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Hilary Sanfey,
Sanfey MD
University of Virginia
Mrs. J.S.
Your patient in the ER is a 55 yearyear-old
female with a short history of upper
abdominal discomfort and chills. Her family
noticed she was jaundiced.
History
Focused HPI and relevant symptoms
Medications particularly those associated with
liver damage e.g. fluconazole,
fluconazole, acetaminophen
Alcohol
A
use
I.V. drug use
History of biliary surgery and/or malignancy
Previous transfusions / pregnancies
Occupational
p
exposure
p
e.g.
g to solvents
Characterization of
symptoms
Temporal
p
sequence
q
Alleviating /
Exacerbating factors:
Associated
signs/symptoms
Pertinent PMH
ROS
MEDS
Relevant
R l
tF
Family
il Hx
H .
Hx.
History
Characterization of Symptoms
Abdominal Discomfort
Chills
Shiveringg and unable to gget warm
Jaundice
Associated with pruritus
pruritus,, dark urine and pale stools
History
Temporal sequence
Pain
Chills
Noticed 24 hours after onset of pain
Jaundice
Noticed by family on day of visit
Historyy
Alleviating / Exacerbating factors:
None
N
noted
t d
PMH
MVA in 1985 received a blood transfusion
Two children uneventful pregnancies
Appendectomy 1970
ROS
Non contributory
MEDS
Antacids (OTC) for indigestion which has been
increasing in frequency
History
Relevant Family Hx
Hx..
Non relevant
Specifically no other family members have been
j
jaundiced
di d or ill
Social History
History
Associated signs/symptoms:
g
y p
Pale stools
Pruritus
Nausea
Anorexia
Weight loss nil
Chills
Differential Diagnosis
Based on History and Presentation
Ch l iti
Cholangitis
Cholecystitis
Cholelithiasis / choledocholithiasis
B i or malignant
Benign
li
bili
biliary
stricture
i
Pancreatic or biliary tumor
Hepatocellular jaundice
Hepatitis B / C
Alcoholic cirrhosis
Metastatic liver disease
Physical Examination
What would you look for?
Physical Examination
What would you look for?
Vital signs
General examination should take note of the
presence or absence of jaundice, excoriation,
palmar erythema, spider nevae,
nevae, or tremor
Focused physical examination should include
examination of the abdomen for tenderness,
masses, hepatosplenomegaly or ascites.
ascites.
Physical
y
Examination,, Patient J.S.
HEENT:
NC
GenitalGenital-rectal: NC
Chest:
NC
Neuromuscular: NC
CV:
NC
Breast:
NC
Appearance:
In mild distress
Overweight
Jaundiced
Excoriation of skin
38.9
100/min
110/80
Epigastric tenderness
Mild distension
Decreased bowel sounds
No ascites or rebound
No masses
Rectal exam
shows gray stool (Guaiac
(Guaiac negative)
Would
Wou
d you likee to
o revise
ev se you
your
Differential Diagnosis?
Cholangitis
Cholecystitis
y
Cholelithiasis / choledocholithiasis
Benign or malignant biliary stricture
Pancreatic or biliary tumor
Laboratory
What studies would you obtain?
Laboratory
CBC
Comprehensive
C
h i metabolic
t b li panell (includes
(i l d
electrolytes and LFTs)
INR
Blood cultures
37%
(35 47)
WBC
16,000 K/Ul
(4--11)
(4
Sodium
142 MMol/L
(135--145))
((135
Potassium
3.7
MMol/L
(3.5--5.0)
(3.5
Chloride
101 MMol/L
(98--107)
(98
CO2
28
(19--27)
(19
INR
16
1.6
MMol/L
(0.0(0 0-1.2)
(0.0
1 2)
14 mg / dl
Conjugated bili
10.5 mg / dl
Alk phos
800 U/L
AST
177 U/L
(13 39 U/L)
ALT
195 U/L
(9 52 U/L)
A l
Amylase
208 IU/L
Lipase
1.5 IU/L
(0 1.5 I U/L)
BUN
18 mg / dl
(7 25 mg / dl)
Creatinine
1.1 mg / dl
Lab Results
WBC
An elevated WBC with left shift is consistent with
infection or inflammation
Amylase / Lipase
Many acute abdominal conditions produce a chemical
hyperamylasemia. Elevated amylase in setting of
normal lipase is unlikely to be acute pancreatitis
INR
The
h PT ((INR)) may be
b prolonged
l
d in
i patients
i
with
ih
obstructive jaundice due to malabsorbtion of Vitamin
K
NPO
I V fluids
I.V.
I.V. broad spectrum antibiotics
N
Nasogastric
i tube
b if vomiting
i i or distended
di
d d
Analgesia
Studies
RUQ US
Angiogram
HIDA Scan
OTHER:
CT Scan:Abd/Pelvis
CT Scan: Other
MRI
PET SCAN
Extremity Film
Bone Scan
US Pelvis
MRCP
Studies Results
Discussion of imaging
g g studyy
Ultrasound is the initial study of choice in most
patients with suspected biliary disease. For gallstones
the sensitivity and specificity are 95%. U/S can detect
stones as small as 3mm in diameter and is highly
sensitive
iti for
f detecting
d t ti intra
i t andd extra
t hepatic
h ti biliary
bili
dilatation but not CBD stones.
Ultrasound of Gallbladder
Radiology
The ultrasound demonstrates:
Cholangitis
Cholelithiasis / Choledocholithiasis
Benign or malignant biliary stricture (distal
CBD)
Pancreatic tumor
What next?
1.
2.
3.
4.
Additional Imaging?
Endoscopy?
OR?
Other?
What next?
ERCP vs.
s PTC
PTC
ERCP Findings
ERCP (Endoscopic Retrograde CholangioPancreatography) demonstrates a stone in the
common bile at the ampulla. A sphincterotomy
i performed
is
f
d andd the
th stone
t
is
i extracted
t t d
What potential complications may occur
after ERCP?
ERCP
Complication
p
rate is 10%
Bleeding
perforation
Duodenal p
Pancreatitis
Final Diagnosis
1. Cholangitis secondary to
2.
2 Choledocholitiasis
What are ?
Charcots triad
Reynaldss pentad
Triangle of Calot
ANSWERS
Charcot
Charcotss triad
Right upper quadrant pain
Jaundice
Fever / chills
Reynoldss pentad
I addition
In
dditi tto th
the above
b
ttriad
i d th
the patient
ti t may h
have
pus in the biliary tree acute suppurative
cholangitis with
cholangitis
Hypotension
Mental confusion
Answers
Triangle
g of Calot
This is the three sided area bordered by the
inferior margin of the liver, cystic duct and
common hepatic duct. The cystic artery and
right hepatic artery traverse this triangle
Further Management
24 hours after the ERCP the p
patient has
improved LFTs and is now afebrile with a WBC
of 12,000.
What ne
next?
t?
Further Management
Continue IV fluids
Continue IV antibiotics
Correct INR
Laparoscopic Cholecystectomy
(vs. open cholecystectomy) is now
the procedure of choice.
Answer
To minimize the p
possibility
y of developing
p g
hepato--renal failure
hepato
Drug related
D
l t d
Pneumonia
M.I.
D.V.T.
QUESTIONS ?
Should patients with asymptomatic gallstones have an
elective cholecystectomy?
cholecystectomy?
QUESTIONS ?
In a jjaundiced patient
p
with an enlarged
g palppalp
p
pable gallbladder the most likely diagnosis is:
Choledocholithiasis
Carcinoma of the head of the pancreas
Explain your answer
Courvoisiers Law
In the p
presence of jaundice
j
a palpable
p p
gallbladder is unlikely to be due to stone
If the obstruction was due to stone, the thick
walled gallbladder would probably not distend
QUESTIONS?
Q S O S?
Acknowledgment
The preceding educational materials were made available through the