B64-36 Venous Thromboembolism as a Primary Presentation of Cholangiocarcinoma

Abstract Background While cancer-associated thrombosis is a well-established occurrence (1), the incidence of venous thromboembolism (VTE) as the presenting symptom of malignancy is unclear. One retrospective analysis from White et al. demonstrated an approximate 10 to 15% incidence of a new cancer diagnosis in patients with preceding unprovoked VTE suggesting a potential causal link (2). However, another retrospective study from Naqvi et al. suggested that there was no significant difference in provoked or unprovoked VTE and a new diagnosis of malignancy (3). Thus, this case adds to the growing literature of VTE as a primary presentation of malignancy. Case We present the case of an 82-year-old male with a past medical history pertinent for squamous cell carcinoma treated with wide base excision, hypertension, and benign prostatic hyperplasia who presented to a freestanding Emergency Department for dyspnea on exertion with associated lightheadedness and dizziness. On examination, patient had labored breathing, harsh II/VI systolic murmur, bilateral 3+ pitting edema, scleral icterus, mildly distended abdomen, and SpO2 noted at 88-89%. Labs significant for Total Bilirubin 2.9, AST 142, ALT 166, Total Alkaline Phosphatase 389. CTA Chest showed bilateral pulmonary emboli. Patient was promptly placed on a therapeutic heparin drip. Venous duplex of lower extremities demonstrated widespread VTEs. MRI abdomen with and without IV contrast demonstrated multiple intrahepatic lesions, the largest extending to the gallbladder fossa and communicating with the gallbladder, highly concerning for cholangiocarcinoma, with intra and extra-hepatic biliary dilation at the level of the ampulla. Conclusion In patients presenting with unprovoked DVT, current literature suggests up to 15% are diagnosed with cancer within the following year. This case further demonstrates hypercoagulability as the initial symptom of newly diagnosed malignancy and highlights the importance of considering malignancy in unprovoked VTEs. While additional screening for occult malignancy in cases of unprovoked VTE is not currently recommended, it is important for clinicians to consider malignancy in cases of unprovoked VTEs in the appropriate clinical setting. Discussion This case further adds to the body of literature demonstrating the hypercoagulability associated with malignancy. Furthermore, this also represents the importance of consideration of occult malignancy in the presentation for new onset bilateral pulmonary emboli. This abstract is funded by: None