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Clinical presentation
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.
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Robin Spiller, Editor
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