Gastroenterology clinical image challenge: An 84-year old woman with a history of hysterectomy and right-sided heart failure was admitted to the geriatrics department following a fall and subfebrility. Clinical examination showed no abdominal tenderness or significant injuries. Laboratory evaluation revealed an elevated C-reactive protein level (125 mg/L; upper limit of normal [ULN], 5.0 mg/L) and cholestatic liver abnormalities, with elevated gamma-glutamyl transferase (300 U/L; ULN, <39), bilirubin (2.14 mg/dL; ULN, <0.7 mg/dL) and raised alanine aminotransferase (798 U/L; ULN, <31 U/L).
An underlying cholangitis was suspected. Abdominal ultrasound examination was inconclusive owing to obesity and poor visualization. A computed tomography scan was performed, showing an air-filled periampullary lesion (Figure) as well as bile duct dilatation. Subsequent magnetic resonance cholangiopancreatography was performed (Figure).
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