Gall Bladder Carcinoma with Ampullary Carcinoma: A Rare Case of Double Malignancy
The patient, a 57-year-old lady, presented with progressive jaundice with severe pruritus for 2 months. She had pain in right upper quadrant for last 2 months. She also had anorexia with a weight loss of about 10 kg in last 2 months. There was no history of gastrointestinal (GI) bleed or vomiting. Examination showed deep icterus and a 2-cm firm supraclavicular lymph node. On abdominal examination, there was soft hepatomegaly 3 cm below the costal margin with no free fluid. Rest of the systemic examination was normal. The laboratory findings were: Conjugated hyperbilirubinemia (total 23.0 mg/dl, conjugated 18.0 mg/dl) with raised alkaline phosphatase (362 IU/ml). On contrast-enhanced computed tomography (CECT) abdomen, there was a mass lesion in gall bladder (GB) fundus and lower end of the common bile duct (CBD), with CBD compression at two sites (just below the hilum and the lower end of CBD), and bilobar intrahepatic biliary radical dilatation [] with no evidence of local or distant spread. Magnetic resonance chalangiopancreaticography (MRCP) was done for delineation of the biliary anatomy and revealed a patent confluence and narrowing at multiple sites []. Fine needle aspiration cytology (FNAC) from the left supraclavicular lymph node was positive for malignant cells []. The patient was taken up for endoscopic retrograde cholangiopancreatography (ERCP) for palliative biliary drainage. On side viewing endoscopy (SVE), there was a large periampullary growth []; biopsy was taken [], choangiogram was done [], and a metal stent was placed in the CBD []. Post ERC, the patient was asymptomatic and USG revealed no intrahepatic biliary radical dilatation and pneumobilia and a normal caliber CBD. Post procedure, the liver function tests (total bilirubin 9.7mg/dl, alkaline phosphatase (ALP) 768 IU/ml) showed an improvement. Ampullary biopsy revealed atypical cells, high nuclear-cytoplasmic ratio, round nuclei, fine chromatin, inconspicuous nucleoli, granular cytoplasm, and significant mitotic figures. She was discharged and has normal liver function tests at 1 month of follow-up.