2 867B-1 Right Case Reports in Medicine Figure 1: ERCP showing irregular wall contours, variable intrahep- atic stenoses, and two distal common bile duct stones. Figure 3: Concentric ﬁbrosis and portal tract inﬂammation (inter- mediatepower view). Figure 2: Marked expansion of portal tracts by ﬁbrosis and inﬂam- mation (low-power view). length and dilated intrahepatic and common bile duct. Further, relevant blood tests showed that the perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) were present while other autoimmune antibody (including antin- uclear, antimitochondrial, antismooth muscle antibody), HBsAg, anti-HCV and HIV antibody were absent. During the next 3 days, his hemoglobin was topped up to 8.7 g/dL by two units of packed cell. Then endoscopic ret- rograde cholangiopancreatography (ERCP) was performed and found multiple irregularities over bilateral intrahepatic bile ducts: common bile duct was not dilated but with two small stones distally (Figure 1). These stones were extracted after papillotomy. The liver biopsy was also performed and revealed that the portal tracts had mixed inﬂammatory inﬁltrate, some interlobular bile ducts having concentric, laminated (onion-skin) ﬁbrosis around them, and focal bile ductular proliferation. These were consistent with primary sclerosing cholangitis, Stage III (Ludwig) (Figures 2, 3 and 4). Therefore, this gentleman was diagnosed to have primary sclerosing cholangitis coexisting with ulcerative colitis. He was put on medications including ursodeoxycholic acid Figure 4: Atrophic interlobular bile duct (high-power view). 500 mg bd, enteric coated mesalazine 2000 mg bd, and iron supplement. He was regularly followed up for the past 4 months and his condition was stable in which his hemoglobin remained static with hemoglobulin level around 9 g/dl and the alkaline phosphatase improved to 204 U/L. 3. Discussion The diagnosis of primary sclerosing cholangitis (PSC) in this patient is established by the biochemical proﬁle of chronic cholestasis, typical strictures and pruning of the biliary tree upon cholangiography, and ring ﬁbrosis around the bile ducts in liver biopsy. The coexisting iron deﬁciency anemia should lead to the suspiciousness of coexisting inﬂammatory bowel disease which was conﬁrmed by colonoscopy in our case. Firstly reported by Dr. K. Delbet in 1924 by constellation of symptoms including pruritus and cholestatic liver pattern, PSC is characterized pathologically by the progressive, ﬁbrous-stenosing and obliterating, predominantly segmental inﬂammation of the intra- and extrahepatic bile ducts and