1208 Question: A 79-year-old man presented to his physician with a history of upper abdominal pain. The laboratory results included a white blood cell count of 12.0 10/L(normal, 4–10 10/L); total bilirubin of 14 mmol/L (normal, 0–21), and Creactive protein of 3.5 mg/dL (normal, 0–0.1). Ultrasonography showed a gallbladder wall of 5 mm with wall edema. He was diagnosed as having an incipient acute cholecystitis with mild inflammation and was initially treated with oral antibiotics. However, because no improvement was observed even by 10 days after the initial diagnosis, the patient was referred to our hospital. His past medical history included a diagnosis of diabetes mellitus and hypertension. Physical examination revealed jaundice, with tenderness in the right hypochondrium. Significant laboratory results included a white blood cell count of 17.5 10/L; total bilirubin of 85 mmol/L; direct bilirubin of 50 mmol/L (normal, 0–10); and C-reactive protein of 18.1 mg/dL. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed a short stenotic segment with upstream dilatation of the right hepatic duct (Figure A, arrow). The left hepatic duct was morphologically normal and endoscopic retrograde cholangiopancreatography confirmed the opening of the left hepatic duct (Figure B; RHD, right hepatic duct; LHD, left hepatic duct). What is the diagnosis? Look on page 1502 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
