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A 50-year-old man presented with a 4-week history of jaundice that developed progressively. He had chronic hepatitis B. During the last 3 months, he had complained of repetitive bouts of right upper abdominal pain with fever. Clinical examination was normal except for jaundice. Biological tests revealed a normal complete blood count and abnormal liver tests with cholestatic and cytolytic features (γ-glutamyl transpeptidase = 850 IU/l (normal<43 IU/l), alkaline phosphatase = 299 IU/l (normal<126), total bilirubin = 134 μm/l (normal<22), aspartate transaminase = 101 IU/l (normal<59), alanine transaminase = 116 IU/l (normal<72). The α-fetoprotein level was normal and the CA 19-9 level was elevated at 139 IU/ml (normal<37 IU/ml). HBsAg and IgG anti-HBc were positive.
On abdominal ultrasonography, the intrahepatic bile ducts were dilated. No parenchymal tumour was detected and the gallbladder was unremarkable. Magnetic resonance cholangiopancreatography showed a homogeneous liver parenchyma and a filling defect of the hepatic duct with upward dilatation. Endoscopic retrograde cholangiography was carried out and is shown in fig 1.
What is the diagnosis and management?
See page 1425 for answer
Robin Spiller, Editor
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