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case_images: Examination results before and on admission. (A-C) The TBIL, gamma-GT, ALP, AST, and ALT changing curve of the patient. The measuring frequency was every 3 days in the local hospital. (D, E) The abdominal and contrast-enhanced CT scan showed a hyperdense mass in the common bile duct (biliary stent). The pancreatic parenchyma is plump, and adipose tissue around the pancreas is cloudy, which suggested pancreatitis. (F) MRCP showed stenosis of the common bile duct. (G, H) PET-CT did not show any signs of malignancy. TBIL, total bilirubin; gamma-GT, gamma-glutamyl transpeptidase; ALP, alkaline phosphatase; AST, aspartate aminotransferase; ALT, alanine aminotransferase.
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case_images: All the clinical indicators of laboratory results were better on his admission compared to the results before stent deployment (Figures 1A-C). The pancreatic parenchyma is plump, and the adipose tissue around the pancreas is cloudy, which suggested the possibility of pancreatitis (Figures 1D, E). Magnetic resonance cholangiopancreatography (MRCP) also suggested pancreatitis and stenotic distal common bile duct, but periampullary cholangiocarcinoma was not excluded (Figure 1F). Positron emission tomography (PET)-CT did not show any signs of malignant lesions (Figures 1G, H).
case_images: Examination results after admission. (A-D) The EUS scan showed the stent in the common bile duct and inhomogeneous echo of pancreatic parenchyma. (E-H) Gastroscopy found the rough mucosa of descending duodenum region and the remaining stent, but biopsy suggested inflammation. EUS, endoscopic ultrasonography.
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case_images: The remaining stent in the common bile duct and an inhomogeneous echo of pancreatic parenchyma were seen through endoscopic ultrasonography (EUS) (Figures 2A-D). However, the biopsy of the rough mucosa in the descending duodenal region still suggested inflammation (Figures 2E-H).
case_images: Examination results after readmission. (A-C) EUS confirmed a lesion in lower common bile duct. (D) The serum level of TBIL after pancreatoduodenectomy. (E, F) Pathology evaluation confirmed the diagnosis as moderately differentiated adenocarcinoma of common bile duct. EUS, endoscopic ultrasonography; TBIL, total bilirubin.
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case_images: Then he underwent the second EUS examination through which a lesion in the lower common bile duct was confirmed (Figures 3A-C). For further treatments, he underwent pancreatoduodenectomy and achieved favorable clinical results (Figure 3D). Based on the histopathological evaluation of resected specimen, the following diagnosis was confirmed as moderately differentiated adenocarcinoma of the common bile duct (Figures 3E, F).