**3.3 Clinical presentation**

*Cells of the Immune System*

A 39-year-old Caucasian female with a body mass index (BMI) of 36 and a history of hamishoto's thyroiditis, presented to the ED with worsening itching and jaundice. Patient's thyroid function tests were within normal range. Cholesterol was 310 mg/dL, ALP 318, ALT 24, AST 21, and GGT 1120 U/L. Liver US showed no signs of bile duct dilation. Anti-mitochondrial antibody (AMA) titers were elevated. Patient was diagnosed with primary biliary cholangitis (PBC) and was started on ursodiol.

Now what do we take from these three different cases, all of whom presented or were seen to have jaundice? To understand the different presentations of jaundice,

The causes of jaundice can be classified in different ways such as pre-hepatic (hemolytic), hepatic (hepatocellular), and post-hepatic (obstructive) (see **Table 1**). Now, we can differentiate between them in many laboratory and clinical findings

Understanding the classification, differentiating lab results and approach towards jaundice is important. **Figure 1** can help you as a guide in term of what to do and what to expect. It is helpful to keep it in mind as we go through the

Now that we have established the approach towards obstructive jaundice. We

EC is an uncommon, benign, self-limiting cause of biliary structure characterized by transmural eosinophilic infiltration of the biliary tree which may result in obstructive jaundice. The severity and prognosis vary considerably and may affect

The cause of eosinophilic cholangitis is unknown. In some reports, hypereosinophilic syndrome (HES) has been mentioned as possible cause. The diagnosis of

1.Sustained eosinophilia (more than 1500 eosinophils per cubic millimeter) for

2.The absence of other causes of eosinophilia, including parasitic infections and

Since all reported cases do not appear to have completely met the criteria for HES, the relationship between eosinophilic cholangitis and HES is uncertain. An allergic mechanism is thought to play a key role in the development of eosinophilic cholangitis, hence the name. In most reported cases, there was an increased level of IgE, interleukin 5, or eosinophilic cationic protein. The latter is one of the major cationic granules released by activated eosinophils and is the most

(see **Tables 2** and **3**) and know how to approach it (see **Figure 1**).

**3. Approach to eosinophilic cholangitis**

will dig deeper into eosinophilic cholangitis.

part or the entire biliary tree mimicking malignancy [5].

hypereosinophilic syndrome is based on the following criteria [6]:

The exact pathogenesis is poorly understood.

3.Signs and symptoms of organ involvement.

**2.3 Case-3**

let us classify it.

chapter.

**3.1 Introduction**

**3.2 Pathogenesis**

allergies.

more than 6 months.

**174**

Nash et al. conducted a study where they collected around 23 cases of EC revealing that this disease [9]:


One of the challenges that accompanies eosinophilic cholangitis is the fact that it can present with a multitude of nonspecific signs and symptoms that makes it hard to differentiate from malignancy such as:


At this point, it can be anything and a more in-depth investigation is required. So where do we go from there?
