Green Sludge: Intraductal Papillary Mucinous Neoplasm of the Bile Duct Presenting with Intermittent Biliary Obstruction Due to Abundant Mucus

Excerpt

A 71-year-old man with a past medical history of rheumatic fever and hypertension was initially evaluated at an outside hospital with a history of episodic right upper quadrant abdominal pain associated with fever, jaundice, and weight loss. On the basis of multiple evaluations during these episodes, a tentative diagnosis of recurrent cholangitis was reached. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and extraction of “sludge” and subsequently underwent cholecystectomy for presumed gallstone disease, but no gallstones were identified and gallbladder pathology was unremarkable. Despite the cholecystectomy, recurrent pain and jaundice persisted, leading to two additional ERCPs over the subsequent 9 months with “sludge” again extracted during the procedures. Persistence of symptoms combined with a weight loss of 30 lbs prompted referral to the Stanford gastroenterology clinic for a second opinion. …