Delayed diagnosis of cholangiocarcinoma presenting with shoulder pain: A case report

Rationale: Shoulder pain is a common type of musculoskeletal pain. While musculoskeletal issues are primary causes of shoulder pain, it is important to note that referred pain in the shoulder area can also originate from non-musculoskeletal problems.

Patient concerns: A 60-year-old male presented with a month-long stabbing pain in the right shoulder that was worsened by deep breathing. He had no trauma history or neurological symptoms. He also experienced a 5 kg weight loss over 3 months. Physical examination was normal. Shoulder X-ray suggested degenerative arthritis. Despite medication including opioids, his pain persisted and worsened to a 10/10 severity, spreading to the right flank and anterior chest.

Diagnosis: An abdominal CT scan revealed multiple hepatic nodules, ascites, and right pleural effusion, suggesting a systemic condition.

Interventions: This prompted immediate referral to oncology, where subsequent investigations confirmed the diagnosis of intrahepatic cholangiocarcinoma.

Outcomes: The patient deteriorated and passed away during the buildup phase for cancer treatment.

Lessons: This case underscores the importance of considering systemic conditions in patients presenting with seemingly localized symptoms such as shoulder pain. It highlights the significance of thorough evaluation and prompt referral for further investigations when necessary.