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Biliary diverticula in sclerosing cholangitis
BILIARY DIVERTICULA IN SCLEROSING CHOLANGITIS
B A
C A 76-year-old woman presented with malaise. There was no history of symptoms of cholestasis or altered bowel habit. Laboratory studies included the following: alkaline phosphatase, 364 IU/L (normal: 12-38 IU/L); alanine transaminase, 151 IU/L (9-52 IU/L); and γ-glutamyl transferase, 597 IU/L, (10-66 IU/L). Serum bilirubin, albumin, a coagulation pro-
918
GASTROINTESTINAL ENDOSCOPY
file, complete blood count, triglycerides and cholesterol, serum iron, and tests for autoimmune liver disease (antinuclear antibody, antimitochondrial antibody, anti LKM antibody, ANCA) were normal. Transabdominal US demonstrated bilobar focal intrahepatic bile duct dilation with a normal extrahepatic bile duct; gallstones were not seen. By EUS there was hypoechoic thickening of the extrahepatic bile duct wall to 7 mm (A; CBD, common bile duct; PD, pancreatic duct), with extension to both hepatic ducts, with a thread-like lumen 1 to 2 mm in diameter (B) with irregular mucosa. No mass lesion or regional lymphadenopathy was identified. A tentative diagnosis of primary sclerosing cholangitis (PSC) was made. Endoscopic retrograde cholangiography (C) demonstrated multiple intramural diverticula of the extrahepatic bile duct, again suggestive of PSC. A liver biopsy confirmed the diagnosis. Colonoscopy including ileoscopy was normal. Jeremy Tibble, MD John K. Meenan, MD Mark L. Wilkinson, MD Department of Gastroenterology Guy’s and St. Thomas’ Hospital London, United Kingdom Alistair McNair, PhD Queen Elizabeth Hospital, Woolwich London, United Kingdom doi:10.1067/mge.2003.246
VOLUME 57, NO. 7, 2003
B A
C A 76-year-old woman presented with malaise. There was no history of symptoms of cholestasis or altered bowel habit. Laboratory studies included the following: alkaline phosphatase, 364 IU/L (normal: 12-38 IU/L); alanine transaminase, 151 IU/L (9-52 IU/L); and γ-glutamyl transferase, 597 IU/L, (10-66 IU/L). Serum bilirubin, albumin, a coagulation pro-
918
GASTROINTESTINAL ENDOSCOPY
file, complete blood count, triglycerides and cholesterol, serum iron, and tests for autoimmune liver disease (antinuclear antibody, antimitochondrial antibody, anti LKM antibody, ANCA) were normal. Transabdominal US demonstrated bilobar focal intrahepatic bile duct dilation with a normal extrahepatic bile duct; gallstones were not seen. By EUS there was hypoechoic thickening of the extrahepatic bile duct wall to 7 mm (A; CBD, common bile duct; PD, pancreatic duct), with extension to both hepatic ducts, with a thread-like lumen 1 to 2 mm in diameter (B) with irregular mucosa. No mass lesion or regional lymphadenopathy was identified. A tentative diagnosis of primary sclerosing cholangitis (PSC) was made. Endoscopic retrograde cholangiography (C) demonstrated multiple intramural diverticula of the extrahepatic bile duct, again suggestive of PSC. A liver biopsy confirmed the diagnosis. Colonoscopy including ileoscopy was normal. Jeremy Tibble, MD John K. Meenan, MD Mark L. Wilkinson, MD Department of Gastroenterology Guy’s and St. Thomas’ Hospital London, United Kingdom Alistair McNair, PhD Queen Elizabeth Hospital, Woolwich London, United Kingdom doi:10.1067/mge.2003.246
VOLUME 57, NO. 7, 2003