Cholangiocarcinoma

TO THE EDITOR: I read with great interest the review on "Jaundice in the Adult Patient," (1) by Drs. Roche and Kobos in the January 15, 2004, issue of American Family Physician. I think it is an easy to read and well-organized review; however, it contained certain inaccuracies.

The authors state, "Abdominal pain is the most common presenting symptom in patients with pancreatic or biliary tract cancers." (1) In fact, the most common presentation in patients with pancreatic cancer is jaundice (72 percent of patients versus 36 percent of patients with abdominal pain). (2) Furthermore, by the time patients present with abdominal pain, they usually have unresectable tumors. (3)

In the paragraph discussing posthepatic causes of jaundice, the authors estimate that cholangiocarcinoma "is associated with an approximately 50 percent survival rate." (1) This survival rate is too optimistic, because it is well known that cholangiocarcinoma is usually associated with a very poor prognosis. Cholangiocarcinoma is almost always a fatal malignancy, primarily because it usually is diagnosed at a late stage (similar to pancreatic cancer). (4)

Finally, in their discussion of serum testing, the authors report that hemolysis "is indicated by the presence of fractured red blood cells (schistocytes) and increased reticulocytes on the smear." I would like to clarify that schistocytes are seen only in microangiopathic hemolysis (disseminated intravascular coagulopathy, thrombocytopenic purpura), which is a subset of the hemolytic anemia family, but not present in all forms of hemolytic anemia, and with intravascular prostheses.

MOUSSA F. YAZBECK, M.D.

St. Edward Mercy Medical Center North Logan Mercy

Hospital 500 E. Academy Paris, AR 72855

REFERENCES

(1.) Roche SP, Kobos R. Jaundice in the adult patient. Am Fam Physician 2004;69:299-304.

(2.) Yazbeck M.F. Update on pancreatic cancer. The resident reporter of the American Gastroenterology Association, vol 7. November 2002.

(3.) Feldman M, Friedman LS, Sleisenger MH. Sleisenger & Fordtran's Gastrointestinal and liver disease: pathophysiology, diagnosis, management. 7th ed. Philadelphia: Saunders, 2002

(4.) Sohn TA, Lillemoe KD, Cameron JL, Huang JJ, Pitt HA, Yeo CJ. Surgical palliation of unresectable periampullary adenocarcinoma in the 1990s. J Am Coll Surg 1999;188:658-66.

EDITOR'S NOTE: This letter was sent to the authors of "Jaundice in the Adult Patient," who declined to reply.

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