A 55 year old north Indian male patient presented with history of painless progressive jaundice for 6 months and few episodes of intermittent fever for 3 months. There was loss of appetite and weight loss of 5 kg over the previous 6 months. There was no history of hematemesis or malaena. The patient did not drink alcohol, was a non smoker, and nondiabetic.
His performance status was 80% on Karnoffsky scale. On clinical examination, the patient was deeply jaundiced with pallor; no lymph nodes were palpable. He had mild hepatomegaly with palpable gallbladder. Blood parameters were as follows: Hemoglobin 8.9 g%, total bilirubin 18.4 mg/dl (conjugated12.4, unconjugated 6.0), alkaline phosphatase 850, aspartate aminotransferase 110, alanine aminotransferase 85. Viral markers for hepatitis were nonreactive. Serology for HIV I and II was nonreactive.
Ultrasonography showed dilated proximal (CBD) with dilated intrahepatic biliary radicles and soft tissue shadow in lower end of CBD. There were multiple echogenic shadows in proximal CBD.
Endoscopic retrograde cholangio pancreatogram (ERCP) revealed a stricture at the lower end of CBD, biliary stenting was not possible through the tight stricture.
Magnetic resonance cholangio pancreaticogram (MRCP) showed soft tissue lesion in the terminal end of CBD suggestive of cholangiocarcinoma.
Guided FNA from the lesion for cytological evidence was not carried out.
Surgical resection for lower end CBD stricture was planned and a pylorus preserving pancreaticoduodectomy (PPD) was successfully carried out. Intraoperative findings did not suggest any metastasis or stigma of tuberculosis.
Postoperative recovery was complicated by minor pancreatic leakage and wound infection. Oral feeding (fluids) was resumed on third postoperative day and the patient was able to eat normal diet by 7th postoperative day. Within 2 weeks, the pancreatic leakage dried up and abdominal drains were removed.
Histopathology revealed granulomatous inflammation at lower end of CBD and periampullary region along with granulomatous lymphadenitis, both consistent with tuberculosis.
The patient was started on antitubercular medication (four drug regime of INH, rifampicin, pyrazinamide, and ethambutol) without significant adverse effects. He had a steady recovery - his serum alkaline phosphatase and bilirubin level reaching normal values by 8th postoperative week.
The patient is on follow up for the last 7 months, has gained weight and doing well.