A woman with abdominal pain, jaundice and elevated CA 19.9

A 54-year-old woman presented to the emergency department (ED) complaining of severe epigastric and right hypo- chondrial pain with back radiation, weight loss of 14 kg within the previous 3 months, asthenia, hyperchromic urine (for the last 7 days) and jaundice (for the last 3 days). For these symptoms, the general practitioner prescribed cipro-floxacin 500 mg twice a day and esomeprazole. Her past medical history was unremarkable. The blood tests indicated elevated hepatic markers— serum glutamic oxaloacetic transaminase (SGOT) 403 IU/l (reference range RR: 10–35 IU/l), serum glutamic pyruvate transaminase (SGPT) 650 IU/l (RR: 10–40 IU/l in female), total bilirubin 7.2 mg/dl (RR: 0.2–1.2 mg/dl), conjugated bilirubin 6.90 mg/dl (RR: < 0.3 mg/dl) and slightly elevated C-reactive protein (CRP) 4.33 mg/dl (RR: < 0.5 mg/dl)— and normal complete blood count and electrolytes. For the presence of jaundice, the patient underwent an upper abdominal ultrasound, which revealed a distended gallbladder with diffuse wall thickening, but no obvious evidence of calcific gallstones. Intra- and extrahepatic bile ducts, as well as the common bile duct, appeared dilated and the intrapancreatic portion of the bile duct seemed partially occupied by a hyperechogenic material, suggesting the presence of a distal cholangiocarcinoma. Given the suspicion of malignancy, the patient was admit- ted to the medical department. To confirm our hypothesis, we decided first to dose the CA 19.9, which was reported as extremely elevated: 9606.00 IU/ml (RR: 0–27 IU/ml). CA 19.9 is a carbohydrate antigen usually synthesized by both the pancreatic and biliary ductal cells and by the epithelial cells of the stomach, colon, endometrium and salivary glands.