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Case #5

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Expand Physical Exam

06/02/XX

69-year-old male with increased liver enzymes. Recent ultrasound, CT of gallbladder at outside facility showed gallstones. On exam neck supple, chest clear. Abdomen soft and nontender without adenopathy.

Expand X-Rays & Scans

05/27/XX

CXR negative for malignancy.

Expand Scopes

05/27/XX

ERCP attempted, blocked by apparent gallstone.

06/30/XX

Diagnostic laparoscopy w/cholecystectomy and intraoperative cholangiogram. Excisional biopsy of peritoneal masses x 2.

Expand Pathological Reports

06/30/XX

Cholecystectomy: 2.5 cm moderately differentiated adenocarcinoma invades through muscle wall into adjacent adipose tissue. Lymphatic space invasion present. Invasive carcinoma and high grade dysplasia present at apparent cystic duct margin and within < 1.0 mm of cauterized hepatic margin. Peritoneal biopsy: poorly differentiated adenocarcinoma compatible with gallbladder lesion.

Expand Treatment

06/30/XX

Laparoscopic cholecystectomy.

08/01/XX

Started chemo: Gemzar.