Secondary sclerosing cholangitis uncovered during endoscopic retrograde cholangiopancreatography in a patient with chronic choledocholithiasis

Untreated biliary cholestasis such as in the case of choledocholithiasis with biliary obstruction can lead to inflammatory strictures, recurrent cholangitis, the formation of more stones and eventually secondary biliary cirrhosis. This can lead to a shortened life expectancy. We report a case of a 61 year old male from Somalia, who presented with recurrent painless jaundice. He had had similar presentations in another country but lacked documentation to show the treatment ensued. Liver function tests (LFTs) at our institution showed evidence of cholestasis. Repeated initial radiological studies failed to show any biliary dilatation and/or obstruction but did reveal evidence of liver cirrhosis with portal hypertension. A liver biopsy at this stage showed bile plugs consistent with a cholestatic picture, as well as evidence of secondary biliary cirrhosis. A magnetic resonance cholangiopancreatography (MRCP) confirmed the presence of biliary dilatation secondary to choledocholithiasis. He underwent an endoscopic retrograde cholangiopancreatography (ERCP), which showed common bile duct stones and an associated biliary stricture, as well as features suggestive of secondary sclerosing cholangitis (SSC) of the intrahepatic ducts. Dilatation and stenting of the stricture were performed, while complete stone clearance was achieved at the second ERCP. LFTs decreased gradually thereafter. Biliary drainage in a patient with cholestasis from a mechanical cause should be the mainstay of treatment. Every effort should be made to prevent the development of chronic cholestasis due to the risk of developing SSC and biliary cirrhosis. Our patient had unfortunately developed chronic choledocholithiasis, with radiological and histological evidence of liver cirrhosis at the time of presentation at our institution.