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MALIGNANT CBD OBSTRUCTION Group D

MALIGNANT CBD OBSTRUCTION Group D. Malignancies. Cholangiocarcinoma (CCC) Gall Bladder CA Carcinoma of the Ampulla of Vater Tumors Metastatic to the Liver Pancreatic CA Non Malignant: Hemangiomas, Adenomas and Focal Nodular Hyperplasia. Cholangiocarcinoma.

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MALIGNANT CBD OBSTRUCTION Group D

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  1. MALIGNANT CBD OBSTRUCTION Group D

  2. Malignancies • Cholangiocarcinoma (CCC) • Gall Bladder CA • Carcinoma of the Ampulla of Vater • Tumors Metastatic to the Liver • Pancreatic CA • Non Malignant: Hemangiomas, Adenomas and Focal Nodular Hyperplasia

  3. Cholangiocarcinoma • Typically refers to mucin- producing adenocarcinomas that arise from the bile duct • Grouping according to Origin *Intrahepatic *Hilar/ Central (65%)- diagnosed with ERCP and direct visualization; often invades the porta hepatis *Peripheral/ Distal (30%)- diagnosed with percutaneous biopsy

  4. Cholangiocarcinoma • Usually arise from PRIMARY biliary cirrhosis - Klatskin tumors- usually arise from CBD bifurcation with collapsed bladder mandating visualization of entire biliary tree • Predisposing factors: • Primary sclerosing cholangitis • Autroimmune disease (10- 20%) • O. Viverrini and C. Sinensis infection • Chronic Biliary Inflammation and Injury, Alcoholic Liver Disease, Choledocholithiasis, Choledochal Cysts (10%), Caroli’s Disease

  5. Cholangiocarcinoma • Usually presents as painless jaundice with pruritus, weightloss and alcoholic stools • Immunologic Markers and Staining • Cytokeratin 7, 8, 9 positive and Cytokeratin 20 negative • CEA, CA- 19- 9, CA- 125 • Ancilliary Procedures • US- dilated bile ducts together with MRI, MRCP and Helical CT

  6. Cholangiocarcinoma • Treatment • Hilar CCC (resectable in 30%) includes bile duct resection and lymphadenectomy with typical survival in 24 mos • Distal/ Mainduct CCC includes resection of extrahepatic bile ducts with pancreaticoduodenectomy • Post operative adjuvant therapy is required for locoregional recurrences

  7. Cholangiocarcinoma • Intraluminal brachytherapy and photodynamic therapy • Na porfimer IV and intraluminal red light laser phtoactivation • Neoadjuvant therapy with sensitizing chemotherapy • Hepatic and Systemic arterial gemcitabine

  8. Bismuth-Corlette Classification and PTBD Reference: HPB (Oxford). 2005; 7(4): 254–258.doi: 10.1080/13651820500373093. From http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2043101

  9. Gall bladder CA • Poorer prognosis but more common than CCC (5% 5 year survival rate); • Females are more predisposed than males in a 4:1 ratio • other predisposing factors : history of gallstone and chronic cholecystitis • PE: Usually accompanied by RUQ pain and weight loss

  10. Gall bladder CA • Biologic markers: CEA and CA 19-9 • Ancilliary Procedures: US, CT and MRCP • Treatment: Surgery for stage I would be simple cholecystectomy (5 year survival about 100%) and stage II would be radical (5 year survival about 60- 90%)

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