Cholangiocarcinoma of the Common Bile Duct and Hepatic Hilum (Bismuth II) Complicated by Covid-19 – Case Report

Abstract

Background

Cholangiocarcinoma is a rare tumour that originates from the epithelial lining and the peribiliary glands of the bile ducts. Our report’s scope pertains to the diagnosis of perihilar cholangiocarcinoma, which was first described by Klatskin. Unfortunately, patients ask for medical assistance only after the development of jaundice due to biliary obstruction. Achieving the best standard of care requires meticulous workup and evaluation through a multidisciplinary team to correctly determine the eligibility of a patient for resection surgery.

Case presentation

A 78 years old male patient presents with jaundice and pruritus. Total bilirubin level is 24 mg/dl and imaging studies show a 2×2.5 cm tumour of the hepatic hilum. After the necessary preoperative consults, the patient underwent a surgical procedure, consisting of hepatic hilum resection, separate left and right hepatico-jejunal anastomoses en-Roux. Anastomoses are protected by 2 Kehr drains on the ducts. The first six postoperative days were uneventful, but on the 7^th day the patient develops notable abdominal meteorism and diarrhoea of mostly biliary content for the following 3 days. The case is complicated by episodes of excessive haematochezia. Fibroscopy shows no active haemorrhaging site, but CT scan notes small bowel microinfarctions thus explaining haematochezia. It also confirms COVID-19 with a bilateral interstitial pneumonia and a microthrombus on the right peripheral lung segments. Following a careful treatment regimen, the patient was discharged in good health from the hospital.

Discussion

Studies show that COVID-19 gastro-intestinal symptoms were anorexia, diarrhoea, nausea, vomiting or diffuse abdominal pain. Haematochezia has been unusual. Hospitalized patients, on a bed-rest regimen with comorbidities had a tendency for small bowel microinfarctions. It is widely thought that ischaemia and bowel hypoperfusion is related to the cytokine storm, not a direct effect of the virus. A cytokine storm may be followed by an abnormal coagulation function, as in our patient.

Conclusion

Prior to major surgeries, especially in the hepato-biliary apparatus there is a mandatory evaluation to determine the operability of a patient. Not only the extent of the primary tumour, but also the comorbidities need to be taken into account. Following a rigorous surgical technique, a close monitoring of the patient and involving a multidisciplinary team of radiology, infectious disease, gastro-hepatology, oncology and intensive care doctors in the treatment plan has successfully treated such a rare and complex case.

Keywords: General Surgery, Bile Duct Tumor, Cholangiocarcinoma, Bismuth-Corlette, COVID-19.

DOI: 10.7176/ALST/96-03

Publication date: December 31^st 2022