CC 59F O RUQ pain Duration 1 week

증 례 C/C : 59/F 김 O 순 RUQ pain (Duration : 1 week ago) R. O. S : F/C (-/+), Anorexia(+), Dark colored urine(+) P/H : HTN / Type 2 DM(+/+)=> 5년전 진단, 약물치료중. No known hx of Pul TB, Hepatitis OP Hx : L 4~5 compression fx op (4년전) Cervical cancer =>TAH (7년전) P/I : 내원 일주일여전부터 우측 상복부 동통 지속되어 근처병원 경유, 복부 초음파상 IHBD stones with cholecystitis 의심되어, 본원 응급실 통해 내원함.

증 례 P/E G/A : Acute ill looked appearance Eye : Mild icteric sclera Chest : NBS s rale, RHB s murmur Abdomen : Soft & flat Normoactive bowel sound Tender palpable mass in RUQ area Murphy sign (+) Extremity : No pitting edema V/S BP 130/70 mm. Hg RR 20/min HR 60/min BT 36. 7 ℃

Laboratory finding Lab WBC 5800 /mm 3 Hb 11. 7 mg/d. L Plt 265, 000 /mm 3 ESR 48 mm/hr CRP 15. 0 mg/L BUN/ Cr 18/0. 6 mg/d. L AST/ ALP/ GGTP 336/542/330/1394 IU T-B/ D-B 9. 75/4. 47 mg/d. L Amylase/Lipase 308/1210 U/L HBs Ag/Anti-HBs/Anti-HBc/Anti-HCV (-/+/-/-) AFP 1. 87, CEA 1. 15 ng/d. L CA 19 -9 29. 41 U/d. L

Chest PA

Abdomen CT

ERCP & ENBD

Abdomen MRI

Operation OPERATION (2008. 9. 16) Bile duct resection & hapaticojejunostomy OP findings CBD 에 약 3 x 3 cm sized mass 관찰됨. Proximal Bile duct surgical margin frozen Bx: positive 2 nd margin Bx : negative Distal Bile duct surgical margin frozen Bx: negative

Microscopic findings Large cell carcinoma Small cell carcinoma

Microscopic findings Small cell carcinoma Large cell carcinoma

Immunohistochemical findings Small cell carcinoma CK (+) Large cell carcinoma CK (+) CG (-) SYP (+) CG (+) SYP (+)

Final diagnosis Primary bile duct carcinoma with GB invasion (Stage IVa) : Combined small and large cell neuroendocrine carcinoma • Acute pancreatitis d/t hemobilia • HTN • Type 2 DM

Neuroendocrine tumors (NETs) Tuomrs composed of neuroendocrine cells, which are cells that produce and secrete regulatory hormones and are present throughout the nervous and endocrine/hormonal system. Most neuroendocrine tumor occur in gastrointestinal tract and pancreas, the lung being the next most frequent location. WHO Classification Well-diffentiated neuroendocrine tumor with benign or uncertain behaviour. Well-diffentiated neuroendocrine carcinoma, with low-grade malignant behaviour. Poor-differtiated neuroendocrine carcinoma, with high-grade malignant behaviour.