A 60-Year-Old Man With Chronic Cough and Green Sputum

Abstract

Question: A 60-year-old man with a past medical history of pancreatic neuroendocrine tumor with metastasis to the liver, chronic cholangitis, and liver abscess presented with a 2-month history of productive cough with green sputum and right upper quadrant pain. Past surgical history includes partial liver resection, liver chemoembolization and Y-90 microsphere radiation, cholecystectomy, and multiple intraabdominal surgeries. On examination, the patient was a cachectic-appearing white male. Oral cavity examination shows a greenish coating on tongue but no jaundice. Significant laboratory results included an alkaline phosphatase level of 523 U/L (normal, 55-135), aspartate aminotransferase of 57 U/L (normal, 10-40), and normal bilirubin level. Computed tomography was nondiagnostic. Magnetic resonance cholangiopancreatography without contrast revealed several nonspecific areas of abnormal increased T2 signal adjacent to the liver at the hepatic dome and within the right lower lobe of the lung, numerous poorly defined hepatic lesions. As part of his evaluation, a HIDA scan was performed (Figure A, results at 5 minutes; Figure B, at 40 minutes). Endoscopic retrograde cholangiopancreatography (ERCP) was then performed for diagnosis and therapeutic intervention (Figure C). What is the diagnosis? What is the appropriate management? Look on page 576 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.