Abstract

Introduction: 48 years old Iraqi female presented in 2012 with 4 months upper abdominal pain with elevation of the liver enzymes and arthralgia, 1 year after sleeve gastrectomy for obesity with 25 kg weight loss. Labeled as auto immune hepatitis and was started on prednisolone 20 mg and azathioprine 100 mg, attended our center for second opinion. Her past history was impressive for gestational diabetes and ulcerative colitis diagnosed before 15 years and treated for 1 year with remission. Strong family history of diabetes including father, mother, brothers, and her uncle has ulcerative colitis.
Investigations: Showed high liver enzymes, ALT 159, AST 286, ALP 455 and GGT 378, high eosinophil count. Imaging showed fatty liver with mild dilatation of the biliary system but CT scan, MRI, MRCP were not conclusive. ERCP showed features of sclerosing cholangitis with dominant stricture right hepatic duct, brushing and biopsy showed inflammatory changes. Colonoscopy showed pan colitis with ileal involvement, biopsy showed colitis with eosinophilic infiltration. She was treated with mesalazine, ursodiol, prednisolone and azathioprine. Regular follow over 4 years showed normal liver enzymes and last colonoscopy was reported as normal.
Conclusion: A patient developed elevated liver enzymes after sleeve gastrectomy for obesity. Imaging and endoscopies showed typical sclerosing cholangitis with dominant right hepatic bile duct stricture, colonoscopy showed pan colitis with high eosinophilic infiltration. The problem was the evaluation of the dominant stricture and the exclusion of malignancy.

Keywords: Gestational diabetes; Ulcerative colitis; Fatty liver; Cholangitis