Clinical Presentation and Diagnosis

The clinical presentation of intrahepatic cholangiocellular cancers is that of a liver mass. Patients may present with abdominal pain, an abdominal mass, anorexia, weight loss, night sweats, and malaise or may even be asymptomatic. The serum alkaline phosphatase activity is usually elevated, but patients are rarely jaundiced. Serum tumor markers, including carcinoembryonic antigen, cancer antigen (CA) 19-9, and CA 1255, may be elevated. The diagnosis of intrahep-

atic cholangiocellular carcinomas is then established with a needle biopsy specimen of a dominant liver mass showing AC in the absence of an alternative primary lesion. The clinical presentation of the perihilar ductal cholangiocarcinoma is often jaundice, pale stools, dark urine, and pruritus. Cholangitis with fever, chills, and abdominal pain is unusual in the absence of biliary interventions. A cholestatic biochemical profile with unilobar bile duct obstruction is also a common presentation. The pathologic diagnosis of duc-tal cholangiocarcinoma is more challenging because these tumors are very desmoplastic and often extend and encircle bile ducts in the submucosal space. Endoscopic biopsies and brushings are positive in only 40 to 70% of patients. A single-cell technique such as digitalized image analysis to assess cellular aneuploidy and fluorescent in situ hybridization to quantitate chromosomal duplication are promising laboratory techniques for the diagnosis of cholangiocarcinoma, and they may double the diagnostic yield obtained with routine brush cytology. In the absence of histologic confirmation of cholangiocarcinoma, the diagnosis of this cancer is often based on composite clinical rather than pathologic criteria. Serum CA 19-9 values greater than 100 U/L in the absence of cholangitis are highly suggestive of cholangio-carcinoma and may be elevated in up to 85% of patients with this condition. A computed tomographic scan, magnetic resonance imaging (MRI) study, or Doppler ultrasonography showing a mass lesion and/or vascular encasement with loss of flow in a hepatic artery or portal venous structure also is often diagnostic. In more difficult cases, positron emission tomography with [18F]2-deoxy-D-glucose maybe useful.

In patients with underlying PSC, the diagnosis of cholangiocarcinoma represents a difficult challenge. The differentiation of a dominant benign stricture from a cholangiocarcinoma can be exceedingly difficult. In this setting, repeated biopsies and brushings over time, as well as serial CA 19-9 measurements, are warranted. In contrast to cholangiocarcinoma in the absence of PSC, MRIs are not helpful in this setting.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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