A 29-year-old woman with abdominal tuberculous lymphadenitis (ATL) being treated with
anti-tuberculosis drugs underwent detailed investigations for a common bile duct (CBD)
stricture. Contrast-enhanced computed tomography (CECT) revealed an extrahepatic portal
venous obstruction (EPVO) and a cavernous transformation of the portal vein (CTPV).
The EPVO was likely caused by portal vein thrombosis due to ATL-related chronic inflammation.
Testing revealed a slight elevation of serum biliary enzymes, but no jaundice. CECT
suggested a CTPV-related origin for the CBD stricture ([Fig. 1a], [Fig. 1b]), which was confirmed by endoscopic ultrasound (EUS) ([Fig. 2a]); the mid to lower portion of the CBD appeared smooth on endoscopic retrograde cholangiography
([Fig. 2b]).
Fig. 1 a, b Contrast-enhanced computed tomography showing the common bile duct stricture caused
by cavernous transformation of the portal vein.
Fig. 2 a Endoscopic ultrasound showing the common bile duct (CBD) stricture caused by cavernous
transformation of the portal vein (CBD: asterisk). b Endoscopic retrograde cholangiography showing the CBD stricture, which was smooth
from the mid to the lower portion of the duct.
Intraductal ultrasonography (IDUS) showed that the narrowest point was externally
compressed by multiple hypoechoic features ([Fig. 3a]). Downstream, hypoechogenic features were visible inside the CBD wall ([Fig. 3b]; arrow). These findings were suggestive of paracholedochal and epicholedochal biliary
varices.
Fig. 3 a Intraductal ultrasound image showing the narrowest point of the common bile duct
(CBD) surrounded by the cavernous transformation of the portal vein outside the CBD
wall. b Hypoechogenic features (arrow) inside the CBD wall.
Digital cholangioscopy (Spyglass DS; Boston Scientific, Marlborough, Massachusetts, United States) showed normal mucosa in the upper CBD and confirmed compression of the CBD midportion
by biliary varices. The CBD mucosa showed hyperemia with sporadic red spots and telangiectasia
([Fig. 4a], [Fig. 4b]; heads). Biliary varices were also detected in the CBD lumen, consistent with the
hypoechogenic features observed on IDUS ([Fig. 5]). Interestingly, the varices were reducible by water conveyance ([Video 1]). We determined that the stricture was caused by biliary varices.
Fig. 4 a, b Sporadic red spots and telangiectasia (arrowheads) in the common bile duct mucosa.
Fig. 5 Biliary varix detected in the common bile duct lumen.
Video 1 Digital cholangioscopy of a patient with common bile duct (CBD) stricture shows a
biliary varix and hyperemia of the CBD mucosa.
Despite bleeding from the biliary mucosa during biopsy, spontaneous hemostasis was
achieved. We followed-up on the CBD stricture because the patient did not have obstructive
jaundice.
Biliary varices are related to portal hypertension, primarily EPVO [1]. EUS [2] and IDUS [3] are useful tools for diagnosing biliary varices.
Although few reports describe cholangioscopic observations of biliary varices in detail
[4]
[5], we suggest that cholangioscopy is useful to diagnose biliary varices.
