A unique case of abdominal pain.

Abstract

www .Poste rP resen ta tions .com Gallbladder cancer is rare type of cancer with a long-term poor prognostic outcome. Gallbladder cancer reportedly makes up < 1% of all cancers and about 10% of all hepatobiliary cancers. Due to patients remaining asymptomatic in the early stage of disease, the prognosis at diagnosis is quite poor, due to most cases being diagnosed in advanced stages, with the ten-year survival rate being around 13%. The majority of cases are diagnosed by an incidental mass finding on imaging completed for other reasons, or most often, detected incidentally during cholecystectomy for presumed benign gallbladder disease during pathologic review. This case study aims to bring attention to this rare type of cancer. In this case a 40-year-old Hispanic female presented with epigastric abdominal pain for 10 days. There was no back or flank pain, nor changes in bowel habits, dysphagia, odynophagia, vomiting, hematochezia, melena, or jaundice. The pain was characterized as burning epigastric pain, and with radiation “to the back of the mouth”, with no worsening or alleviating factors. The patient had no cough, chest pain, shortness of breath, palpitations, dizziness, headache, fatigue, rash, or edema. She had been on no new medications, no new food exposure, or recent travel. The patient's last menstrual period was the previous week. Physical examination revealed epigastric tenderness to palpation with light and deep palpation, and additionally she had a fullness/mass-like sensation in the epigastrium with palpation. The patient was initially treated with PPI therapy, and laboratory evaluation was completed including a CBC, CMP, UA, lipase, and urine Hcg, as well as a CT scan of the abdomen and pelvis was ordered due to the abdominal fullness on examination. There were no abnormalities seen on laboratory workup. Patient returned to the clinic 6 weeks later with no improvement with PPI therapy; however, patient did not complete her initially ordered CT scan. At this time H. pylori serum antibody testing was completed which was positive, as well as the CT scan of the abdomen and pelvis which revealed cholelithiasis without evidence of cholecystitis and a moderate sized hiatal hernia. Patient was treated for her H. pylori, and referred to general surgery, and underwent a laparoscopy cholecystectomy. Pathologic evaluation of the gallbladder revealed well-differentiated adenocarcinoma invading the perimuscular connective tissue. Surgical oncology evaluated patient who recommended staging CT scan of the chest and dedicated liver CT imaging along with CEA and CA 19-9 testing which were normal without any evidence of distance metastasis. Segment 4B/5 liver resection and portal lymphadenectomy was completed which showed no histologic abnormality. Patient was seen by medical oncology who recommended adjuvant chemotherapy with capecitabine for 6 months. This case exemplifies the unexpected nature of gallbladder cancer, and the importance to remain diligent in our goal for early diagnosis and improved prognosis. Abstract