Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Dec 16, 2019; 11(12): 589-595
Published online Dec 16, 2019. doi: 10.4253/wjge.v11.i12.589
Eosinophilic cholangitis: A case report of diagnostically challenging eosinophilic infiltrative biliary obstruction
Amar Dodda, Karen Matsukuma, Shiro Urayama
Amar Dodda, Shiro Urayama, Department of Internal Medicine/Division of Gastroenterology and Hepatology, University of California–Davis, Sacramento, CA 95817, United States
Karen Matsukuma, Department of Pathology and Laboratory Medicine, University of California–Davis, Sacramento, CA 95817, United States
Author contributions: Dodda A reviewed the literature and contributed to manuscript drafting; Matsukuma K evaluated the biopsy specimens and provided analysis/images of relevant findings, contributed to the manuscript drafting; Urayama S performed the procedures, reviewed the literature, contributed to manuscript drafting and provided oversight for important intellectual content.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Amar Dodda, MD, Advanced Endoscopy Fellow, Department of Internal Medicine/Division of Gastroenterology and Hepatology, University of California–Davis, 4150 V St, Suite 3500, Sacramento, CA 95817, United States. amardb@gmail.com
Telephone: +1-312-5600650
Received: June 8, 2019
Peer-review started: June 10, 2019
First decision: August 2, 2019
Revised: October 17, 2019
Accepted: November 4, 2019
Article in press: November 5, 2019
Published online: December 16, 2019
Processing time: 168 Days and 3.4 Hours
Abstract
BACKGROUND

Evaluation of biliary strictures primarily focuses on ruling out malignancy in older age groups. With endoscopic tools such as endoscopic ultrasound (EUS) and cholangioscopy, improved biliary visualization has enhanced the investigation of intraluminal biliary lesions and provided modalities for targeted biopsies. Benign biliary strictures, however, may pose a diagnostic dilemma.

CASE SUMMARY

A 71-year-old female with past medial history of hypothyroidism presenting for abnormal biliary imaging. Patient’s previous evaluation was concerning for common bile duct dilation with cholelithiasis, for which she underwent a cholecystectomy. Due to persistent symptoms and worsening liver function tests, she presented to our institution for further workup. Subsequently, the patient underwent an EUS and multiple ERCP’s with cholangioscopy; biliary biopsies revealed no evidence of malignancy but concerning for prominent eosinophilic infiltration. After further review of multiple pathology specimens and the benign clinical course, we diagnosed the patient with eosinophilic cholangitis.

CONCLUSION

Eosinophilic cholangitis is a rare disease and can present as a challenging case diagnostically. This case raises the potential utility of quantitative eosinophilic infiltration reporting in creating an objective diagnostic metric for eosinophilic cholangitis.

Keywords: Eosinophilic cholangitis; Diagnostic criteria; Endoscopic ultrasound; Endoscopic retrograde cholangiopancreatography; Case report

Core tip: Eosinophilic cholangitis is a rare cause of benign biliary strictures. The diagnosis is based predominantly on histopathologic findings in the setting of excluding malignancy, particularly in older age group. Previously, no quantitative eosinophilic threshold has been discussed in establishing the diagnosis of eosinophilic cholangitis, and hence the diagnosis is based on exclusion and suggestive findings. This case report provides the first look at eosinophils per high power field to help define eosinophilic cholangitis.