case_images: PMC6885758_01
case_images: Bilirubin and ALT trend in relation to patient's diagnosis and treatment.
case_images: CRIHEP2019-9383019.001.jpg
case_images: PMC6885758_01_CRIHEP2019-9383019.001.jpg
case_images: fig1
case_images: Labs showed elevated liver enzymes in an obstructive pattern (Figure 1). Repeat labs showed resolution of ACE inhibitor levels and liver chemistries except ALP (Figure 1).
case_images: The biopsy demonstrates mildly distorted hepatic architecture due to marked inflammation and presence of granulomas. There is cholestasis. Many non-necrotizing epithelioid granulomas, some confluent, are seen in the portal tracts, periportally and in the lobules. Portal tracts demonstrate mild acute and chronic inflammation (in association with granulomas), bile duct damage and mild proliferation of bile ductules accompanied by neutrophils. Ceroid-laden macrophages are seen in the lobules. There is periportal fibrous expansion and focal portal-portal bridging.
case_images: CRIHEP2019-9383019.002.jpg
case_images: PMC6885758_01_CRIHEP2019-9383019.002.jpg
case_images: fig2
case_images: An ultrasound-guided liver biopsy was therefore performed (Figure 2).
case_images: MRI abdomen-enhancing mass in the region of the ampulla, with resulting significant dilation of the biliary tree and the main pancreatic duct.
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case_images: PMC6885758_01_CRIHEP2019-9383019.003.jpg
case_images: fig3
case_images: Magnetic Resonance Cholangiopancreatography revealed persistently enlarged perihepatic and periportal lymph nodes and a mass in the ampulla of the pancreas (Figure 3).
case_images: Upper endoscopy with EUS guided biopsy: A large celiac node, measuring about 4 cm in diameter, along with multiple enlarged lymph nodes noted in the porta hepatis and the lesser sac.
case_images: CRIHEP2019-9383019.004.jpg
case_images: PMC6885758_01_CRIHEP2019-9383019.004.jpg
case_images: fig4
case_images: Endoscopic Retrograde Cholangiopancreatography showed a biliary stricture and a double-duct sign (proximal pancreatic and common bile duct dilation) with biliary stricture biopsy displaying a cluster of atypical glandular cells, likely adenocarcinoma (Figures 4 and 5).
case_images: Biliary stricture adenocarcinoma at 400X. Small cluster of atypical glandular cells present, which is highly suspicious for adenocarcinoma. The cytopathology report from brushings showed adenocarcinoma.
case_images: CRIHEP2019-9383019.005.jpg
case_images: PMC6885758_01_CRIHEP2019-9383019.005.jpg
case_images: fig5
case_images: Endoscopic Retrograde Cholangiopancreatography showed a biliary stricture and a double-duct sign (proximal pancreatic and common bile duct dilation) with biliary stricture biopsy displaying a cluster of atypical glandular cells, likely adenocarcinoma (Figures 4 and 5).