Mar 2 • Clinical Question
New station - Cholangiocarcinoma
🩺 Clinical Scenario
A 68-year-old man presents with progressive painless jaundice, dark urine, pale stools, pruritus and weight loss. He is febrile and hypotensive.
You are the surgical SHO asked to assess and outline investigations + definitive management, including endoscopic vs surgical bypass, and supportive management of complications (e.g., encephalopathy).
🔍 Understanding the Condition
❓ What is cholangiocarcinoma?
A malignant tumour of the biliary epithelium (intrahepatic, perihilar/Klatskin, or distal extrahepatic).
🚨 Immediate Concern
❓ In this unwell jaundiced patient with fever and hypotension, what are you worried about?
Ascending cholangitis leading to septic shock (needs urgent antibiotics + source control via biliary drainage).
🧪 Investigations
✅ You said FBC and LFTs are already mentioned — keep them, but add the full investigation set:
❓ What blood tests will you do (in addition to FBC + LFTs)?
- U&E / creatinine (AKI, baseline for contrast)
- CRP
- Clotting profile (PT/INR) (cholestasis → vitamin K deficiency; pre-procedure safety)
- Blood cultures (before antibiotics if possible)
- VBG/ABG + lactate (sepsis severity, perfusion)
- Group & save / crossmatch (if unstable/procedures expected)
- Tumour marker: CA 19-9 (supportive, not diagnostic)
❓ What imaging will you do for suspected cholangiocarcinoma / obstructive jaundice?
Answer (core MRCS pathway):
- Ultrasound abdomen (first-line to confirm duct dilatation + exclude gallstones)
- CT scan (contrast, staging) – assess mass, vascular invasion, metastases, resectability
- MRCP – best non-invasive delineation of level and extent of biliary obstruction/strictures
- ERCP – diagnostic and therapeutic (brushings/biopsy + stenting)
- PTC – if ERCP not possible/failed, especially for hilar obstruction
✅ If the exam asks “what are the key investigations?” your headline answer can be:CT + MRCP + ERCP (plus USS as initial)
⚕️ Treatment Plan
❓ What is your treatment ?
1) Resuscitate and treat sepsis if present
- ABCDE, IV access, fluids, cultures, broad-spectrum IV antibiotics
- Correct coagulopathy (vit K ± FFP if needed)
- Early senior + ICU involvement if shock
2) Relieve biliary obstruction (source control / palliation)
- Endoscopic bypass (ERCP stent)
- Surgical bypass if endoscopic/percutaneous options not suitable or fail
3) Oncology / MDT
- HPB MDT for staging and plan
- Palliative chemotherapy for unresectable disease (common pathway)
🔧 Endoscopic Bypass (ERCP)
❓ What will you do for endoscopic bypass?
ERCP with:
- Cholangiogram
- Brush cytology/biopsy (where appropriate)
- Biliary stent insertion across the stricture
❓ Which stents are available?
- Plastic stents
- Self-expanding metallic stents (SEMS) (covered or uncovered)
❓ Indications: when to use metal vs plastic?
SEMS (metal)
- Malignant strictures (e.g., cholangiocarcinoma) especially when:
Plastic stents
- Benign obstruction / short-term drainage, especially:
✅ Exam-friendly one-liner:
- Tumour → SEMS
- Stones / benign → Plastic
🪡 Surgical Bypass Options
❓ What surgical bypass procedures can be done?
- Hepaticojejunostomy (often Roux-en-Y) to bypass proximal obstruction
- (Depending on level) other biliary-enteric bypasses may be considered in MDT context
❓ When do you consider surgical bypass?
- Endoscopic/percutaneous drainage failed or not feasible
- Patient fit enough for surgery
- Palliative strategy to reduce recurrent cholangitis and jaundice
❓ What else is offered in unresectable disease?
- Palliative chemotherapy via MDT (HPB/oncology)
🧠 Differentiating Congenital vs Acquired Bile Duct Disease
❓ How do you differentiate congenital vs acquired bile duct disease?
Congenital (e.g., choledochal cysts, biliary atresia history)
- Longstanding history from childhood/young age
- Recurrent pancreatitis/cholangitis since young age
- MRCP/CT showing cystic dilatation patterns typical of choledochal cysts
- Sometimes association with congenital anomalies
Acquired (more common in adults)
- Stones, malignancy (cholangiocarcinoma / pancreatic cancer), strictures
- PSC (especially with IBD/UC)
- Iatrogenic strictures (post-op)
- Parasitic infections in endemic regions
Targeted autoimmune/serology (supportive—not a stand-alone discriminator)
- PSC is associated with p-ANCA positivity in some patients (not diagnostic)
- c-ANCA is more classically associated with GPA (Wegener’s)
- Anti-dsDNA suggests SLE (not a primary test for “bile duct disease differentiation”)
✅ What examiners usually want:History + imaging (MRCP) + cholestatic labs + risk factor profile (PSC/IBD, stones, surgery, infection).
🧪 Hepatic Encephalopathy Add-On
❓ One biochemical test for hepatic encephalopathy?
Serum ammonia (supportive; HE is primarily a clinical diagnosis).
❓ What is the function of lactulose?
- Osmotic laxative (causes diarrhoea to clear nitrogenous waste)
- Treatment of hepatic encephalopathy (reduces ammonia absorption)
❓ Mechanism of lactulose
- Gut bacteria metabolise lactulose → organic acids (e.g., lactic/acetic/formic)→ increases osmotic load → draws water into bowel → increased stool output
- Acidifies colonic contents converting:NH₃ (ammonia) → NH₄⁺ (ammonium)→ NH₄⁺ is less absorbable → trapped in gut and excreted in stool
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New station - Cholangiocarcinoma
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