Brush biopsy was negative for malignancy. By exclusion, a diagnosis of recurrent pyogenic cholangitis was made. A right external and a left internal external percutaneous biliary drainage was placed with relief of symptoms. 

The best diagnostic clues are intra and extrahepatic biliary dilatation due to multilevel strictures and calculi within them without gallbladder calculi, a combination of variable density calculi/sludge, and regions of segmental liver atrophy secondary to chronic biliary obstruction.

Recurrent pyogenic cholangitis is a diagnosis made after exclusion of the common differential diagnosis for this condition, that include Intrahepatic stones secondary to biliary stricture of a known cause like previous surgery, trauma, sclerosing cholangitis, and cholangiocarcinoma.

The condition is usually associated with poor nutritional status and biliary parasitic infestation by Clonorchis sinensis and/or Ascaris lumbricoides and is primarily seen in Southeast Asians.