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Case Summary & Clinical Analysis

Patient Overview

• Patient: Surinder, S/O Zher Singh, 49 yr/M
• Institution: Indira Gandhi Medical College and Hospital (IGMC), Shimla, Himachal Pradesh
• Department: General Surgery / Gastroenterology
• Date of ERCP: 12 July 2024

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Diagnosis

Primary Diagnosis: Carcinoma Gallbladder (Ca GB) with Extrahepatic Biliary Obstruction (EHBO)

1. Etiology of obstruction: Compression of the Common Bile Duct (CBD) by lymph nodes (LN) at the Porta hepatis
2. Dilated CBD (confirmed on USG)
3. Mild cholangitis (secondary to biliary obstruction)
4. Intrahepatic Biliary Radicle Dilatation (IHBRD)

Imaging Evidence (CECT Abdomen - 15/5/20)

• Heterogeneous enhancing mass involving the fundus and body of the gallbladder (P/GB)
• Infiltrating adjacent liver parenchyma - a hallmark of T3/T4 disease
• Exophytic extension with abdominal lymphadenopathy
• Small hypodense lesion in the liver - ? metastasis

USG Abdomen

• Approximately 4-8 mm lesion at the CBD tip with extension
• Hypoechoic lesion with microliths/C noted
• IHBRD present
• Hypoechoic lesion in the bed of the pancreas and porta region (suggesting nodal/vascular involvement)

PET Whole Body (6 July 26)

• Ordered as part of staging in a suspected case of carcinoma with gallbladder/liver mass
• Multiple hypodense liver lesions with elevated FDG uptake - increased for metastases
• Small hypodense Hypodense lesions in liver - suggest liver metastases
• Multiple metastatic lymph nodes (up to 10 lymph nodes)
• Multiple hyper-metabolic mass lesion in gallbladder, involving lymphatic chains - Hilar, periportal, and perihepatic

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Tumor Markers

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Laboratory Values (Serial Monitoring)

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Clinical History Summary

• Presenting complaints:
  • Right hypochondrium pain - initially biliary type, then constant back pain for 12 days
  • Worsening pain episodes for 1 week
  • Pin-prick like sensations
  • Yellowish discoloration of sclera (jaundice) for 12 days
  • High-colored urine + itching of whole body (cholestatic pruritus)
  • Passage of clots + weight loss
  • 1 spike of fever 2 days prior
• Social history: Non-smoker, Alcohol drinker
• No known comorbidities
• On examination: Pallor (+), Icterus (+), mild tenderness in Rt. hypochondriac region; no pedal edema, no cyanosis

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Surgical Procedure: ERCP (12 July 2024)

• Block at the level of the Hilum (hilar/Bismuth-type obstruction)
• Delineation of right ductal system only on initial contrast injection
• Narrowing confirmed at the hilar region

1. Wire-guided CBD cannulation
2. Selective wire placement into the right ductal system - dilated with 7F Sohendra dilator
3. Second wire placed into the left ductal system
4. Two 7 Fr x 10 cm plastic stents placed across the block, one into each ductal system (bilateral stenting of both right and left biliary systems)

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Treatment Plan

Immediate (Inpatient - July 2024)

Short-term Follow-up Plan

• FNAC reports to be reviewed at 4-week follow-up
• Biliary SEMS (Self-Expanding Metal Stents) placement planned after 4 weeks (after confirming tissue diagnosis and assessing response)
• Review in 4 weeks with FNAC results
• In case of pain / jaundice / fever - report immediately

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Staging & Resectability Assessment

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Overall Management Summary

Unresectable Ca GB + Hilar Biliary Obstruction (Bismuth II-III)
        ↓
ERCP → Bilateral Plastic Stent Placement (7Fr x 10cm × 2)
        ↓
Treat cholangitis (Faropenem) + Pruritus (Atarax + Calamine) + Liver support (Ursocol)
        ↓
FNAC from GB mass + Liver lesion → Tissue Diagnosis
        ↓
4-week review: Upgrade to Biliary SEMS (for durable palliation 8-12 months)
        ↓
PET-CT Whole Body → Full metastatic staging
        ↓
Molecular testing (MSI/MMR/TMB) → If MSI-H: Pembrolizumab
        ↓
Oncology referral for palliative chemotherapy ± radiation

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Key Teaching Points

1. Ca GB presenting with jaundice almost always indicates hilar involvement or porta lymphadenopathy - this is advanced (Stage III-IV) disease.
2. ERCP with bilateral stenting is the gold standard for palliation of hilar biliary obstruction before planned SEMS placement.
3. Plastic stents are placed first while awaiting tissue diagnosis; SEMS are placed once malignancy is confirmed (as SEMS cannot be removed).
4. CA 19-9 and CEA are supportive markers, not diagnostic in isolation.
5. Ursocol (UDCA) helps reduce cholestatic liver injury; Atarax addresses the distressing pruritus of obstructive jaundice.
6. Molecular profiling (MSI, dMMR, TMB) guides modern systemic therapy decisions in unresectable disease.

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Updated Comprehensive Case Summary - Surinder S/O Zher Singh

Consolidated Patient Details

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Chronological Disease Course

Initial Presentation (June 2023 - Early Evaluation)

• Liver: Normal size, echo texture, and outline; but with few central and peripheral IHBRD (Intrahepatic Biliary Radicle Dilatation)
• GB: Obstructed/distended; lumen shows echogenic foci giving definite posterior acoustic shadowing with tumefactive sludge; wall thickness normal
• Prox. CBD: Prominent
• Pancreas: Significant finding - cystic lesion 1.8 x 2 cm with few internal septations in the head of pancreas; MPD (Main Pancreatic Duct) measures 4 mm
• Spleen, Bilateral kidneys, UB: Normal
• Free fluid: No ascites
• Impression:
  1. Microlithiasis with sludge
  2. Hypoechoic lesion in head of pancreas with prominent CBD and MPD - Advised further evaluation

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Additional USG (25/6/26) - Appendix Assessment

• Appendix measures 4.8 mm (normal, <6 mm)
• Echogenic focus 2 mm near tip - ? Appendicolith
• No periappendiceal stranding or collection
• Conclusion: No acute appendicitis; incidental appendicolith noted. This ruled out appendicitis as a cause of abdominal pain.

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Emergency Visit (24/06/2026)

• BP: 122/80 mmHg
• PR: 84 bpm
• RR: 16/min
• SpO2: 96%
• ECG ordered (as baseline / pre-procedure)

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Radiotherapy Department Referral (06/07/2026)

"Dept of Radiotherapy - Referred by ma'am Dept of Interventional Radiology. The patient is a K/C/O (known case of) ? Ca GB of 6.5 x 5.5 x 5.4 cm (U/V) mass with liver mets. Kindly assess the patient for FNAC / Biopsy from GB mass and give your expert opinion regarding further management."

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PET-CT Whole Body (06/07/2026)

• ↑ FDG uptake in GB mass: 6.5 x 5.5 x 5.4 cm
• Liver segment I lesion - suggestive of hepatic infiltration (caudate lobe - a poor prognostic sign)
• Liver segment IV & V: 3.0 x 2.5 cm lesion
• Multiple enlarged lymph nodes: peripancreatic, aortocaval, paracaval, and anterior diaphragmatic nodes - all FDG avid
• Stage conclusion: Metastatic Ca GB - Stage IVB (T3-4, N2, M1)

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USG-Guided Biopsy (08/07/2026)

"Under all aseptic conditions, USG-guided biopsy was done from GB mass infiltrating into liver. Procedure was uneventful. Sample handed over to the patient."

• Signed off by Manish (9/7/26) with instruction to register in Unit I for further discussion
• This USG-guided core biopsy is the definitive tissue sampling step to confirm histological diagnosis (adenocarcinoma of GB expected)

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Pre-Anaesthesia Check (10/07/2026) - For Planned ERCP

• BP 100/60 (relatively low), HR 48/min (bradycardia), SpO2 96%
• ECG: Sinus bradycardia, HR 48/min, T-wave inversion pattern (concerning - needs cardiology clearance)
• Icterus present, Pallor present
• Abdomen soft, normal bowel sounds
• Airway: Mallampati Grade II - Safe for procedure
• Thyromental distance >6.5 cm, mouth opening 3 fingers

1. NPO after midnight
2. Tab Pantocid 40 mg at 6 AM with sips of water
3. Tab Alprazolam 0.25 mg at night (anxiolysis)
4. High-risk ERCP consent obtained
5. Arrange 1 unit PRBC (packed red blood cells)

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Surgical Planning Note (03/07/2026) - General Surgery

"F/c/o Tumour, obstructive - ? Ca GB e infiltration into duodenum - Radical Surgery - planned for Extended Cholecystectomy + Whipple's Procedure"

"As the disease seems to be Unresectable - Pt is advised for FNAC from GB and Liver and patient referred to Dept of Radiotherapy for palliative management."

• Pt is CPIB (reviewed by Solid consultant SU-II)
• There are mild IHBRD; FNB (Fine Needle Biopsy) mass 6.9 and 3.6 mm respectively
• FNAC is amenable from GB and liver masses

• Povidone 2G, Syringe 20cc, Gel from 6-8cc, Gloves 6.5-(2), 3-way cannula SCC-10cc, Syringe 10cc

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Final Diagnosis (Confirmed)

Carcinoma Gallbladder (Ca GB) - Stage IVB

• Large GB mass: 6.5 x 5.5 x 5.4 cm
• Direct hepatic infiltration (Segments I, IV, V)
• Hilar biliary obstruction (Bismuth type II-III) - IHBRD + dilated CBD
• Regional and distant lymphadenopathy (porta, peripancreatic, aortocaval, paracaval, diaphragmatic)
• ? Duodenal infiltration (raised in surgical note)
• Disease declared UNRESECTABLE

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Complete Treatment & Management Plan

Phase 1 - Immediate Palliation (July 2024)

• ERCP with bilateral 7Fr x 10cm plastic stents (right + left ductal systems)
• Antibiotics: Faropenem 300 mg BD x 7 days
• Pruritus: Atarax 25 mg TDS x 1 week + Calamine lotion topically
• Liver support: Ursocol 450 mg BD x 2 weeks

Phase 2 - Tissue Diagnosis (08 July 2026)

• USG-guided biopsy from GB mass infiltrating liver (uneventful)
• FNAC from liver metastasis also planned
• Histopathology awaited to confirm adenocarcinoma of GB and enable molecular profiling (MSI/dMMR/TMB-H for pembrolizumab eligibility)

Phase 3 - Durable Biliary Palliation (4-week review)

• Biliary SEMS (Self-Expanding Metal Stents) to replace plastic stents
• Metal stents last 8-12 months vs 4.8 months for plastic - essential for this palliative patient

Phase 4 - Systemic & Radiation Therapy

• Referred to Dept of Radiotherapy / Interventional Radiology for:
  • Palliative chemotherapy (Gemcitabine + Cisplatin is the standard first-line for unresectable Ca GB)
  • Radiation for pain/local control
  • If MSI-H/dMMR on biopsy → Pembrolizumab (immune checkpoint inhibitor)

Phase 5 - Cardiac Monitoring

• ECG showed sinus bradycardia (HR 48/min) + T-wave inversions on PAC
• Requires cardiology review before any further procedures
• May need Holter monitoring / Echo before systemic chemotherapy initiation

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Summary Flow

Ca GB (6.5x5.5x5.4 cm) + Liver mets + Multi-station LN + EHBO
            ↓
Declared UNRESECTABLE (Extended Cholecystectomy + Whipple - abandoned)
            ↓
ERCP: Bilateral plastic stent placement (July 2024)
            ↓
Emergency re-presentation (Jun 2026): Pain abdomen, stable vitals
            ↓
USG abdomen: IHBRD confirmed, appendix normal (appendicolith incidental)
            ↓
PET-CT (06/07/26): ↑FDG in GB, liver Seg I/IV/V, multiple nodal stations
            ↓
USG-guided biopsy (08/07/26): GB mass → liver - sample sent for HPE
            ↓
Pre-anaesthesia check (10/07/26): ASA III, ECG-bradycardia, ERCP planned
            ↓
Awaiting: HPE + molecular profiling → Palliative chemo / Immunotherapy
            ↓
Upgrade to Biliary SEMS at 4-week review

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Key Clinical Notes for the Treating Team

1. ECG bradycardia (HR 48/min) + T-wave inversions must be addressed before ERCP/chemotherapy - get cardiology opinion
2. Mild hyponatremia (Na+ 130) needs correction; may reflect SIADH or poor oral intake in a cachectic malignancy patient
3. Biopsy histology is the single most important next step - adenocarcinoma confirmation + MSI/dMMR testing unlocks pembrolizumab eligibility
4. The cystic lesion in the pancreatic head (1.8x2 cm, June 2023) needs to be followed up - may represent an IPMN or metastatic deposit; MRI pancreas protocol should be considered
5. If HPE confirms adenocarcinoma, Gemcitabine + Cisplatin (GemCis) is the standard first-line palliative regimen per current guidelines
6. Patient and family should receive palliative care counselling - prognosis in Stage IVB Ca GB is 3-6 months median survival

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Formal Lab Reports & ECG Analysis - Surinder Singh

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1. ECG Report

Automated Measurements

Machine Interpretation

"801 Sinus Bradycardia - Undefined Abnormal ECG" NOTE: Report needs clinician review

Lead-by-Lead Analysis

ECG Interpretation

1. Normal variant in these inferior-lateral leads (especially without chest symptoms)
2. Early ischemic change in the high lateral / inferior territory
3. Raised intracranial pressure effect (less likely here)
4. Metabolic/electrolyte disturbance - hyponatremia (Na+ 130) or hyperkalaemia can blunt/invert T-waves
5. Effect of jaundice/bilirubinemia on cardiac conduction (rare but documented)

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2. Complete Blood Count (CBC)

CBC Results

Differential Count

Absolute Counts

CBC Interpretation

• Mild normocytic anaemia (Hb 11.8) - typical "anaemia of chronic disease/malignancy." Does not suggest haemolysis or iron deficiency in isolation
• Leukocytosis (13,550) with neutrophilia - consistent with active cholangitis, tumour-related inflammatory response, or underlying infection
• Relative lymphopenia - a recognised feature of advanced malignancy; also associated with worse prognosis in Ca GB
• NLR (Neutrophil-to-Lymphocyte Ratio) = 10.57/1.49 = ~7.1 - highly elevated (normal <3); NLR >5 in Ca GB is a validated poor prognostic marker

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3. Tumour Markers

Critical Interpretation

• CEA >4 ng/mL has 50% sensitivity and 93% specificity for Ca GB (per Sleisenger & Fordtran's GI & Liver Disease)
• This patient's CEA is 4.4 times the upper limit - highly supportive of malignancy
• CEA also rises in metastatic disease, correlating with tumour burden

• This is a well-known pitfall. Approximately 5-10% of the population are Lewis antigen-negative (Le^a-b- blood group) and cannot produce CA 19-9 regardless of malignancy
• A normal CA 19-9 does NOT exclude Ca GB or cholangiocarcinoma
• This patient's near-zero CA 19-9 strongly suggests he is a Lewis antigen non-secretor - the biopsy and CEA must guide management, not CA 19-9

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4. Liver Function Tests (LFT) / Biochemistry

Bilirubin

Liver Enzymes

• Alcohol-related liver disease (this patient is a drinker - relevant)
• Biliary obstruction with secondary hepatocellular injury
• Liver metastases causing hepatic parenchymal damage

Renal Function & Electrolytes (25.06.2026)

Serum Proteins (25.06.2026)

Coagulation Studies (25.06.2026)

Virology (Serology) - 25.06.2026

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5. HbA1c & Glucose (25.06.2026)

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Integrated Lab Summary & Clinical Significance

What These Results Tell Us

┌─────────────────────────────────────────────────────────────────┐
│                    KEY ABNORMALITIES                            │
├──────────────┬──────────────────┬───────────────────────────────┤
│ ECG          │ HR 49, T-inv     │ Bradycardia - cardiology r/v  │
│              │ aVL/III          │ before chemo/ERCP             │
├──────────────┬──────────────────┬───────────────────────────────┤
│ Hb           │ 11.8 g/dL ↓     │ Anaemia of malignancy -       │
│              │                  │ may need EPO/transfusion pre- │
│              │                  │ chemotherapy                  │
├──────────────┬──────────────────┬───────────────────────────────┤
│ TLC + ANC    │ 13.5k, 10.57k ↑ │ Active cholangitis/infection  │
│ NLR = 7.1   │                  │ Poor prognosis marker         │
├──────────────┬──────────────────┬───────────────────────────────┤
│ CEA          │ 22.96 ng/mL ↑↑  │ Active malignancy confirmed;  │
│ CA 19-9      │ <2 (near zero)   │ Lewis non-secretor - do NOT   │
│              │                  │ use CA 19-9 for monitoring    │
├──────────────┬──────────────────┬───────────────────────────────┤
│ AST/ALT/ALP  │ 537/250/173 ↑↑  │ Obstructive + hepatocellular  │
│ Bilirubin    │ 3.40 (direct↑↑) │ Injury - stent working but    │
│              │                  │ liver infiltration ongoing    │
├──────────────┬──────────────────┬───────────────────────────────┤
│ Albumin      │ 4.50 (Normal)   │ Hepatic synthesis intact -    │
│ INR          │ 0.99 (Normal)   │ Safe for procedures; good     │
│              │                  │ prognostic sign               │
├──────────────┬──────────────────┬───────────────────────────────┤
│ HbA1c        │ 5.5% (Normal)   │ Non-diabetic - no dose        │
│              │                  │ adjustments for steroids/chemo│
├──────────────┬──────────────────┬───────────────────────────────┤
│ HBsAg/HCV    │ Non-reactive    │ Safe for hepatotoxic chemo    │
│              │                  │ (no viral reactivation risk)  │
└──────────────┴──────────────────┴───────────────────────────────┘

Immediate Action Points Based on Reports

1. Cardiology referral - Sinus bradycardia HR 49 + abnormal ECG must be cleared before proceeding with ERCP or chemotherapy initiation
2. CEA = 22.96 - Use this as the baseline tumour response marker going forward (not CA 19-9, which is falsely negative due to Lewis non-secretor status)
3. AST 537 U/L - Very high; this patient needs urgent biliary decompression (already done with stents) and liver-protective measures; repeat LFTs after stent placement to check response
4. Hb 11.8 g/dL - Acceptable for ERCP; however if chemotherapy starts, Hb <10 may require erythropoietin or transfusion support
5. INR 0.99 and Albumin 4.5 - Good synthetic function; supports hepatic reserve for tolerating systemic chemotherapy
6. Bilirubin 3.4 mg/dL (still elevated but partly controlled by stents) - Target is to bring below 1.5 mg/dL before chemotherapy initiation, as most chemo protocols (GemCis) require bilirubin <1.5-2.0 for full dosing

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COMPLETE STRUCTURED CASE PRESENTATION

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SECTION 1: IDENTIFICATION DATA

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SECTION 2: DIAGNOSIS

Primary Diagnosis

Carcinoma Gallbladder (Ca GB) - Stage IVB (T3-4, N2, M1)

• Large GB mass: 6.5 × 5.5 × 5.4 cm
• With direct hepatic infiltration (Liver Segments I, IV, V)
• With Extrahepatic Biliary Obstruction (EHBO) - Hilar type (Bismuth II-III)
• With multi-station lymphadenopathy (porta hepatis, peripancreatic, aortocaval, paracaval, anterior diaphragmatic)
• UNRESECTABLE disease

Secondary Diagnoses

1. Obstructive jaundice secondary to CBD compression by porta hepatis lymph nodes + direct tumour extension
2. Mild cholangitis - secondary to biliary obstruction
3. IHBRD - Intrahepatic Biliary Radicle Dilatation (bilateral)
4. Anaemia of chronic disease - Hb 11.8 g/dL, normocytic
5. Sinus bradycardia with T-wave inversions (III, aVL) - ECG finding requiring cardiology clearance
6. Incidental appendicolith (2 mm, asymptomatic, no appendicitis)
7. Alcohol use - social history (relevant to liver and surgical risk)

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SECTION 3: CHIEF COMPLAINT

1. Pain in the right hypochondrium - present for approximately 1 month, acutely worsened over 1 week
2. Yellowish discoloration of eyes and skin (jaundice) - for 12 days
3. High-coloured (dark) urine + generalised itching - for 12 days
4. Constant back pain - for 12 days (suggesting retroperitoneal/posterior extension of tumour)
5. Weight loss - progressive
6. Fever - 1 spike 2 days prior to admission

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SECTION 4: HISTORY OF PRESENT ILLNESS

• Dark (cola-coloured) urine - indicating bilirubinuria from obstructive jaundice
• Generalised pruritus (whole body itching) - from bile salt deposition in skin
• Pale/clay-coloured stools were noted (consistent with obstructive jaundice)

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SECTION 5: PAST MEDICAL HISTORY

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SECTION 6: PAST SURGICAL HISTORY

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SECTION 7: PRESENT SURGICAL / PROCEDURAL HISTORY

Chronological Procedure Timeline

Surgical Planning Note (03/07/2026)

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SECTION 8: PERSONAL HISTORY

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SECTION 9: FAMILY HISTORY

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SECTION 10: GENERAL PHYSICAL EXAMINATION

On Examination (compiled from multiple notes)

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SECTION 11: VITAL SIGNS CHART

Systemic Examination

• Soft
• Mild tenderness in the right hypochondriac region on deep palpation
• No rigidity or guarding
• Normal bowel sounds
• Liver/Spleen within normal limits on palpation (though imaging shows infiltration/obstruction)
• No palpable mass noted on examination (large GB mass 6.5 cm confirmed on imaging)

• Mallampati Grade II
• Thyromental distance >6.5 cm
• Mouth opening: 3 fingers
• No loose teeth / dentures
• Neck movements adequate
• Safe for endoscopic/anaesthetic procedures

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SECTION 12: INVESTIGATION DATA CHART (COMPREHENSIVE)

A. Haematology (CBC)

B. Biochemistry - LFT

C. Renal Function & Electrolytes

D. Coagulation Studies

E. Tumour Markers

F. Metabolic / Endocrine

G. Serology / Virology

H. ECG (24/06/2026)

I. Imaging Summary

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SECTION 13: MEDICATION CHART

Active / Prescribed Medications

Pre-Anaesthesia / Pre-Procedure Orders (10/07/2026)

Planned / Upcoming Medications

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SUMMARY SNAPSHOT

SURINDER SINGH | 47M | IGMC Shimla | CR: 921022402907711
─────────────────────────────────────────────────────────────────
DIAGNOSIS: Ca GB Stage IVB (6.5×5.5×5.4 cm) + Liver Mets +
           Multi-station LAD + EHBO (Hilar, Bismuth II-III)
           → UNRESECTABLE
─────────────────────────────────────────────────────────────────
SYMPTOM ONSET: RHC pain 1 month → Jaundice + back pain 12 days
               → Weight loss + fever
─────────────────────────────────────────────────────────────────
KEY LABS:    Hb 11.8↓ | TLC 13.55↑ | NLR 7.1↑ (poor prognosis)
             T.Bil 3.4↑ | AST 537↑ | ALT 250↑ | ALP 173↑
             CEA 22.96↑↑ | CA19-9 <2 (Lewis non-secretor)
             INR 0.99 ✅ | Albumin 4.5 ✅ | HbA1c 5.5% ✅
             HBsAg/HCV/HIV: All Non-Reactive ✅
─────────────────────────────────────────────────────────────────
ECG:         Sinus Bradycardia HR 49 | T-inv III/aVL
             → Cardiology clearance needed
─────────────────────────────────────────────────────────────────
PROCEDURES:  ERCP done (12/7/24) - bilateral plastic stents
             Biopsy done (8/7/26) - HPE pending
             PET-CT (6/7/26) - Stage IVB confirmed
─────────────────────────────────────────────────────────────────
PLAN:        1. Cardiology consult (bradycardia + T-inv)
             2. Await HPE + molecular testing (MSI/dMMR)
             3. SEMS upgrade (4-week review)
             4. GemCis chemo when Bil <1.5 + cardiac cleared
             5. Palliative care counselling
─────────────────────────────────────────────────────────────────
PROGNOSIS:   Stage IVB Ca GB → Median survival 3-6 months
             Favourable: Normal albumin, INR, no DM, HBV-ve
             Unfavourable: NLR 7.1, liver mets, multi-LN, CEA↑