We report the case of a 54-year-old woman underwent cystectomy for multiple episodes of residual bile duct stones treated endoscopically as a medical history.
The patient was admitted for epigastric pain radiating to the back, accompanied by nausea and vomiting, hours of evolution, without fever or dysthermic sensation.
The patient was discharged the day before due to residual cholelithiasis resolved endoscopically. No other pathological findings were observed in endoscopic retrograde cholangiopancreatography (ERCP).
On physical examination, the patient presented pain in the right hypochondrium and epigastrium to palpation, with no signs of peritonitis and mildly distended abdomen.
Laboratory tests showed leukocytosis with neutrophilia, hyperbilirubinemia and mild elevation of transaminases with normal amylase, as well as marked SGV 1 hour.
Anti-parietal cell antibodies were positive and serum IgG4 was negative.
Blood cultures were taken on admission, without isolation of microorganisms.
Ultrasound showed several space-occupying lesions suggestive of liver abscesses, so it was decided to complete the study by magnetic resonance imaging.
This showed multiple lesions in both liver lobes, between 1 and 7 centimeters in diameter, hyperintensely ill-defined in T2-weighted sequences with fat suppression, and with homogeneous hepatic abscess and intravenous contrast during the study.
Dilatation of the main bile duct with repletion defects at the level of the distal common bile duct and in the common liver was also observed, along with stenosis at the level of the confluence hiliar, which had not been previously observed.
We tried to perform percutaneous drainage guided by ultrasound, not being possible due to the absence of significant liquefaction.
With intravenous antibiotic treatment the patient became asymptomatic and remained afflicted.
A new control magnetic resonance imaging was performed, showing a significant decrease in liver lesions, but without ruling out a neoplasic origin of the same, as well as irregularity in the origin of the left hepatic branch that raises the doubt.
ERCP was performed and two microcalciums were extracted confirming stenosis of the left hepatic branch. Samples were taken for cytological study, which were negative for malignancy.
Finally, it was decided to perform an ultrasound guided biopsy of the lesions, without incidents.
The histological study of the lesion showed a proliferation of myofibric cells with elongated nucleus and cytoplasm, positive for actin and desmin with immunohistochemical techniques.
It also showed an increased population of IgG4 positive plasma cells, which in some areas exceeded the number of 30 per high-power field, with an IgG4/IgG ratio greater than 40%.
All these findings were suggestive of lymphoplasmacytic inflammatory pseudotumor of the liver, probably related to systemic IgG4-related disease.
In addition, the liver not corresponding to the lesion showed bile duct damage and some periductal concentric fibrosis without IgG4 cells at this level.
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The patient, after having received antibiotic treatment due to possible overinfection of the lesions due to ERCP, was discharged with descending steroid treatment, with good clinical and pathological evolution given.
