Case Presentation: A 53-year-old Sierra Leonean man with schistosomiasis presented with two months of jaundice and abdominal distension. Two years earlier, he was diagnosed with schistosomiasis complicated by non-cirrhotic portal hypertension, splenomegaly, and esophageal and gastric varices. Initially on this presentation, this patient was septic due to MDRO E.Coli bacteremia secondary to spontaneous bacterial peritonitis and was newly diagnosed with cirrhosis attributed to chronic schistosomiasis.
Notably, this patient presented with common bile duct obstruction with total bilirubin of 27mg/dL (direct bilirubin 12.4mg/dL) caused by extrinsic compression by a large cholecystic varix encircling the narrow portion of the common bile duct. These ectopic varices are a distinctly uncommon complication of portal hypertension, confirmed by both MRCP and ERCP. The patient’s hyperbilirubinemia resolved within two days after common bile duct stent placement.

Discussion: Obstructive jaundice is a common clinical scenario, however extrinsic compression of the common bile duct by a cholecystic varix is a rare entity. This patient’s presentation of post-hepatic obstructive jaundice with severe hyperbilirubinemia was similar to that of more prosaic processes such as common bile duct intrinsic or extrinsic obstruction by stone or pancreatic head mass, for instance. Gallbladder varices form due to collaterals between the cholecystic and pericholecystic venous systems which are usually associated with portal vein thrombosis. Similar to esophageal or gastric varices, the pathophysiology of cholecystic varices involves portal hypertension leading to dilation and reversal of blood flow in these portal vessels. Our case suggests that it may be prudent to perform MRCP prior to ERCP or other interventions to evaluate for atypical varices.

Additionally, our case highlights chronic schistosomiasis, a known but rare cause of cirrhosis. If untreated, the migration and subsequent entrapment of eggs in various organ systems leads to the late phase of disease, often years after initial exposure. Hepatosplenic involvement is common in chronic infection from any of the main Schistosoma species, specifically following entrapment of schistosome eggs in the portal vessels causing inflammation and collagen deposition. This fibrosis and subsequent portal hypertension are distinct from most etiologies of cirrhosis, which are primarily hepatocellular processes. Early diagnosis and treatment of schistosomiasis is therefore imperative to avoid these late sequalae.

Conclusions: We present the first documented case of cholecystic varices causing extrinsic biliary obstruction due to schistosomiasis sequalae. Although rare, it is a possible cause of hyperbilirubinemia which can be treated successfully with stent placement. Chronic schistosomiasis infection should be considered for patients from endemic regions presenting with portal hypertension and cirrhosis.

IMAGE 1: Note collateral vessel encircling the narrow portion of the CBD