From Choledocholithiasis to Metastatic Pancreatic Adenocarcinoma: A Diagnostic Odyssey Highlighting Missed Red Flags.
6 affiliations
- 1Medicine, Allama Iqbal Medical College, Lahore, PAK.
- 2Internal Medicine, East Medical Ward, Mayo Hospital, Lahore, PAK.
- 3Anesthesiology, Thumbay Group, Ajman, ARE.
- 4Medicine, Nawaz Sharif Medical College, Gujrat, PAK.
- 5Internal Medicine, Jinnah Hospital Lahore, Allama Iqbal Medical College, Lahore, PAK.
- 6College of Medicine, Royal College of Surgeons in Ireland, Dublin, IRL.
Abstract
Pancreatic adenocarcinoma is one of the deadliest types of cancer, with a very gloomy prognosis, especially if the cancer is at an advanced stage at the time of diagnosis. Among young adults, the vague symptoms that are usual with pancreatic cancer can be confused with those of a benign biliary condition, so the diagnosis is often late. It may be quite challenging to recognize that a bile duct obstruction with jaundice is due to a periampullary tumor, which is similar to a bile duct stone, unless one suspects it very strongly. We present the case of a 38-year-old man who suffered from increasing abdominal pain, significant weight loss, and obstructive jaundice. An initial triphasic CT showed the presence of dilated intrahepatic biliary ducts and a dilated common bile duct (CBD) with duodenal spots that were thought to be passed gallstones. At the same time, a liver lesion was identified as a probable hemangioma. The diagnosis was postponed even though the liver function tests were progressively deteriorating (total bilirubin increased to 10.4 mg/dL and alkaline phosphatase to 1394 U/L). Further endoscopic retrograde cholangiopancreatography (ERCP) revealed a distal CBD stricture without stones; therefore, a plastic stent was placed. No tissue sampling was obtained during ERCP. Five months later, an extremely high carbohydrate antigen 19-9 (CA 19-9) (>500 U/mL) and a repeat triphasic CT showed a 43 × 45 mm pancreatic head tumor with liver and lung metastases. These findings supported a clinical-radiological diagnosis of metastatic pancreatic malignancy, presumed pancreatic adenocarcinoma; histopathological confirmation of the pancreatic or hepatic lesions was not obtained. Subsequent ascitic fluid cytology showed malignant cells consistent with adenocarcinoma, but immunocytochemistry was not available, so the pancreatic primary was not independently established. This case highlights that if a biliary stricture occurs without a stone that can be identified in a patient with progressive obstructive jaundice, the stricture should be considered malignant until demonstrated otherwise. Early obtaining of tissue for diagnosis and appropriate use of tumor markers as supportive rather than definitive tests are the main elements to steer clear of a long diagnostic odyssey.
Related
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BibTeX
@article{farooq2026from,
title = {{From Choledocholithiasis to Metastatic Pancreatic Adenocarcinoma: A Diagnostic Odyssey Highlighting Missed Red Flags.}},
author = {Abdullah Farooq and Jazeela Saud and Henok E Sisay and Husnain Hanif and Muhammad Subhan and Alwaleed Alfadhli},
journal = {Cureus},
year = {2026},
month = sep,
doi = {10.7759/cureus.116897},
url = {https://europepmc.org/article/MED/42928765},
note = {CC BY},
}
RIS
TY - JOUR
TI - From Choledocholithiasis to Metastatic Pancreatic Adenocarcinoma: A Diagnostic Odyssey Highlighting Missed Red Flags.
AU - Abdullah Farooq
AU - Jazeela Saud
AU - Henok E Sisay
AU - Husnain Hanif
AU - Muhammad Subhan
AU - Alwaleed Alfadhli
PY - 2026
DA - 2026/09/25
JO - Cureus
DO - 10.7759/cureus.116897
UR - https://europepmc.org/article/MED/42928765
AB - Pancreatic adenocarcinoma is one of the deadliest types of cancer, with a very gloomy prognosis, especially if the cancer is at an advanced stage at the time of diagnosis. Among young adults, the vague symptoms that are usual with pancreatic cancer can be confused with those of a benign biliary condition, so the diagnosis is often late. It may be quite challenging to recognize that a bile duct obstruction with jaundice is due to a periampullary tumor, which is similar to a bile duct stone, unless one suspects it very strongly. We present the case of a 38-year-old man who suffered from increasing abdominal pain, significant weight loss, and obstructive jaundice. An initial triphasic CT showed the presence of dilated intrahepatic biliary ducts and a dilated common bile duct (CBD) with duodenal spots that were thought to be passed gallstones. At the same time, a liver lesion was identified as a probable hemangioma. The diagnosis was postponed even though the liver function tests were progressively deteriorating (total bilirubin increased to 10.4 mg/dL and alkaline phosphatase to 1394 U/L). Further endoscopic retrograde cholangiopancreatography (ERCP) revealed a distal CBD stricture without stones; therefore, a plastic stent was placed. No tissue sampling was obtained during ERCP. Five months later, an extremely high carbohydrate antigen 19-9 (CA 19-9) (>500 U/mL) and a repeat triphasic CT showed a 43 × 45 mm pancreatic head tumor with liver and lung metastases. These findings supported a clinical-radiological diagnosis of metastatic pancreatic malignancy, presumed pancreatic adenocarcinoma; histopathological confirmation of the pancreatic or hepatic lesions was not obtained. Subsequent ascitic fluid cytology showed malignant cells consistent with adenocarcinoma, but immunocytochemistry was not available, so the pancreatic primary was not independently established. This case highlights that if a biliary stricture occurs without a stone that can be identified in a patient with progressive obstructive jaundice, the stricture should be considered malignant until demonstrated otherwise. Early obtaining of tissue for diagnosis and appropriate use of tumor markers as supportive rather than definitive tests are the main elements to steer clear of a long diagnostic odyssey.
SN - 2168-8184
ER -