Unusual Discovery During ERCP: Bile Duct Adenoma

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Cholangiocarcinoma represents an uncommon heterogenous group of tumors that can affect the liver, the hilum, the bile duct or the gall bladder. We report a patient with hilar cholangiocarcinoma (Klatskin's tumor) and an extremely rare adenomatous polyp in the mid portion of the common bile duct seen incidentally during cholangioscopy. A 74-year-old male presented to the office with acholic stools for the past 2 weeks, jaundice, and muscle pain since starting Crestor. He had a remote history of alcohol abuse but quit >10 years ago. He denied any other risk factors for liver disease and there was no family history of liver disease. Physical exam was unremarkable except for significant jaundice. Four days earlier T. bilirubin was 12.9, alkaline phosphatase 357, AST 85, and ALT 182. Four months prior T.bilirubin was 1.0, alkaline phosphatase 257, AST 41, and ALT 51. Abdominal ultrasound 1.5 years ago showed no evidence of cholecystolithiasis, the common bile duct measured 8 mm without intrahepatic dilation. The liver had homogeneous echotexture, and no mass was seen. Additional new studies showed: AFP - 4.0, Ca 19-9 - 132, GGT — 698. CT with contrast revealed significant right and left intrahepatic biliary ductal dilation, no extrahepatic biliary ductal dilation with hyperenhancement throughout the common hepatic duct that focalizes to a 2cm mass suspicious for hilar cholangiocarcinoma. ERCP was performed: The cholangiogram revealed a tight short stricture just below the bifurcation. A papillotomy was performed and cholangioscopy was carried out, the strictured area appeared friable and irregular. It was biopsied. In the mid CBD an area of elevated tissue (polyp) was identified (photo A) and biopsied. Histological exam of the hilum biopsy showed adenocarcinoma(photo B) and the biopsy of the polyp showed adenoma and cholesterolosis (photo C). The patient was referred to a university hospital for possible surgery and oncologic treatment. We report a rare finding: an adenomatous polyp with cholesterolosis in the common bile duct. CBD polyps may be hyperplastic, hamartomatous, inflammatory, cholesterol, papillary neoplasms or adenomatous. With greater use of cholangioscopy more polyps may be detected which in time may bring a better understanding of the natural history of biliary neoplasms and improve therapeutic options for the patients with these rare but deadly cancers.1389_A.tif Figure 1: CBD polyp on cholangioscopy1389_B.tif Figure 2: Pathology of the hilar adenocarcinoma1389_C.tif Figure 3: Pathology of the CBD adenoma