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Image challenge: An alternative cause of bile duct obstruction

What caused an air-filled periampullary lesion, as well as bile duct dilatation, in a patient presenting with an elevated C-reactive protein level and cholestatic liver abnormalities?

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).

What is the diagnosis? What is the treatment of choice?

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.

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