Diagnostic pitfalls of obstructive jaundice in an elderly patient with ulcerative colitis

Background: Primary sclerosing cholangitis (PSC) is an idiopathic, chronic, progressive cholestatic liver disease characterized by strictures and dilatations of the biliary tree. PSC is commonly associated with ulcerative colitis, the course of the disease might be complicated by cholangitis, secondary biliary cirrhosis, and cholangiocarcinoma.

Case report: We present a case of a female patient treated with ulcerative colitis for four decades, which was in remission since 6 years. At the age of 73 she was repeatedly hospitalised due to fever, obstructive jaundice and abdominal discomfort. Primary sclerosing cholangitis was diagnosed with endoscopic retrograde cholangiography although previous biochemical measurements demonstrated normal liver function for decades. Steroid and ursodeoxycholic acid therapy was provided, however, jaundice occured intermittently. 6 months later she was admitted to our department because of jaundice, nausea, fever and upper abdominal pain. Endoscopic retrograde cholangiography showed typical features of hilar cholangiocarcinoma (stage Bismuth IV). Examination of brush cytology specimens obtained from ductus choledochus confirmed the diagnosis biliary malignancy.

Conclusions: The incidence of cholangiocarcinoma increases with age and usually affects individuals in their 6^th or 7^th decade of life. Those patients with underlying risk factors such as PSC generally present 2 decades earlier. In elderly patients with obstructive jaundice – even with long history of ulcerative colitis – secondary causes of biliary strictures such as malignancies should be excluded before making the diagnosis of primary sclerosing cholangitis. In addition to the cholangiographic findings, bile duct brushing is crucial for the differential diagnosis, providing an important screening technique for cholangiocarcinoma.