An Unusual Cause Of Obstructive Jaundice

Abstract

Purpose: Obstructive jaundice is a common clinical problem encountered in medical units which occurs either due to extrahepatic cholestasis or in intrahepatic cholestasis. This case history highlights a very unusual case of intrahepatic cholestasis. 38 old mechanic was referred for ERCP evaluation of obstructive jaundice in august 2007. He gave a past history of exploratory laparotomy for stab injury to the umbilical region 10 years prior to the presentation with no evidence of damage to the hepatobiliary tract. A subsequent choledocho-duodenostomy for a benign terminal common bile duct stricture was done 4 years after the initial surgery. He denied alcohol consumption and was not on drugs or herbal remedies. There were no symptoms suggestive of inflammatory bowel disease. There was no family history of jaundice. Examination revealed moderate icterus and an abdominal surgical scar indicating previous surgery. Rest of the general examination and system examination were normal. Results of the investigations were as follows. Hb 10.1g/dl, MCV normal. ESR 42 mm, CRP 6 mg/dl, AST 70U/L, ALT 98 U/L, Serum bilirubin 34 mg/dl, direct bilirubin 26 mg/dl, indirect bilirubin 08 mg/dl, hepatitis screen negative, autoantibody profile, normal, abdominal ultrasound normal, ERCP, normal. The liver biopsy revealed histological features of vanishing bile duct syndrome. Obstructive jaundice is a common clinical problem encountered by the gastroenterologists worldwide. If the answer is not straightforward, the rarities should be entertained. Conclusion The possible autoimmune reaction could have been triggered off due to exposure to major bile duct antigens during biliary surgery and the clinicians should entertain this possibility on a positive background where the other recognized causes of bile duct syndromes are absent.