PMC5519466_01
Timeline of the patient's clinical course. AUS: abdominal ultrasonography, ACT: abdominal computed tomography, MRCP: magnetic resonance cholangiopancreatography, DIC-CT: drip infusion cholecystocholangiography, EUS: endoscopic ultrasonography, ERCP: endoscopic retrograde cholangiopancreatography, EGD: esophagogastroduodenoscopy, CZOP: cefozopran, MNZ: metronidazole
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Fig. 1 provides a timeline of the patient's clinical course as described in this article.
Contrast-enhanced abdominal computed tomography (CT) on admission revealed distention of the gallbladder with peripheral cholecystic (A) and perihepatic (B) fluid collections without gallstones.
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Abdominal ultrasonography and contrast-enhanced computed tomography (CT) showed distention of the gallbladder with peripheral cholecystic and perihepatic fluid collections without gallstones (Fig. 2).
Magnetic resonance cholangiopancreatography (MRCP) (A) and drip infusion cholecystocholangiography (DIC) -CT (B) findings before metronidazole treatment. The images demonstrated a stricture of the hilar bile duct and cystic duct obstruction.
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Magnetic resonance cholangiopancreatography (MRCP) on Day 7 and drip infusion cholecystocholangiography (DIC)-CT on Day 11 demonstrated a stricture of the hilar bile duct and cystic duct obstruction (Fig. 3).
(A) Endoscopic retrograde cholangiography revealed a slightly stenotic lesion of the hilar bile duct, and we conducted transpapillary bile duct brush cytology and a biopsy of the hilar bile duct stricture. (B) Transpapillary intraductal ultrasonography of the bile duct indicated a continuously thick wall from the upper to the lower bile duct with a smooth circular symmetric outer margin, a smooth inner margin, and a homogenous internal echo pattern.
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ERC on Day 13 revealed a slightly stenotic lesion of the hilar bile duct with a smooth luminal surface (Fig. 4A), and transpapillary intraductal ultrasonography (IDUS) of the bile duct indicated a continuously thickened wall from the upper to the lower bile duct with a smooth circular symmetric outer margin, a smooth inner margin, and a homogenous internal echo pattern (Fig. 4B).
A histopathological evaluation due to the findings on transpapillary bile duct brush cytology (A) and the biopsy (B). (A) Numerous active trophozoites of Giardia lamblia (arrows) (Giemsa stainingx100). (B) Numerous active trophozoites of Giardia lamblia (arrows) in the bile duct wall but no malignant findings (Hematoxylin and Eosin staining x100).
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We conducted transpapillary bile duct brush cytology and a biopsy of the hilar bile duct stricture for histopathological evaluation, which revealed numerous active trophozoites of G. lamblia but no malignant findings (Fig. 5).
MRCP (A) and DIC-CT (B) findings after metronidazole treatment. The images demonstrated dramatic improvement in the hilar bile duct stricture, and a cystic duct was detected.
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MRCP and DIC-CT were conducted to validate the efficacy of metronidazole therapy for biliary tract and disprove malignant disease. MRCP and DIC-CT demonstrated dramatic improvement in the hilar bile duct stricture, and a cystic duct was clearly detected (Fig. 6).