P1515 - A Case of High Tumor Marker CA 19-9 in Acute Acalculous Cholecystitis - Diagnostic Dilemma

Saphal N. Subedi, MD¹, Myo Myint Tun, MD¹, Shwe Yee Htet, MD¹, Uma D. Gupta, MD², Brijesh Ghimire, MD^1
1Interfaith Medical Center, Brooklyn, NY; ²One Brooklyn Health-Interfaith Medical Center, Brooklyn, NY

Introduction: CA19-9 is a reliable tumor marker for digestive tract tumors. Koprowski et al. discovered this marker in human colorectal cancer cell lines in 1979 [1]. Serum CA 19-9 levels can also be elevated in various benign conditions such as cholangitis, cholestasis, jaundice, liver cirrhosis, hepatitis, and other non-malignant conditions [2,3,4,5]. However, in these cases, the elevation is typically mild. We present a case of a 70 years old male with acalculous cholecystitis with elevated Ca 19-9 with imaging and other markers negative for cancer.

Case Description/Methods: 70 years old male with a medical history of Diabetes mellitus and Hypertension presented to the Emergency Department with right-upper quadrant abdominal pain of 3 days, 5/10 in severity, without nausea, vomiting, diarrhea, or fever. Vital signs were stable. Abdomen was nontender and murphy sign was negative. WBC was 18,000 with a left shift, lactic acid was 1.3, ALP was 76, and ALT/AST levels of 11/15. Bilirubin was 0.3. CEA and CA 125 levels were normal. But, CA 19-9 was 1054. CXR and urine analysis were normal. Abdominal ultrasound revealed gallbladder wall thickness near the upper limits of normal and the presence of dependent sludge, without gallstones. CT scan of the abdomen confirmed acute cholecystitis. A HIDA scan suggested biliary obstruction at the level of the cystic duct. As per Multidisciplinary decision IR guided Cholecystostomy tube was placed after 2 days of admission. Patient’s pain improved and repeat CA 19-9 was 138 after a week trending down to 38. Klebsiella was cultured from the gallbladder fluid and was treated with antibiotics. Follow-up included a cholecystogram to assess cystic duct patency. Repeat test after 2 weeks showed no dilation of the intra or extrahepatic biliary ducts and no thickening of the gallbladder wall.

Discussion: In this case, acute cholecystitis leads to a significant elevation in serum CA 19-9 levels. Previous studies have shown that only a small percentage of patients (4.7%) with acute cholangitis or cholestasis have serum CA 19-9 levels above 1,000 U/ml [7]. Differentiating between benign and malignant diseases in patients with significantly elevated serum CA 19-9 levels can be challenging. In our case, the serum CA 19-9 level decreased following IR-guided cholecystostomy. To make the distinction, we suggest monitoring changes in serum CA 19-9 levels, performing imaging studies, and utilizing rapid pathological diagnosis methods during surgery to minimize unnecessary procedures.


Disclosures:


Saphal N. Subedi, MD¹, Myo Myint Tun, MD¹, Shwe Yee Htet, MD¹, Uma D. Gupta, MD², Brijesh Ghimire, MD¹. P1515 - A Case of High Tumor Marker CA 19-9 in Acute Acalculous Cholecystitis - Diagnostic Dilemma, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.