73 year old male, chinese known to have DN HTN and stroke, comes in with history of jaundice, pruritus, tea colored urine for 3days. Says he bruises more easily nowadays. No pale smelly stools that float up. No vomiting out blood or passing dark colored smelly stools. No SOB or feeling lethargic and faint.

No loss of weight or appetite. Says abdomen a bit more swollen but can't really say.

Risk factors: drinking 500ml of beer a day for the last 50 years, smoking 10 sticks for 50 years. No sex with CSW, no drug abuse with needles, no transfusion.

Med hx: left sided stroke that resolved leaving only a slight weakness that does not impair his function. HTN DM no high lipids.

Meds: warfarin, gliben, atenolol, amilopidine, famotidine.

Fam history: son has stroke.

PE:
Jaundice, no flap, no spider naevi, fetor hepaticus, no gynaecomastia, no visible veins.
mass in right hypochondrium 4 cm below costal margin. Firm not hard, smooth surface moves with respi, non tender. Abdomen distended but percussion note resonant throughout. No shifting dullness. No palpable kidney or spleen. No pedal sacral edema. Din check iguninal hernia or do PR.

DISCUSSION

Am quite a pock cos I couldn't tell the diff between a gallbladder and liver. This was a case of a gallbladder. No murphy's. The tell tale signs were all there. A liver that's causing such a jaundice would be cirrhotic, prob from alcoholism. There would be signs of portal hypertension and CLD too. In this case, the liver hardly felt cirrhotic at all.

This means that the jaundice must have come from an obstruction. Blood causes like ABO incompat and Thal would not give you a soft liver. And he was 73.

A cholestatic jaundice with an enlarged liver can mean some liver damage. The jaundice is for 3 days.

A cholestatic jaundice with an enlarged, non-tender gallbladder. This is bad news. Courvourseir's law. Stones dun give you large gallbladder cos it causes fibrosis, and the gallbladder can't enlarge.

Take home message: beware of a "liver" mass that feels otherwise normal in consistency in the presence of such a jaundice. The liver will not have a normal consistency if it is the cause of the jaundice. Always consider a lesion in the biliary tree... And remember that the gallbladder can get enlarged.

It was a cholangioCA. Risk factors would include choledochal cyst, onichorsis, primary sclerosing cholangitis.

Presentation is usually asymptomatic, or with jaundice, pruritus, plus or minus a murphy's. Special test includes CA19-9, PTC, MRCP.

Rx with biliary-enteric resection, lobetomy of liver. Distal lesions do a Whipple pancreaticoduodenectomy. Staging I in wall, II thru wall into surrounding, III in liver, gallbladder pancreas, IV main portal vein and in the common hepatic artery, duodenum, stomach, ab wall.

Prognosis:
10-30 % for curative resection of prox lesions.
30-50% for distal lesions.