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A new biliary duct (BD) stricture raises questions about the presence of malignancy, especially with a history of metastatic pancreatic cancer. A few cases of colloid carcinoma (CC) of the pancreas have been published, but none have described recurrence in the biliary tract. We report a case of intrahepatic biliary CC that recurred after two years after the last dose of immunotherapy for pancreatic CC. In addition to a unique biliary cancer case presentation, this case raises awareness of the best strategy for cancer surveillance.

A 50-year-old man presented to the emergency department with dark urine and altered mental status. Upon examination, the patient was found to be jaundiced with normal vitals. Laboratory investigation demonstrated macrocytic anemia and abnormal liver function tests. During his hospitalization, he developed delirium tremens in addition to the discovery of acute hemolytic anemia, hypercholesterolemia, and hypertriglyceridemia. Therefore, he was diagnosed with Zieve's syndrome (ZS), a rarely reported disease characterized by hemolytic anemia, cholestatic jaundice, and transient hyperlipidemia. Physicians encountering acute hemolytic anemia in a patient with concomitant acute liver injury should consider ZS as a differential diagnosis, as prompt recognition of the syndrome can help prevent unnecessary procedures and therapy.

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