Eosinophilic cholangitis is a potentially underdiagnosed etiology in indeterminate biliary stricture

Rare Presentation of Eosinophilic Cholangitis in a 32-Year-Old Man

Eosinophilic cholangitis (EC) is a rare condition characterized by eosinophilic infiltration of the bile ducts, often mimicking diseases like primary sclerosing cholangitis or cholangiocarcinoma. We report the case of a 32-year-old man with severe epigastric pain and elevated liver function tests. Initial imaging revealed common bile duct dilation and multiple strictures, initially suggestive of primary sclerosing cholangitis. Multiple endoscopic retrograde cholangiopancreatographies with brushings showed benign cytology but revealed polysomy on fluorescence in situ hybridization. A biopsy confirmed EC. High-dose corticosteroids led to significant clinical improvement. This case underscores the importance of considering EC in the differential diagnosis of biliary diseases, as timely diagnosis and treatment can lead to excellent outcomes.

A case of eosinophilic cholangitis without bile duct stenosis diagnosed by bile duct biopsy

Eosinophilic cholangitis (EC) is a rare benign disease that is often misdiagnosed as a malignancy due to the development of biliary stricture. This disease is generally diagnosed by liver biopsy or surgery. Herein, we report a case of EC diagnosed in an 86-year-old Japanese woman, who presented with fever, elevated eosinophil count, and elevated liver enzyme level, based on intraductal ultrasound evaluation showing bile duct wall thickening and bile duct biopsy of the same site. We diagnosed this case as EC based on the triad of wall thickening of the biliary system, histopathological findings of eosinophilic infiltration of the biliary tract, and reversibility of biliary abnormalities without treatment. Bile duct biopsy during endoscopic retrograde cholangiopancreatography (ERCP) is rarely used to confirm the diagnosis of EC without bile duct stenosis. For EC and cholecystitis associated with eosinophilia, bile duct biopsy under ERCP, which is less invasive, should be considered. This patient was older than the previously reported patients, and the value of a minimally invasive diagnosis was high.

A case of juvenile eosinophilic cholangitis: Rapid peripheral blood hypereosinophilia after admission leading to diagnosis

A 15-year-old boy was referred to our hospital with elevated hepatobiliary enzyme levels and jaundice. Magnetic resonance cholangiopancreatography performed at the previous medical facility revealed a stricture of the intrahepatic and extrahepatic bile duct. Computed tomography showed dilatation and wall thickness of the intrahepatic bile ducts. Primary sclerosing cholangitis or cholangiocarcinoma was suspected. Endoscopic retrograde cholangiopancreatography (ERCP) showed stricture in the intrahepatic and extrahepatic bile duct. On admission, the eosinophil count in the peripheral blood was normal; however, rapid hypereosinophilia in the peripheral blood was observed after admission, leading us to suspect eosinophilic cholangitis (EC). A bile duct biopsy showed inflammatory cells and eosinophil infiltration during a second ERCP. The patient was diagnosed with EC based on histopathology.

A case of eosinophilic cholangiopathy mimicking cholangiocarcinoma

Eosinophilic cholangiopathy is an uncommon etiology of biliary stenosis, which is characterized by eosinophilic infiltration. Clinically, it is difficult to distinguish eosinophilic cholangiopathy from other causes of obstructive cholangiopathy before pathologic confirmation. We report a case of eosinophilic cholangiopathy. A 30-year-old male patient complained of right upper quadrant abdominal pain. Magnetic resonance cholangiopancreatography showed distended gallbladder and multifocal bile duct strictures with diffuse wall thickening. His bilirubin level increased continuously even after endoscopic retrograde cholangiopancreatography. He underwent laparoscopic cholecystectomy for cholecystitis and pathology of resected gallbladder revealed marked eosinophilic infiltration with no malignant component. His pain improved after cholecystectomy and multifocal bile duct strictures with wall thickening were rapidly improved after steroid therapy.

[Differential diagnoses of biliary tract diseases : Computed tomography and magnetic resonance imaging]

CLINICAL/METHODICAL ISSUE

Bile duct diseases can be found in all age groups and show an increased prevalence in northern Europe. Pathologies range from benign diseases to malignant tumors with very poor survival.

STANDARD RADIOLOGICAL METHODS

Magnetic resonance imaging (MRI) and computed tomography (CT) are the radiological methods of choice for a detailed evaluation of the bile duct system in addition to sonography. By assessing the lumen and the wall of the bile ducts as well as the surrounding structures, both obstructive and nonobstructive pathologies can be diagnosed and differentiated with high sensitivity and specificity.

METHODICAL INNOVATIONS

Technical developments with postprocessing modalities as well as the use of biliary-excreted liver-specific MR contrast agents improve the diagnosis of bile duct diseases and enable morphological and functional assessment.

PERFORMANCE

Due to high patient tolerance, minimal procedural risk in contrast to invasive endoscopic methods and the possibility of three-dimensional post-processing, beside CT, MRI with magnetic resonance cholangiography (MRC) represents the method of choice in patients with sonographically or clinically suspected bile duct disease and has significantly reduced the indications of diagnostic endoscopic retrograde cholangiopancreatography (ERCP). A complementary multimodality and multiparametric imaging approach is particularly helpful for preoperative assessment.

PRACTICAL RECOMMENDATIONS

Rapidly evolving technology for both MRI and CT represent opportunities and challenges. By understanding the advantages and limitations of modern MR and CT techniques and by knowing the spectrum of bile duct pathologies, improved diagnosis and narrowing of possible differential diagnosis can be achieved.

Practical Management of Indeterminate Biliary Strictures

Indeterminate biliary strictures pose a diagnostic and therapeutic challenge. Although underlying malignancy is a primary concern, biliary strictures may result from benign processes. An accurate diagnosis is paramount to define the treatment strategy and minimize morbidity. The limitations of traditional endoscopic retrograde cholangiopancreatography-based tissue acquisition with cytology brushings are well-documented. Endoscopic retrograde cholangiopancreatography is generally unable to determine a stricture's etiology. Complementary advanced endoscopic imaging and multimodal tissue acquisition have evolved. Careful consideration of the clinical presentation, location of the stricture, and interpretation of imaging constitute the most optimal approach for diagnosis and management.

Cholangitis: Diagnosis, Treatment and Prognosis

Cholangitis is a serious life-threatening situation affecting the hepatobiliary system. This review provides an update regarding the clinical and pathological features of various forms of cholangitis. A comprehensive search was performed in the PubMed, Scopus, and Web of Knowledge databases. It was found that the etiology and pathogenesis of cholangitis are heterogeneous. Cholangitis can be categorized as primary sclerosing (PSC), secondary (acute) cholangitis, and a recently characterized form, known as IgG4-associated cholangitis (IAC). Roles of genetic and acquired factors have been noted in development of various forms of cholangitis. PSC commonly follows a chronic and progressive course that may terminate in hepatobiliary neoplasms. In particular, PSC commonly has been associated with inflammatory bowel disease. Bacterial infections are known as the most common cause for AC. On the other hand, IAC has been commonly encountered along with pancreatitis. Imaging evaluation of the hepatobiliary system has emerged as a crucial tool in the management of cholangitis. Endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography and endoscopic ultrasonography comprise three of the modalities that are frequently exploited as both diagnostic and therapeutic tools. Biliary drainage procedures using these methods is necessary for controlling the progression of cholangitis. Promising results have been reported for the role of antibiotic treatment in management of AC and PSC; however, immunosuppressive drugs have also rendered clinical responses in IAC. With respect to the high rate of complications, surgical interventions in patients with cholangitis are generally restricted to those patients in whom other therapeutic approaches have failed.

Eosinophilic cholangitis treatment with budesonide

Eosinophilic cholangitis is a rare cause of deranged obstructive liver function tests. It has been described as a great mimicker for malignant biliary strictures and bile duct obstruction. There are only case reports available on treatment experience for eosinophilic cholangitis. A large proportion of patients present with biliary strictures for which they have undergone surgery or endoscopic treatment and a small proportion was given systemic corticosteroid. We share our treatment experience using budesonide which has fewer systemic side effects to prednisolone and avoids invasive management.