatal checkups are conducted by primary care and family medicine physicians. Jaundice in pregnancy is associated with maternal complications and high maternal and perinatal mortality rates.[20] At primary care level, pregnant patients with jaundice should be referred to higher centers as they require multidisciplinary approach.[21]

[TAG:2]Conclusion[/TAG:2]

Though rare, cholangiocarcinoma can occur in pregnancy and postpartum state.

Symptoms and signs of a neoplastic process maybe masked during pregnancy.

Low index of suspicion and limited diagnostic modalities may prevent early diagnosis of malignancy in pregnant women.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

None.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2]



 

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