Obstructive Jaundice Unmasking Suspected Cholangiocarcinoma: Diagnostic Challenges and Early Multidisciplinary Intervention

Abstract

Introduction: Perihilar cholangiocarcinoma is a rare but aggressive malignancy arising at the biliary confluence and often presents late due to its subtle and insidious progression. Obstructive jaundice is the most frequent initial manifestation, typically accompanied by pruritus and cholestatic biochemical abnormalities. Early recognition and timely intervention are critical to prevent complications and enable multidisciplinary oncologic planning.

Case Presentation: A 67-year-old male with a history of systemic hypertension presented with progressive jaundice for 20 days and pruritus with sleep disturbance for one week, without fever or constitutional symptoms. Laboratory evaluation revealed total bilirubin 26.3 mg/dL, direct bilirubin 17.8 mg/dL, alkaline phosphatase 497 U/L, and leukocytosis with a total count of 12,800 cells/µL. Tumor marker assessment showed CEA 2.3 ng/mL and CA 19-9 of 59.40 U/mL. Multislice contrast-enhanced CT of the abdomen demonstrated an ill-defined 2.3 × 1.4 cm enhancing lesion involving the confluence of the right and left hepatic ducts and the common bile duct, with bilateral intrahepatic biliary dilatation measuring 10.6 mm. The distal common bile duct appeared normal. The gallbladder was contracted.

Discussion: This case highlights the typical yet often delayed presentation of perihilar cholangiocarcinoma. The combination of progressive jaundice, cholestatic liver function abnormalities, and characteristic imaging features supported the diagnosis. Although tumor marker elevation was mild, CA 19-9 can be variably increased in obstructive states. Early biliary decompression remains essential to improve hepatic function, facilitate subsequent therapy, and reduce morbidity. Multidisciplinary input is crucial due to the complex anatomical involvement and limited resectability rates in hilar tumors.

Conclusion: Perihilar cholangiocarcinoma should be considered in elderly patients presenting with progressive obstructive jaundice. Prompt evaluation, early biliary drainage, and coordinated multidisciplinary care are essential for optimal management and improved outcomes.