Kat (not real name) is a 64-year-old Indonesian lady from Aceh. Her problems started about three weeks ago when she felt dizzy and had abdominal pain. A doctor in Aceh did an USG and said there was something in her gallbladder.
Kat and her family came to a private hospital in Penang for further management. MRI of her abdomen showed:
- a lesion in the region of bifurcation of the common bile duct. It measures 42.4 x 50.0 x 24.5 mm.
- gallbladder was grossly distended.
- Para-aortic lymph node was enlarged, measuring 52.7 x 49.0 mm.
Diagnosis: Klatskin tumour with biliary obstruction and para-aortic lymphadenopathy.
Her blood test results are as below.
|Total bilirubin||286.8 H|
|Direct bilirubin||210.4 H|
|Indirect bilirubin||76.4 H|
|Alkaline phosphatase||505 H|
|C Reactive protein||15.6 H|
The attending surgeon, Dr. B suggested that Kat undergo a procedure to install a metal stent to relieve the blockage. This procedure would cost about RM6,000.
Kat and her family came to seek our advice first before undergoing the procedure. This is rather surprising! Generally patients come to us after all medical procedures failed them. So this morning, we gave them the following advice:
- Yes, should go ahead with the stenting procedure. It is better not to wait for too long because your bilirubin level is already too high (see above).
- The problem associated with stenting is that blockage can occur again after a few months (and for the unlucky ones even within a few weeks).
- Because of this it is wiser to use a plastic stent first instead of a metal one.
- I cautioned Kat and her family that it is important that they go to a “reputable” doctor who is known to be able to do a good job. Not long ago, I had a case where the patient’s gallbladder was removed only to be told later that she had Stage 4 liver cancer! You don’t want to go to such doctor. So we have to be careful.
- From the feed-back from patients, I know that Dr. A could do a good job! Kat should see him first before agreeing to let Dr. B do the procedure.
- A had done an excellent job for Bak, a patient who is also from Aceh. A stent was installed for his blocked bile duct. Every 5 to 6 months, Bak had to come back to the hospital to change the plastic stent. After 4 or 5 changes, everything was okay. And the good part of this story is that this surgeon did NOT object or did not get angry when Bak refused to undergo chemotherapy. Bak told the surgeon he wanted to take herbs instead. And most important of all, today, Bak has no more problem with his cancer! Bak’s wife came back to our centre one day and told us that her husband can now live a normal, healthy life.
A few days later Kat and her family came to see us again. The stenting procedure was done by Dr. A as suggested. Kat went into the operation room at 6 pm and was out by 7 pm. The procedure cost RM 3,890. She was discharged the next day.
Note: Let me be clear that we did not receive any monetary reward for referring Kat to Dr. A or any doctor for that matter.
After all done is done, Kat and her family wanted to pay us our consultation fee! Our answer: Free-of-Charge!
Our reward this morning was to be able to see Kat to being treated well. From the facial expressions of those who came, we knew that they were very pleased. Our little advice had helped them a lot! Praise be to God!
Understanding Klatskin Tumour and It’s Treatment
Klatskin tumour is a type of cholangiocarcinoma or a tumour of the bile duct system. It occurs at the confluence of the right and left hepatic bile duct. It is named after Dr. Gerald Klatskin. See illustration below.
The tumour blocks the drainage of the bile duct giving rise to symptoms such as jaundice (yellowing of the skin), bilirubinaria (dark urine), pruritus (itchy skin) and abdominal pain besides weight loss.
What is the cause? Don’t know.
How to treat? Placement of stent to open the duct and relieve jaundice. ” Cholangiocarcinoma represents a rare malignancy. Without intervention, death due to progressive jaundice is inevitable. The goals of therapy, therefore, are resection of all disease and relief of biliary obstruction.”
Prognosis: Intrahepatic bile duct cancer: 5-year survival — Localized 15% Regional 6% Distant 2%
Extrahepatic bile duct cancer: 5-year survival — Localized 30% Regional 24% Distant 2%