title: Trousseau's Syndrome in Cholangiocarcinoma: The Risk of Making the Diagnosis.
abstract: We report a case of Trousseau's syndrome with cholangiocarcinoma complicated by a fatal pulmonary embolism after liver biopsy. A 69-year-old man who presented with right upper quadrant pain was found to have portal vein thrombosis and nonspecific liver hypodensities after imaging by computerized tomography. Following four days of anticoagulation, heparin was held for percutaneous liver biopsy. After the biopsy, he developed acute hepatic failure, acute kidney injury, lactic acidemia, and expired. Autopsy revealed intrahepatic cholangiocarcinoma and a pulmonary embolism. Trousseau's syndrome with cholangiocarcinoma is rarely reported and has a poor prognosis. This case highlights a fundamental challenge in the diagnosis and early management of intrahepatic cholangiocarcinoma with hypercoagulability. Diagnostic biopsy creates an imperative to reduce post-operative bleeding risk, but this conflicts with the need to reduce thrombotic risk in a hypercoagulable state. Considering the risk of withholding anticoagulation in patients with proven or suspected cholangiocarcinoma complicated by portal vein thrombosis, physicians should consider biopsy procedures with lesser bleeding risks, such as transjugular liver biopsy or plugged percutaneous liver biopsy, to minimize interruption of anticoagulation.
authors: Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA mfb10@case.edu.
authors: Matthew F
authors: MF
authors: Blum
authors: Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA.
authors: Vincent Y
authors: VY
authors: Ma
authors: Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA.
authors: Anthony M
authors: AM
authors: Betbadal
authors: Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.
authors: Robert A
authors: RA
authors: Bonomo
authors: Department of Pathology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.
authors: Rajeeva R
authors: RR
authors: Raju
authors: Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.
authors: Clifford D
authors: CD
authors: Packer
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000737:chemistry / Q000627:therapeutic use; D001706:Biopsy; D001707:Biopsy, Needle; D018281:Cholangiocarcinoma / Q000150:complications* / Q000175:diagnosis; D006493:Heparin / Q000737:chemistry; D006801:Humans; D008099:Liver / Q000473:pathology; D008297:Male; D010689:Phlebitis / Q000150:complications* / Q000175:diagnosis; D049268:Positron-Emission Tomography; D011379:Prognosis; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis; D012306:Risk; D014057:Tomography, X-Ray Computed
chemical_list: D000925:Anticoagulants; D006493:Heparin
keywords: Biopsy; Cholangiocarcinoma; Heparin; Large-Core Needle; Portal vein; Venous thrombosis