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Diagnostic Dilemma

Diagnostic Dilemma

A 68-year-old man is referred for further evaluation and treatment of
jaundice. He describes pruritus, intermittent mild midabdominal discomfort,
and progressive weight loss. There is no history of fever. His history is
significant for renal cell carcinoma with pulmonary metastasis.

The patient’s physical examination is positive for evidence of
jaundice, malnutrition, and abdominal distension with hepatomegaly. There is
no tenderness. Rectal examination revealed light brown stool that is guaiac-positive.

Workup is significant for abnormal liver chemistries and imaging studies.
Bilirubin is 9 mg/100 mL and the alkaline phosphatase is 630 units/L.
Abdominal ultrasonography and CT scan reveal filling defects in the liver
and marked intra- and extrahepatic bile duct dilatation. In addition, there
are multiple enlarged lymph nodes and fullness in the region of the
pancreatic head.

Endoscopic retrograde cholangiopancreatography (ERCP) was performed to
further evaluate and treat this patient with evidence of biliary
obstruction. When the endoscope was passed into the descending duodenum, a
large friable mass was noted in the region of the ampulla.

The most likely cause of this patient’s jaundice is:

a. Adenocarcinoma of the ampulla
Metastatic ampullary renal cell carcinoma
c. Pseudotumor of the ampulla
d. Biliary stone

The correct answer to the question is b. Although the patient’s
history of jaundice and intermittent abdominal pain can be consistent with
any of the choices, at endoscopy the patient was found to have malignancy at
the ampulla of Vater (hepaticopancreatic ampulla). The histology of the
tumor was consistent with the patient’s renal cell carcinoma.


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