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ICI Cholangitis — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyICI CholangitisSCE Medical Oncology

A 58-year-old woman on ipilimumab + nivolumab for melanoma develops immune-related cholangitis (elevated ALP 8× ULN, GGT 12× ULN, bilirubin 60 µmol/L). MRCP shows diffuse intrahepatic bile duct wall thickening without obstruction. What is this pattern?

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Correct answer: E — ICI-related sclerosing cholangitis — a variant of ICI hepatotoxicity affecting bile ducts rather than hepatocytes; it can mimic primary sclerosing cholangitis and may be less responsive to corticosteroids than hepatocellular ICI hepatitis

ICI-related cholangitis/sclerosing cholangiopathy is a distinct pattern of ICI hepatotoxicity characterised by cholestatic LFTs (elevated ALP/GGT > ALT), bile duct wall thickening/irregularity on MRCP, and often a more indolent but steroid-resistant course compared with hepatocellular ICI hepatitis. Management includes ICI discontinuation, ursodeoxycholic acid (adjunctive), corticosteroids (may be less effective than for hepatocellular injury), and consideration of mycophenolate or azathioprine for steroid-refractory cases. Biliary stenting is not usually indicated.

Reference: ESMO 2024 irAE Management; Deshpande et al Hepatology 2021