Whenever we admit an especially nice patient to the hospital whose diagnosis seems worrisome and somewhat elusive, we assume the worst — cancer. Of course this has no scientific basis whatsoever; it is simply the experience that all of us have collectively had throughout our training. Such is the case with a patient I admitted last week. He already had a diagnosis of cancer that was previously resected and treated appropriately several years ago. He came because his urine was dark. He had not yet noticed his yellow eyes, and his rich dark skin hid the yellow tint. Only someone looking purposefully would see the yellow tint under the tongue or in his eardrum. Importantly, he had no pain.
Jaundice without pain is a marker of something terrible lurking within. Most often we associate it with pancreatic cancer; the tumor blocks the bile ducts leading to a back-up of bile which causes the yellow discoloration of the body tissues. In this patient’s situation, his significantly abnormal liver tests were all we had to start with. Then came the line of tests — an ultrasound because maybe it is just a stone? No, just some dilated bile ducts but no stone in sight to explain the dilatation. CT scan because maybe there are some liver metastases from possible recurrence of his previous cancer? No liver lesions, no pancreatic lesions…only some local thickening of the bile ducts.
So we get the procedural experts involved. As much as we can muck around with more imaging, what he needed now was some tissue sampling from that area of ductal thickening. Maybe it was just a stricture from where an old stone had been lodged? Maybe…
The procedure looked directly into the tiny biliary tunnels using a camera and revealed a significant stricture causing the biliary backup. A tiny brush allowed the collection of cells from the area of stricture. To relieve the blockage, a stent was deployed to keep the area patent and allow bile to drain naturally again. The effects of this were seen within 24 hours when his liver tests began to normalize. He felt well and we discharged him, vowing to call him with the results of the biopsies. In the meantime, he already had follow-up appointments with multiple doctors, including his oncologist.
Seven days later I scrolled through the old patients in my book, making sure tests were followed up on. Mr. W – ah yes, he had biopsy results pending. I check the chart, expecting the results to still be pending (as they often are in the slow-paced setting we work in). Unfortunately, the results were in — he had cholangiocarcinoma.
Less than 1 in 100,000. That is the incidence of this disease in the U.S. To affect a person who has already suffered from one cancer seems malicious. Moreover, its rarity speaks to its treatment options – dismal. It is at this time that either clinical trials or palliation should be offered.
I asked the oncologist to break the news. I could not bear to tell the patient myself, for all I could remember was his worried, anxious face, and the open Bible in his lap every morning.