A Rare Cause of Obstructive Jaundice: Is Surgery the Only Option?

Abstract

Question: A 71-old men presented with a 2-week history of painless jaundice. Physical examination showed icteric sclera and abdominal examination revealed slight deep tenderness in epigastrium. Laboratory tests showed the following results: aminotransferase (AST), 251 IU/L; alanine transaminase (ALT), 118 IU/L; serum total bilirubin, 4.0 mg/dL and carbohydrate antigen (CA) 19-9, 50.0 U/mL. Also, serum total IgG revealed 1380.90 mg/dL with 135.2mg/dL of IgG4 subclass. Abdominal computed tomography (CT) revealed a relatively well-defined mass with homogeneous density in pancreatic head causing bile and pancreatic duct dilatation (Figure A). The positron emission tomography (PET) CT revealed about 5cm focal abnormal accumulation of fluorodeoxyglucose (FDG) in pancreatic head portion and periportal lymph node (Figure B). Endoscopic ultrasonography (EUS) revealed a heterogeneous low echogenic mass in pancreatic head with multifocal hyperechoic foci and marked bile duct dilatation with ductal invasion (Figure C). EUS-guided tissue acquisition and endoscopic retrograde cholangio-pancreatography was performed. The cholangiography shows short segment stricture at distal common bile duct with upstream ductal dilatation (Figure D), subsequently, decompression with plastic stent placement for obstructive jaundice was done. Histologic findings from EUS-guided tissue acquisition and endo-biliary biopsy revealed abundant infiltration of IgG4 positive plasma cells and lymphocytes around the pancreatic duct with storiform fibrosis (Figure E and F). CME Exam 1: A Rare Cause of Obstructive Jaundice: Is Surgery the Only Option?GastroenterologyVol. 158Issue 8Preview Full-Text PDF