A 77-yr-old man presented in the emergency room with abdominal pain, fatigue, jaundice, and gross haematuria. The patient had no significant comorbidities and had been in good general condition. The patient was on alfuzosin and dutasteride for symptomatic benign prostatic hyperplasia. He had moderate alcohol consumption and was a heavy smoker (approximately 40 cigarettes per day since age 20 yr).
The man became symptomatic roughly 2 mo prior to hospital admission. Over this time, he lost approximately 5 kg in weight, and his abdominal pain became more severe. He rated it 5 on a scale from 0 to 10, with 10 indicating the most severe pain. The pain was chronic with exacerbation and was located in the mesogastric area. Approximately 5 d before hospital admission, he developed jaundice associated with increasing pain and persistent gross haematuria.
On admission to the hospital, he received blood examinations, abdominopelvic ultrasound, and urine analysis. Complete blood count and renal function were normal, as were blood levels of electrolytes, glucose, calcium, phosphorus, magnesium, total protein, and albumin; however, increasing values of total bilirubin, conjugated bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and γ-glutamyl transpeptidase were found. The ultrasound showed dilation of the biliary ducts and bilateral 4- to 6-cm Bosniak I cysts. At urine analysis, high erythrocyte levels were found.
Abdominal and thoracic contrast-enhanced computed tomography scans were performed (Fig. 1). Intrahepatic biliary distension was evident, and the common biliary ducts in prepancreatic and intrapancreatic areas appeared thickened. Hydropic gallbladder was also noted. A small nodule (<1 cm) in the inferior left pulmonary lobe was found. Moreover, in addition to bilateral Bosniak I renal cysts, an endophytic contrast-enhanced mass highly suspicious for upper urinary tract carcinoma infiltrating the renal pelvis was found in the left kidney (maximum diameter 4 cm). No retroperitoneal lymphadenopathies were noted. Endoscopic ultrasound was performed, and intrahepatic biliary and common bile duct distension was found with a complete occlusion of the hepatic hilum. Hypoechoic lesions were reported on the gallbladder, duodenum, and hilum, infiltrating the first portion of the pancreas. Radiologic diagnosis of biliary neoplasm was made with concomitant upper urinary tract urothelial carcinoma of the left kidney. Urine cytology was negative. Flexible cystoscopy was performed, and no lesion was found. Meanwhile, biliary duct drainage and subsequent stent placement were performed, with symptomatic resolution and improvement of liver function, as investigated with blood tests.
Cross-section computed tomography image showing a filling defect in the left renal pelvis, in keeping with urothelial cell carcinoma (white arrowhead), and a mass around the common bile duct (with internal drainage) is seen (white arrow).
Conflicts of interest
The authors have nothing to disclose.
a Division of Oncology/Urology Unit, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
b Urology Unit, Academic Medical Centre Hospital Santa Maria della Misericordia, Udine, Italy
Corresponding author. Division of Oncology/Urology Unit, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.
© 2015 European Association of Urology, Published by Elsevier B.V.