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| CASE REPORT |
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| Year : 2019 | Volume
: 8
| Issue : 11 | Page : 3748-3751 |
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Atypical presentation of intrahepatic cholangiocarcinoma---Fever and ascites in a postpartum lady
Sohini Das1, Manoj Job1, Thomas Kodiatte2, Ramya Iyadurai1
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 Submission | 08-Sep-2019 |
| Date of Decision | 16-Sep-2019 |
| Date of Acceptance | 26-Sep-2019 |
| Date of Web Publication | 15-Nov-2019 |
Correspondence Address:
Dr. Sohini Das
Department of Medicine Unit 5, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jfmpc.jfmpc_748_19
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 2021 Jan 17];8:3748-51. Available from: https://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.
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)
Click here to view |
[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]
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.
| References | |  |
| 1. | Khan AS, Dageforde LA. Cholangiocarcinoma. Surg Clin North Am 2019;99:315-35.  |
| 2. | DeOliveira ML, Cunningham SC, Cameron JL, Kamangar F, Winter JM, Lillemoe KD, et al. Cholangiocarcinoma: Thirty one year experience with 564 patients at a single institution. Ann Surg 2007;245:755-62. |
| 3. | Devoe LD, Moossa AR, Levin B. Pregnancy complicated by extrahepatic biliary tract carcinoma. A Case Report. J Reprod Med 1983; 28:153-5. |
| 4. | Qasrawi A, Abughanimeh O, Abu Ghanimeh M, Arora-Elder S, Yousef O, Tamimi T. Intrahepatic cholangiocarcinoma masquerading as acute fatty liver of pregnancy: A case report and review of the literature. Case Reports Hepatol 2018;2018:1-4. |
| 5. | Gerli S, Favilli A, Giordano C, Donini A, Di Renzo GC. Mixed hepatocellular carcinoma and cholangiocarcinoma during pregnancy: A case report. Eur J Obstet Gynecol Reprod Biol 2015;187:76-7. |
| 6. | Balderston KD, Tiwari K, Azizi F, Yu JK. Intrahepatic cholangiocarcinoma masquerading as the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) in pregnancy: Case report. Am J Obstet Gynecol 1998;179:823-4. |
| 7. | Goswami A, Bhargava N, Dadhich S, Rana K. A young lady with post-partum jaundice and right upper quadrant lump abdomen: An unusual etiology. Ann Gastroenterol 2014;27:82-4. |
| 8. | Dalton E, Castillo E. Post partum infections: A review for the non-OBGYN. Obstet Med 2014;7:98-102. |
| 9. | Sharma SS, Bhattacharjee S, Kashyap A, Thakur A, Dubey S, Dalton E, et al. Cancer and pregnancy : An overview for obstetricians and gynecologists. Am J Obstet Gynecol 2018;10016:315-35. |
| 10. | Andersson TM, Johansson AL V, Fredriksson I, Lambe M. Cancer during pregnancy and the postpartum period : A population-based study. Cancer 2015;121:2072-7. |
| 11. | Xia J, Jiang SC, Peng HJ. Association between liver fluke infection and hepatobiliary pathological changes: A systematic review and meta-analysis. PLoS One 2015;10:1-19. |
| 12. | Fung BM, Lindor KD, Tabibian JH. Cancer risk in primary sclerosing cholangitis: Epidemiology, prevention, and surveillance strategies. World J Gastroenterol 2019;25:659-71. |
| 13. | Grainge MJ, West J, Solaymani-Dodaran M, Aithal GP, Card TR. The antecedents of biliary cancer: A primary care case-control study in the United Kingdom. Br J Cancer 2009;100:178-80. |
| 14. | Xiong J, Lu X, Xu W, Bai Y, Huang H, Bian J, et al. Metabolic syndrome and the risk of cholangiocarcinoma: A hospital-based case–control study in China. Cancer Manag Res 2018;10:3849-55. |
| 15. | Li J, Han T, Xu L, Luan X. Diabetes mellitus and the risk of cholangiocarcinoma: An updated meta-analysis. Prz Gastroenterol 2015;10:108-17. |
| 16. | Sôrensen HT, Frus S, Olsen JH, Thulstrup AM, Mellemkjær L, Linet M, et al. Risk of liver and other types of cancer in patients with cirrhosis. Eur J Gastroenterol Hepatol 2006;10:1061. |
| 17. | Shah V, Arora A, Tyagi P, Sharma P, Bansal N, Singla V, et al. Intrahepatic cholangiocarcinoma masquerading as liver abscess. J Clin Exp Hepatol 2015;5:89-92. |
| 18. | E C, Xie Y, Yang Y, Ji D, Li W, Zhang X. Combined hepatocellular–cholangiocarcinoma with fever of unknown origin: A case report and review of literature. Cell Biochem Biophys 2014;69:1-6. |
| 19. | Weber SM, Jarnagin WR, Klimstra D, DeMatteo RP, Fong Y, Blumgart LH. Intrahepatic cholangiocarcinoma: Resectability, recurrence pattern, and outcomes. J Am Coll Surg 2001;193:384-91. |
| 20. | Changede P, Chavan N, Raj N, Gupta P. An observational study to evaluate the maternal and foetal outcomes in pregnancies complicated with jaundice. J Obstet Gynecol India 2019;69:31-6. |
| 21. | Alghamdi S, Fleckenstein J. Liver disease in pregnancy and transplant. Curr Gastroenterol Rep 2019;21:1-9. |
[Figure 1]
[Table 1], [Table 2]
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