[Intermittent bile duct obstruction as the first manifestation of a hepatocellular carcinoma]

For two months a 73-year-old woman had been suffering from intermittent colicky upper abdominal pain. She had also noted transient colourless stools and finally jaundice. Suspected cholelithiasis led to her admission for cholecystectomy. She had slight jaundice of skin and sclerae. Physical findings were unremarkable except for pain on epigastric palpation.

Sonography and computed tomography showed dilatation of the intrahepatic biliary passages and the proximal common bile duct, the latter containing a polycyclic mass that on endoscopic retrograde cholangiography appeared ovular and was surrounded by contrast medium. It was thought to be an intraductal bile stone.

Laparotomy, performed to remove the suspected stone, revealed a floating intraductal tumour, histologically a hepatocellular carcinoma. Further imaging discovered the primary hepatic tumour.

Although a smooth-walled contrast-sparing mass in the common bile duct usually denotes a stone, other structures may rarely imitate this picture, in particular atypical tumour growth.