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Special Feature
May 2011May 16, 2011

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: University of San Francisco (Ms Martinez), Department of Transplantation, California Pacific Medical Center (Dr Bonacini), and Department of Surgery, Division of Transplant, University of California, San Francisco (Dr Roberts), San Francisco.




Copyright 2011 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2011

Arch Surg. 2011;146(5):625. doi:10.1001/archsurg.2011.98-a

A 34-year-old man presented with gastrointestinal bleeding related to esophageal varices in 2002. The patient's varices were controlled with endoscopic ligation. Evaluation of the cause of the varices revealed extrahepatic portal vein thrombosis with normal findings on liver biopsy. During the follow-up period, he was found to have an increased alkaline phosphatase level; no other laboratory abnormalities of the liver were found, including the serum bilirubin level. The intrahepatic biliary ductal dilation was documented by computed tomographic cholangiography (Figure 1). A biliary stent was placed endoscopically with normalization of the alkaline phosphatase level. Computed tomographic portography demonstrated a patent intrahepatic portal vein and a patent confluence of the splenic and superior mesenteric veins, but with an occluded portal vein between the confluence and the intrahepatic portal vein with extensive venous collaterals.

Figure 1.
Image not available

The intrahepatic biliary ductal dilation was documented by computed tomographic cholangiography.

What Is the Diagnosis?

A.  Common bile duct stones

B.  Portal hypertensive biliopathy

C.  Pancreatic cancer

D.  Primary sclerosing cholangitis