Medical
1. The EKG in Figure 2 shows QT prolongation.
2. Checking the electrolytes (especially calcium, potassium,and magnesium) and correcting appropriately is the firststep. One should look at all the medications the patient isreceiving and discontinue any that would prolong QTinterval.
3. Of the list of medications the patient is receiving,ciprofloxacin is the only one that can possibly prolong QT,since quiniolones have been reported to prolong QTinterval. After ciprofloxacin was stopped, the QT intervaldecreased.
4. Yes. Prolonged QT interval can run in families, and somehave a tendency to develop prolonged QT when exposedto certain medications.
Surgical
1. Cholangiocarcinoma or sclerosing cholangitis. Both canappear as single strictures of the common bile duct. Finalpathology for the patient in this example revealed primarysclerosing cholangitis. This is an idiopathic stricturingdisorder of the extra- and interhepatic biliary tree. Mostoften, the strictures are multiple and, despite the name,cholangitis is relatively unusual.
2. In cases of cholangiocarcinoma, the preferred treatment islocal excision of the common bile duct with completeremoval of the tumor with negative margins assessedintraoperatively, regional lymph node dissection, and, aswas in this case, Roux-en-y choledocojejunostomy.Chemotherapy containing 5-FU and radiation areappropriate adjuvant therapy. Five-year survival is only 20%-50% in surgical series but is clearly better with completemicroscopic excision of tumor. There is proven medicaltherapy for primary sclerosing cholangitis. Ursodeoycholicacid has been used to reduce cholestasis, and systemicallydelivered antibiotics can be necessary for episodes ofcholangitis. Liver transplantation is often the only optionfor long-term survival.
- Ochsner Clinic and Alton Ochsner Medical Foundation
