LESS THAN IT MEETS THE EYE

A 78-year-old patient with previous history of coronary artery disease presented to the emergency department with recent onset abdominal pain and fever. He was diagnosed with cholecystitis and treated medically. Two weeks later, he presented with cholestasis and dilated intrahepatic bile ducts on abdominal US. An EUS was then performed, showing a thickened gallbladder and common hepatic duct compatible with cholecystitis and inflammation due to spontaneous calculus migration. The patient was discharged without cholecystectomy. Due to persistent icteric cholestasis and elevated serum Ca19.9, a second EUS was done showing a thickening of the cystic duct and the common hepatic duct, with an irregular hypoechoic lesion, measuring 1.6 cm probably invading the duodenal wall. An ERCP demonstrated a stricture of the common hepatic duct. Exploration with SpyGlass™ showed a 3 cm long stricture extending to the cystic duct, with a nodular mucosa and irregular dilated vessels. The hepatic hilum was normal. The guided biopsies taken using SpyBite™ forceps and the brush cytology showed signs of inflammation and were negative for neoplasia. The CT-scan showed a thickening of the common hepatic duct extending to the right hepatic and cystic ducts with encasement of the common hepatic artery, right hepatic artery, and the distal portal vein and an abutment of the left hepatic artery. A PET-CT showed a suspicious, hypermetabolic thickening of the common hepatic duct without regional lymph node metastases nor distant metastases. The findings were considered suggestive of a Klatskin IIIA tumor. The patient had a cholecystectomy with resection of the common hepatic and bile duct above the pancreas with right and left hepatico-jejunal anastomosis. The histopathology results were negative for neoplastic tissue. The findings were compatible with a severe chronic inflammation of the gallbladder with severe fibrosis.