A 43-Year-Old Woman With a 7-Month History of Intermittent Abdominal Pain and Weight Loss

Ann S. Fulcher, MD; Aneesa S. Majid, MD; Timothy J. Broderick, MD; Medical College of Virginia of Virginia Commonwealth University, Richmond.

Disclosures

November 09, 2001

Case Presentation

A 43-year-old woman with a 7-month history of intermittent abdominal pain and a 20-pound weight loss presented for evaluation. She denied a history of fever, chills, and jaundice.

The patient had no significant past medical history. Physical examination was unremarkable, except for right upper quadrant tenderness without rebound. Laboratory analysis revealed a normal white blood cell count, normal metabolite levels, normal amylase and lipase levels, and a normal liver chemistry profile. Specifically, the patient demonstrated a serum alkaline phosphatase level of 52 U/L, an alanine aminotransferase level of 23 U/L, aspartate aminotransferase level of 17 U/L, and a total bilirubin of 0.7 mg/dL.

The patient's evaluation included magnetic resonance cholangiopancreatography (MRCP; see Figure 1) and endoscopic retrograde cholangiopancreatography (ERCP; see Figure 2).

Figure 1a. Coronal MRCP image reveals calculi (short arrows) in the dilated extrahepatic bile duct (long arrow). Dilated intrahepatic bile ducts (curved arrow) are also demonstrated. The pancreatic duct (arrowhead) in the pancreatic head, the duodenal bulb (D), and liver (L) are noted.
Figure 1b. Coronal MRCP image obtained anterior to Figure 1A shows crowded, dilated ducts (long arrows) in the left hepatic lobe. The left hepatic ducts contain small calculi (short arrows). The gallbladder (GB) and liver (L) are noted.
Figure 1c. A transverse T1-weighted, enhanced MR image of the liver demonstrates crowded, dilated ducts (long arrows) in the atrophic left hepatic lobe (short arrows). A lesser degree of dilatation involves the right hepatic ducts (curved arrow).

Figure 1a. Coronal MRCP image reveals calculi (short arrows) in the dilated extrahepatic bile duct (long arrow). Dilated intrahepatic bile ducts (curved arrow) are also demonstrated. The pancreatic duct (arrowhead) in the pancreatic head, the duodenal bulb (D), and liver (L) are noted.
Figure 1b. Coronal MRCP image obtained anterior to Figure 1A shows crowded, dilated ducts (long arrows) in the left hepatic lobe. The left hepatic ducts contain small calculi (short arrows). The gallbladder (GB) and liver (L) are noted.
Figure 1c. A transverse T1-weighted, enhanced MR image of the liver demonstrates crowded, dilated ducts (long arrows) in the atrophic left hepatic lobe (short arrows). A lesser degree of dilatation involves the right hepatic ducts (curved arrow).

Figure 1a. Coronal MRCP image reveals calculi (short arrows) in the dilated extrahepatic bile duct (long arrow). Dilated intrahepatic bile ducts (curved arrow) are also demonstrated. The pancreatic duct (arrowhead) in the pancreatic head, the duodenal bulb (D), and liver (L) are noted.
Figure 1b. Coronal MRCP image obtained anterior to Figure 1A shows crowded, dilated ducts (long arrows) in the left hepatic lobe. The left hepatic ducts contain small calculi (short arrows). The gallbladder (GB) and liver (L) are noted.
Figure 1c. A transverse T1-weighted, enhanced MR image of the liver demonstrates crowded, dilated ducts (long arrows) in the atrophic left hepatic lobe (short arrows). A lesser degree of dilatation involves the right hepatic ducts (curved arrow).

An ERCP image confirms the calculi (short arrows) in the dilated extrahepatic bile duct and the calculi (long arrows) in the left hepatic ducts.

What is your diagnosis?

  1. Caroli's disease

  2. Primary sclerosing cholangitis

  3. Mirizzi's syndrome

  4. Recurrent pyogenic cholangitis

  5. Type 1 choledochal cyst

View the correct answer.

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