1. 대한소화기내시경학회 제66회 내시경 집담회 울산의대 서울아산병원 소화기내과 November 27, 2004
대한소화기내시경학회 제66회 내시경 집담회
울산의대 서울아산병원 소화기내과
Good morning, everyone!.
November 27, 2004

2. I. Reason for admission 상복부 통증
II. Present illness /M
내원 2개월전과 1개월전 수시간동안 지속되는 상복부 통증으로 primary clinic에서 medication 후 호전되었으며 내원 1일전 다시 상복부 통증이 발생하여 본원으로 전원되었음.

3. III. Associated symptoms
fever/chill (-/-)
A/N/V/C/D (+/-/-/-/-)
melena/hematochezia (-/-)
jaundice/ general pruritus (-/-)
IV. Past medical Hx
DM(-)/HTN(-)/Tbc(-)
Hepatitis B: 15년전 6개월간 IFN 치료
V. Social Hx
alcohol : (-) smoking : (-)
VI. Family Hx
unremarkable
She did not complaint of weight loss, nausea, or vomiting. She had no history of diabetes, hypertension, or hepatitis. She enjoyed dringing 1-2 times a week. Family history was unremarkable.

4. VII. Physical examination
V/S BT 36.5 c
PR 90 /min
RR 18 /min
BP 124 / 80 mmHg
Mental status alert
G/A not so-ill looking
HEENT pinkish conjunctivae
icteric sclerae
non palpable cervical LAP
CHEST clear breathing sound without crackcle
regular heart beat without murmur
ABDOMEN soft and flat
no organomegaly
normoactive bowel sound
no tenderness
BACK & EXT no CVA tenderness
no pitting edema
On physical exmination, her vital sign was stable. She was alert on admission and no specific findings on physical exam.

5. PT 99.8 % BUN/Cr 11/1.0 HBsAg/Ab (+)/(-) Protein/Albumin 7.7/4.3
VIII. Initial lab data
CBC k
PT 99.8 %
BUN/Cr 11/1.0
Protein/Albumin 7.7/4.3
AST/ALT 153/132
ALP/GGT 111/321
T-/D-bilirubin 3.3/1.7 e’
HBsAg/Ab (+)/(-)
HBeAg/Ab (-)/(+)
HBV DNA (-)
HCV Ab (-)
AFP 4.3
CEA 1.3 CA CA
On laboratory tests, liver function was withing normal limits though ALT and bilirubin were slightly increased. Viral markers were negative and tumor markers were within normal range.

6. Liver sono

7. CT scan
The outside CT scan showed multiple hepatic masses. Of them, a 2cm sized mass in segment IV had different characteristics from other masses. It showed faint enhancement on arterial phase and wash-out on portal phase. It was like tumorous condition so needle biopsy was considered. Other masses were typical hemangiomas.

8. ERCP
The outside MRI revealed high intense mass on seg iv on T2-weighted image. It was similar as that of CT scan.

9. MRCP

10. Cholangioscopy
This is H & E staining. On low power field, the normal liver parenchyma was distorted because of cancer invasion. Infiltration of the cancerous lesion into normal liver was observed. On the high power field, we could see uniform small, round cells. The cells showed positivity on immunohistochemical stains with neuroendocrine markers, chromogranin and synaptophysin.

11. Right lobectomy Bile duct resection and hepaticojejunostomy Cholecystectomy

12. Pathology CK7 CK20 Hepatocyte
The outside MRI revealed high intense mass on seg iv on T2-weighted image. It was similar as that of CT scan.
CK20
Hepatocyte

13. Bile Duct Adenocarcinoma
Bile Duct Cancer
Bile Duct Adenocarcinoma
Most common biliary malignancy
Cholangioscopic types
- Nodular type
- Papillary type
- Infiltrative type
HCC invading bile duct
Bile duct adenocarcinoma is the most common biliary malignancy and this tumor can be classified into three different types according to the cholangioscopic findings: nodular type, papillary type and infiltrative type.

14. Cholangioscopy Usefulness Focal stricture of intrahepatic duct
Early stage bile duct cancer
Premalignant lesion
I would like to emphasize another promising aspect of cholangioscopy.
Focal strictures of intrahepatic duct which are unrelated to stone or parasitic disease often pose diagnostic problems.

15. Focal Stricture of IHD (n=17)
Seo et al (1999, Gastrointest Endosc)
Histology: Adenocarcinoma(9)
Hepatocellular carcinoma(2)
Squamous cell carcinoma(1)
Adenoma(2), Benign stricture(3)
Curative resection: 87.5%
Early stage cancer: 62.5%
When we performed aggressive work-up in the patients with focal stricture of intrahepatic duct unrelated to intrahepatic stone, about 70% were malignant strictures and 12% were premalignant lesions.
Curative resection was possible in 87% and 62.5% of them were early stage bile duct cancer confined to mucosal or fibromuscular layer with no lymp node metastasis and vascular invasion.