[Obstructive jaundice secondary to liver hilar lymph node tuberculosis].

Tuberculosis (TB) of the hepatobiliary system is uncommon and it is a rare cause of bile duct stenosis. The symptoms are nonspecific, the most important of which is jaundice. Hepatobiliary TB is difficult to differentiate from other entities such as cholangiocarcinoma, and many cases require surgery, histology and bacteriological confirmation to reach a definitive diagnosis. Treatment does not differ from pulmonary TB and involves the administration of quadruple therapy for one year. In order to resolve the bile duct obstruction, endoscopic retrograde cholangiopancreatography (ERCP) is used to insert a bile stent; meanwhile, some cases may require surgical decompression. We present the case of a 29-year-old male patient with no prior medical history of interest that came to our Emergency Department due to abdominal pain that had been developing over the previous 3 weeks. The pain was poorly defined, located in the right hypochondrium, and accompanied by jaundice of the skin and mucous membranes with choluria but no other alterations. On admittance, the work-up showed a pattern of extrahepatic cholestasis with bilirubin 4.2 mg/dl and GGT 467 IU/l. Basic biochemistry, complete blood count and coagulation were within normal limits. Tumor marker levels were also normal. Chest and abdominal radiographies presented no alterations. Abdominal ultrasound revealed the presence of a normal-sized gallbladder with biliary sludge, no signs of inflammation and moderate dilatation of the intraand extrahepatic bile duct, observing multiple lymphadenopathies in the area as well as under the spleno-portal axis. The pancreas had a normal appearance with no observed free fluid. Abdominal computed tomography (CT) (Fig. 1) confirmed the dilatation of the bile duct seen on ultrasound, showing narrowing of the common bile duct at the hepatic hilum. We identified a heterogeneous mass of 30 40 mm with ill-defined edges and internal calcifications responsible for the dilatation of the bile duct as well as the cavernous transformation of the portal vein. In addition, intercaval-aortic and gastrohepatic lymphadenopathies larger than 1 cm were detected. We attempted to use endoscopic ultrasound needle aspiration to biopsy the mass, but this was not possible because of the location and collateral circulation. Using ERCP, we inserted a plastic stent (8.5 F 10 cm) in the common bile duct after the bile duct cytology was negative for malignancy. Since the diagnostic tests did not confirm whether the process was benign or malignant, exploratory laparotomy was indicated. We observed local inflammation of the gallbladder and hepatic pedicle with compression of the middle common bile duct caused by a cluster of at least 3 lymphadenopathies. Intraoperative biopsy of one of these lymph nodes confirmed the existence of a