January 2019 Question 1

A 31-year-old man is seen for a 1-week history of epigastric pain and scleral icterus. One month earlier, he developed diarrhea and fatigue, which has continued to persist. He denies any prior medical problems, though he admits he has not seen a doctor in years. He is currently visiting family in the United States, but he resides in South Africa. His laboratory tests are as follows: total bilirubin, 3.5 mg/dL; direct bilirubin, 2.9 mg/dL; alkaline phosphatase, 720 U/L; ALT, 105 U/L; AST, 117 U/L; albumin, 2.1 g/dL; INR, 1.2; HIV viral load 450,000 copies/mL, CD4 count, 25 cells/mm3. An abdominal ultrasound shows intra- and extrahepatic ductal dilation and an ERCP shows strictured intrahepatic ducts with papillary stenosis.