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A 78‐year‐old man was admitted to our hospital with epigastric pain, fever and nausea. Cough, generalised pruritus and eosinophilia had persisted for 5 months before his admission. His temperature was 37.9°C. On examination, there was prominent right subcostal tenderness.
Laboratory tests showed that the packed cell volume was 0.43 and the white cell count was 5.9×109/l, with 22% eosinophils. Liver function tests showed that the aspartate aminotransferase level was 410 U/l, while alanine aminotransferase was 179 U/l, alkaline phosphatase was 360 U/l, γ‐glutamyltransferase was 578 U/l and total bilirubin was 56 μmol/l.
Abdominal computed tomography showed that the gallbladder was mildly distended and there was dilatation of the common bile duct. Magnetic resonance cholangiopancreatography disclosed dilatation of the common bile duct and a 2 cm filling defect in the distal part of the duct. Endoscopic retrograde cholangiopancreatography showed dilatation of the common bile duct and a 1.6 cm filling defect (fig 11).).
What is the likely diagnosis?
See page 1571 for answer