華山論劍-專業案例挑戰/Case 2015-005
Date: 30 Sep. posted by 陳溢松/李青泰/曾政豪醫師學術天地
A 44-year-old man with hyperbilirubinemia before chemotherapy
The 44-year-old man has advanced esophageal cancer with abdominal and neck lymph nodes metastasis (initial stage: cT1bN0M1). He received concomitant chemo-radio-therapy from Dec. 2014. However, the tumor still progressed.
This time, he was admitted for scheduled chemotherapy, however, icteric sclera was noted. Tracing history, he noted yellowish skin for days, and he ever took unknown herbs for weeks till one month before this admission. Physical examination showed anemic Conjunctiva and icteric Sclera. Mild upper abdominal tenderness was noted as well. Patient denied fever, cough, constipation, diarrhea, clay color stool, nausea/vomiting. Lab data revealed liver function impairment and hyperbilirubinemia. Abdominal CT (Fig.1) showed slightly dilated IHD without mass lesions in the liver. PTCD was done due to suspicious of biliary obstruction, and Cholangiogram (Fig.2) showed suspicious of hilar stricture. Hyperbilirubinemia, however, did not improve but progressed.
Lab
WBC
(1000/ul) |
Hb
(g/dl) |
MCV
(fL) |
5.96 |
9.4 |
89.6 |
PLT
(1000/ul) |
Neu(%) |
|
216 |
80.8 |
|
Cr
(mg/dL) |
Bil(T)
(mg/dl) |
Bil(D)
(mg/dl) |
1.9 |
6.95 |
3.25 |
Na
(mEq/L) |
K
(mEq/L) |
|
137 |
3.3 |
|
AST
(U/L) |
ALT
(U/L) |
Alk-P
(mg/dL) |
G.G.T
(U/L) |
91 |
96 |
1603 |
708 |
HBsAg |
Anti-HBs |
Anti-HCV |
HAV IgM |
- |
+ |
- |
- |
LDH
(U/L) |
Hepatoglobin
(mg/dL)(30-178) |
|
187 |
186 |
|
Anisocytosis |
Target cell |
Hypochromic |
1+ |
1+ |
1+ |
Figure1
Figure2
Question: What’s next step will you do? What might cause this hyperbilirubinemia?
