A 69-year-old man was admitted for painless jaundice and a 2-week history of pruritus, dark urine, and acholic stools. Computed tomography (CT) showed a left renal mass with multiple lesions to the chest and reteroperitoneum suspicious for metastatic disease. There was intra- and extrahepatic biliary dilation with gallbladder distention secondary to common bile duct (CBD) calculus. Physical examination revealed jaundice and scleral icterus. Leukocyte count was 5,800 cells/mm3, total serum bilirubin was 19.8 mg/dL, alkaline phosphatase was 855 U/L, aspartate aminotransferase was 446 U/L, alanine aminotransferase was 313 U/L, lipase was 538 U/L, and CA 19-9 was 45 U/mL.
A magnetic resonance cholangiopancreatography (MRCP) showed a filling defect in the distal common bile duct with biliary dilation and a large heterogeneous mass in the left kidney extending into the pararenal fat without evidence of vascular invasion (Figure 1). Endoscopic retrograde cholangiopancreatography (ERCP) showed a dilated common bile duct (12 mm) with a distal mobile filling defect as well as a separate fixed filling defect mimicking a stone. After sphincterotomy, 2 stones were removed. Repeat cholangiogram revealed a persistent distal CBD stricture approximately 2 cm in length (Figure 2). Brush biopsies showed clear cell renal cell carcinoma (RCC; Pax-8 and CD10 positive).
Figure 1. MRCP showing a filling defect in the distal common bile duct with biliary dilation.
Our patient represents the third case of an intracholedochal metastatic lesion without simultaneous liver involvement reported in the literature.1,3 Obstructive jaundice is usually caused by CBD stone or malignant tumors of the gastrointestinal (GI) tract. Although 2 stones were removed from our patient, the persistent dilation of the CBD prompted further evaluation. Our patient’s MRCP showed that the intraluminal filling defect had slight contrast enhancement, suggesting vascular tumor consistent with RCC rather than calculi. Intraluminal metastasis of the distal CBD without synchronous liver involvement is a rare cause of painless, obstructive jaundice, but should be suspected in a patient with a history of RCC.
Figure 2. Cholangiogram showing a persistent CBD stricture.
Author contributions: All authors contributed equally to the writing and editing of the manuscript. H. Omar is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Correspondence: Hina Omar, Advocate Lutheran General Hospital, Internal Medicine, 1775 Dempster Street, Park Ridge, IL 60068 (firstname.lastname@example.org).
Received: February 4, 2015; Accepted: June 2, 2015
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