A rare case of biliary tract stenosis caused by intraductal varices diagnosed by single-operator per-oral cholangioscopy

A 58-year-old man was referred to the transplantation unit for “urgent” orthotopic liver transplantation because of decompensated alcoholic liver cirrhosis (Model for End-stage Liver Disease score: 26) with signs of portal hypertension: esophageal varices F2, gastric antral vascular ectasia, and splenomegaly. A blood test showed high levels of cholestatic enzymes (alkaline phosphatase 289 U/L), total bilirubin 12.6 mg/dL, and direct bilirubin 4.8 mg/dL. A CT scan and a magnetic resonance cholangiography revealed mild dilatation of the left intrahepatic duct and partial stenosis of the right intrahepatic biliary duct at the hilum suggestive of malignancy. The patient was immediately referred to our endoscopy unit by the surgeons for histologic characterization of the stenosis. An ERCP was performed, and the contrast cholangiography confirmed the previous findings. Moreover, 2 substenoses in the right intrahepatic biliary duct (at the hilar bifurcation and about 2 cm above the hilum) were revealed. Not completely confident about the diagnostic hypothesis of malignancy, because the surgeons had specifically requested obtaining biopsy specimens of the biliary strictures during ERCP, and based on the presence of portal hypertension signs, we decided to perform single-operator per-oral cholangioscopy (Video 1, available online at www.giejournal.org), which revealed 4 varices with red mucosal spots localized into the common bile duct (Fig. 1) and a benign stricture of the right intrahepatic duct at the hilar bifurcation. Moreover, a substenosing biliary varix was revealed after the progression on a guidewire passed into the right hepatic duct under cholangioscopic view.