Jaundice in a chronic hepatitis B carrier

Clinical presentation

A 50‐year‐old man presented with a 4‐week history of jaundice that developed progressively. He had chronic hepatitis B. During the last 3 months, he had complained of repetitive bouts of right upper abdominal pain with fever. Clinical examination was normal except for jaundice. Biological tests revealed a normal complete blood count and abnormal liver tests with cholestatic and cytolytic features (γ‐glutamyl transpeptidase = 850 IU/l (normal<43 IU/l), alkaline phosphatase = 299 IU/l (normal<126), total bilirubin = 134 μm/l (normal<22), aspartate transaminase = 101 IU/l (normal<59), alanine transaminase = 116 IU/l (normal<72). The α‐fetoprotein level was normal and the CA 19‐9 level was elevated at 139 IU/ml (normal<37 IU/ml). HBsAg and IgG anti‐HBc were positive.

On abdominal ultrasonography, the intrahepatic bile ducts were dilated. No parenchymal tumour was detected and the gallbladder was unremarkable. Magnetic resonance cholangiopancreatography showed a homogeneous liver parenchyma and a filling defect of the hepatic duct with upward dilatation. Endoscopic retrograde cholangiography was carried out and is shown in fig 1.

Figure 1 Cholangiogram through the ERCP catheter inserted into the common bile duct up to the junction with the cystic duct.There is aneurysmal dilation of the main hepatic duct containing a filling defect with dilated right intrahepatic ducts. The left intrahepatic duct is not visualised.

Question

What is the diagnosis and management?

See page 1425 for answer