Introduction: Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary epithelium. Most patients present with unresectable disease. Metastatic spread is typically via the lymphatic system, most commonly found in the lungs, adrenal glands, and brain. We present a case of CCA metastases to the colon resulting in obstruction.
Case Description/Methods: A 67-year-old white female with history of poorly differentiated CCA status post left hepatectomy and right hepaticojejunostomy 4 years previously, complicated by an umbilical cutaneous metastasis 1 year previously, presented with intractable nausea, vomiting and abdominal pain with moderate distention. CT scan revealed marked retained fecal material with increased pelvic ascites. Diagnostic flexible sigmoidoscopy with biopsies of the high-grade sigmoid stricture was histologically revealing for metastatic carcinoma consistent with a cholangiocarcinoma primary. She subsequently underwent therapeutic sigmoidoscopy with a GIF-XP190 neonatal gastroscope which was advanced to 15 cm where the near complete colonic occlusion was observed. The 5.4 mm scope traversed with resistance under fluoroscopic guidance. The neonatal scope was exchanged for a GIF-2T160 therapeutic gastroscope to pass a 0.035 mm x 450 cm guidewire across the stricture. A 9/12 mm extractor balloon was deployed over the wire and inflated to 12 mm to mark both proximal and distal ends of the stricture while Omnipaque contrast was injected under fluoroscopy to estimate the length of the stricture as 3.5 cm. The balloon catheter was exchanged for a Boston Scientific uncovered 22 mm x 90 mm colonic Wallflex stent. Liquid stool immediately began to drain across the stent decompressing the colon. The patient was able to tolerate a diet and regain normal bowel function without complication, until passing away in hospice care 9 months later.
Discussion: To our knowledge, this is the seventh case of metastatic CCA to the colon reported in the international literature. Our patient presented with colonic obstruction, consistent with previous reports of CCA metastases to the colon as submucosal infiltration results in stricture formation. In this case, CK7+, CK20- staining suggest a 100% positive predictive value for the diagnosis of metastatic CCA. Given the unresectable nature of the disease, palliative colonic stent was used to relieve the pain of colonic obstruction and improve the quality of life.
