Differential diagnosis, investigations and treatment:
His biochemistry revealed a chronic mixed LFT derangement, with a
chronic hyperbilirubinaemia (60 micromol/L), and mildly elevated alanine
aminotransferase (42 IU/L), gamma glutamyl transferase (132 IU/L),
alkaline phosphatase (119 IU/L), albeit a normal white cell count
(8.0x10^9/L). Computed tomography (CT) abdomen and pelvis
demonstrated extensive pneumobilia, with a bridge of tissue between the
gallbladder and duodenum, suspicious for a fistula. The distal common
bile duct could not be visualised. CT cholangiogram to further delineate
the patient’s biliary anatomy revealed a fistula between the common bile
duct and duodenum (Figure 1), and hence was the suspected cause for his
LFT derangement.