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.