Description
A 70-year-old male teetotaller, with a history of chronic obstructive lung disease and hypertension, presented to the emergency department with a 2-day history of right upper quadrant pain and melaena. Investigations revealed total bilirubin 6.8 mg/dL, aspartate and alanine transaminases 88 and 122 IU/L, respectively, alkaline phosphatase 338 IU/L and gamma-glutamyl transpeptidase 223 IU/L. Tests for chronic hepatitis B, hepatitis C and HIV were negative. Serum alpha-fetoprotein was 22.8 ng/mL, whereas carcino-embryonic antigen (CEA), CA 19–9, prostate specific antigen and chromogranin levels were normal. Contrast CT of the abdomen revealed fatty liver with moderate dilation of bilateral intrahepatic biliary radicles (figure 1A) and dilated common bile duct (CBD) with hyperdense contents, without identifiable mass lesions in the liver or biliary tree. Upper gastrointestinal endoscopy revealed haemobilia, and cholangiogram showed normal calibre CBD with filling defects. Endoscopic intraductal ultrasound revealed focal thickening of segment three hepatic duct, and Spyglass cholangioscopy confirmed a...
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