LAUSR

A 60-year-old woman with a history of breast cancer presented with jaundice, epigastric pain, and fever for 1 week. Laboratory results revealed a total bilirubin of 14.9mg/dL and alkaline phosphatase of 365U/L. Abdominal computed tomography revealed a 6.1 ×2.8-cm hilar liver mass with intrahepatic biliary dilatation (▶Fig. 1; ▶Video1); subsequent abdominal magnetic resonance imaging demonstrated an infiltrative soft tissue mass encasing the common hepatic and central intrahepatic ducts, suggestive of intrahepatic cholangiocarcinoma (▶Fig. 2). Endoscopic ultrasound (EUS) demonstrated a fistulous tract, which was draining into the duodenal bulb (▶Video1). EUS-guided fine needle aspiration (FNA) of the liver mass was performed. During endoscopic retrograde cholangiopancreatography (ERCP), despite cannulation of the major papilla, the guidewire could not be advanced to the proximal common hepatic duct; a cholangiogram revealed complete obstruction of the proximal common bile duct (▶Fig. 3). Contrast injection through the fistulous tract in the duodenal bulb confirmed a hepaticoduodenal fistula with marked intrahepatic duct dilatation. The fistula tract was dilated and two plastic biliary stents were placed with their proximal ends in the right and left main hepatic ducts and good flow resulted (▶Fig. 4 and ▶Fig. 5 a). After 2 weeks, the patient’s liver enzymes had notably improved and the plastic stents were exchanged for a covered metal stent (▶Fig. 5 b and ▶Fig. 6). Pathology from the EUS-FNA demonstrated adenocarcinoma morphologically favoring a cholangiocarcinoma, and ▶ Fig. 1 Computed tomography scan of the abdomen/pelvis (coronal view) demonstrating a large hilar liver mass with intrahepatic biliary dilatation (arrow). ▶ Fig. 2 Magnetic resonance imaging of the abdomen/pelvis (T2-weighted, coronal view) demonstrating a hilar liver mass with marked intrahepatic biliary dilatation (arrow). ▶ Fig. 3 Cholangiogram demonstrating complete obstruction of the proximal common bile duct (arrows).