Teaching Case

A 71-year-old patient presented with painless obstructive jaundice with intermittent fever. She reported light-coloured stools and dark urine.
Laboratory tests showed ALT 68 U/L, GT 876 U/L, total bilirubin 10 mg/dL, AST 90 U/L, WBC 4900 g/L, and HGB 110 g/L. The tumour markers AFP, CEA and CA 19-9 were normal.

Ultrasonography revealed dilatation of the intrahepatic and common bile ducts with multiple dilated and tortuous arteries lying around the head of the pancreas. But without showing any mass in the head of the pancreas or in the distal bile duct (Fig. 1)

MRI revealed dilatation of the intrahepatic and upper common bile ducts (Fig. 2) and demonstrated an atherosclerotic stenosis at the origin of the coeliac trunk (Fig. 3) and a dilated and tortuous artery lying over the anterior surface of the head of the pancreas responsible of the obstruction of the lower common bile duct (Fig. 4, 5).

Many different benign and malignant diseases can cause obstruction of the common bile duct. We present a very rare case with bile duct stenosis and obstructive jaundice following development of arterial collaterals of pancreaticoduodenal arcade due to coeliac axis stenosis.
Coeliac axis stenosis is a frequently encountered occlusive vascular disease. The proposed causes of coeliac axis stenosis are atherosclerosis, acute and chronic dissection, and compression of the coeliac axis by the median arcuate ligament [1].

Clinically significant ischaemic bowel disease caused by coeliac axis stenosis is rarely reported due to rich collateral circulation from the superior mesenteric artery (SMA).

Knowledge concerning the collateral vessels from the SMA in a patient with coeliac axis stenosis may be important for regional interventional procedures and surgical management [1, 2] .

In case of coeliac artery stenosis, the pancreaticoduodenal arcades are the major collateral routes from the superior mesenteric artery to the coeliac branches. In most cases both the anterior and posterior arcades develop as collateral pathways, but occasionally one arcade develops as a single dominant channel [3, 4], which is mainly formed by the anterior arcade.

But, it is very important to determine the difference between mechanical compression, seen in portal cholangiopathy caused by portal hypertension, portal cavernoma associated with cholangiopathy; and ischaemic cholangiopathy, an emergency mainly caused by disruption of blood flow through the hepatic artery, which most commonly occurs in people who have had a liver transplant.

For atherosclerotic coeliac artery stenosis, preservation of collaterals is often necessary, but may compromise surgical clearance and as a result, vascular bypass may be necessary to achieve clearance [5, 6].