Rapid cholestasis improvement as key strategy for steroid-refractory immune-related cholangitis: A case report

Steroid-refractory immune-related cholangitis, characterized by biliary obstruction, can be caused by drugs such as immune checkpoint inhibitors (ICIs). While there a few reports of sclerosing cholangitis after ICI administration, the therapeutic importance of local relief of obstruction has not been reported.

A 60-year-old female patient with biliary tract carcinoma and peritoneal metastasis developed elevated liver enzymes following four cycles of combined therapy with anti-PD-1 (Pembrolizumab) and a tyrosine kinase inhibitor. Magnetic resonance cholangiopancreatography indicated a thickening of the upper bile duct and pancreatic sections with narrow lumens. Digital peroral cholangioscopy revealed several erosions and surface vessel tortuosities coating the common bile duct. Endoscopic ultrasound revealed disruption of the middle lumen segment, with poorly defined wall structures. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated mucosal irregularities with tortuous surface vessels along the common bile duct. Angiographic imaging revealed irregular defects in the middle and lower common bile duct segments, while the proximal duct exhibited multifocal stenosis alternating with dilatation. Biopsy samples obtained via ERCP from the elevated mucosal lesions showed dense epithelial inflammatory cell infiltration, consistent with immune-related cholangitis. Both biliary enzymes can be decreased to a certain degree by corticosteroid and ursodeoxycholic acid therapy but are difficult to reduce to normal levels. Liver function normalized, and symptoms improved after local treatment for cholestasis (stent implantation).

Stent placement offers prompt alleviation of cholestasis and constitutes an effective therapeutic strategy for managing immune-related cholangitis.