To report a case of a 68-year-old man with a persistent indeterminate biliary stricture, elevated serum IgG4, and eosinophilia, and to highlight the diagnostic challenges associated with differentiating between benign and malignant conditions.
Approach:
Patient Presentation: A 68-year-old man presented with progressive jaundice, cholestatic liver injury, marked eosinophilia, and elevated serum IgG4.
Imaging and Diagnosis: Imaging revealed an indeterminate common bile duct stricture with upstream biliary dilatation; exploratory laparotomy confirmed distal common bile duct stenosis.
Pathology Findings: Pathology showed chronic inflammatory change with lymphoplasmacytic infiltration and scattered eosinophils, but negative IgG4 staining.
Treatment and Follow-Up: Methylprednisolone was administered, leading to improvement in eosinophils and liver tests, but persistent biliary stenosis was noted.
Key Findings:
The patient exhibited elevated serum IgG4 and eosinophilia, which did not confirm a benign diagnosis.
Persistent anatomical stenosis after corticosteroid treatment necessitated further evaluation for hepatobiliary malignancy.
Interpretation:
This case highlights the diagnostic complexity of indeterminate biliary strictures, indicating that improvements in laboratory values do not necessarily correlate with anatomical resolution.
Limitations:
The case lacked definitive outside pathology and documentation of the cause of death.
The tissue sample obtained was insufficient for a conclusive diagnosis of carcinoma.
Conclusion:
This case is interpreted as a persistent indeterminate biliary stricture with high-risk features rather than confirmed eosinophilic cholangitis or cholangiocarcinoma.
