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A 44‐year‐old Romanian woman with a history of asthma, epilepsy, non‐insulin dependent diabetes mellitus, and depression presented with a gradual weight loss over 1 year, pruritis over 3 months, and a history of dark urine and pale stools for several weeks. She denied any abdominal pain.
Clinical examination revealed a soft, non‐tender abdomen with no organomegaly. The patient was not clinically jaundiced and there was no lymphadenopathy.
Liver‐function tests revealed raised bilirubin (34 μmol/l; normal range 1–14), alkaline phosphatase (449 IU/l; 4–105), and aspartate transaminase (203 IU/l; 1–31) Albumin was normal, and erythrocyte sedimentation rate was raised to 51 mm/h (normal range 0–20). Autoantibody screening tests (including anti‐smooth muscle and anti‐mitochondrial antibodies) was negative. Chest radiography was normal.
A diagnosis of obstructive jaundice was made and abdominal CT scanning was performed after an abdominal ultrasound scan was taken (figure 11).). A subsequent ERCP showed a regular, smooth, bile‐duct stricture, 1–2 cm long, at the distal common bile duct, being 1 cm proximal to the ampulla ,which had a characteristic feature of external compression (figure 22).). The stricture was dilated using a balloon and a plastic stent inserted. Following this, the liver function tests became normal. Brush cytology showed normal glandular epithelial cells.
An exploratory laparotomy was performed later because of suspicion of malignancy, after discussion of the case at a multidisciplinary meeting. During surgery, a thick‐walled bile duct was noted, together with an extensive lymphadenopathy along the portal triads and coeliac axis. After several biopsies were taken from the lymph nodes for final histology (figure 33),), the laparotomy was closed using standard techniques.
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