Bile Duct Hamartoma Mimicking Metastatic Cholangiocarcinoma

Excerpt

A 63-year-old female presented to her primary care physician with weight loss of 30 lbs over the past 3 months, poor appetite, and jaundice. Her blood work revealed a total bilirubin of 12 mg/dl (range 0–1) with direct bilirubin of 10 mg/dl (range 0–0.3), alkaline phosphatase of 553 U/l (range 25–100), ALT 57 U/l (range 15–37), and AST 72 U/l (range 30–65). Further workup was performed including a CA 19–9 level of 549 U/ml (range 0–55) and magnetic resonance cholagiopancreatography (MRCP) revealing bile duct dilatation and multiple liver lesions concerning for metastatic disease. Computed tomography (CT) scan of the abdomen and pelvis showed multiple abnormally enhancing areas in the liver, the largest measuring 2.5 × 4.7 cm with dilated intra and extrahepatic bile ducts. She then had an endoscopic retrograde cholangiopancreatography (ERCP) that showed moderate dilation of the main bile duct as well as left and right hepatic ducts and all the intrahepatic branches along with distal common bile duct stenosis (Fig. 1). Bile duct brushing and biopsy were obtained. Atypical cells were found but were not consistent with malignancy. A biliary stent was placed. An endoscopic-guided ultrasound with fine needle aspiration of the head of pancreas was then performed and showed atypical ductal groups suspicious for adenocarcinoma. The patient underwent a laparoscopic evaluation with liver biopsy of the suspicious lesions and the pathology was consistent with bile duct hamartoma and no evidence of malignancy (Fig. 2). Her obstructive jaundice was due to common bile duct stenosis from benign fibrosis. The bilirubin and CA19-9 gradually decreased to 0.33 mg/dl and 90 U/ml, respectively. Her appetite improved and she started gaining weight. She is having her biliary stent changed every 3 months and CT scans of abdomen every 6 months with stable findings for the last 18 months.

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