A case of a 58 yo man

General Data
• R.T.,58 yo, M, Filipino
• Roman Catholic, from Toledo City, Cebu
• Born on November 25, 1960
• former construction worker
• Admitted for the first time at VSMMC last September
29, 2018 at 7 am for
Chief Complaint

Right Upper Quadrant Pain

History of Present Illness
One month PTA
• sudden onset of stabbing pain at RUQ
• radiates to the back
• pain score of 4/10
• aggravated by lifting heavy objects at work
• relief noted once the patient was able to rest or sit down
• icteric sclera on both eyes
• no other associated symptoms
 History of Present Illness
Two weeks PTA
• pain worsened, score of 6/10 which occurred usually in the morning,
after meals or at night before sleeping
• palliative factors include drinking coffee upon waking up and using 2-
3 pillows at sleep
• took herbal medicines, three times a day for one week but no relief
noted
• no other associated symptoms noted
• condition was tolerated and able to ADLs
History of Present Illness
One hour PTA
• sudden onset of stabbing pain, radiating to the back with a score of
10/10 was noted
• associated symptoms :4 episodes of bilious vomitus ,30ml per
episode
• condition was intolerable
• opted for admission
Past Health History
• 2016:donated blood
• August 2018: Acute Hepatitis, laboratory examinations were done
such as CBC and Ultrasound
• Prescribed with unrecalled medications, compliant and condition was
relieved
• No childhood illnesses
• Immunizations completed
• No previous hospitalizations or any surgical procedures
• No known allergies to food and drugs
Family History

• Arthritis both maternal and paternal side

• No history of HPN, DM, hepatobiliary disorders and malignancies
Personal and Social History
• construction worker for 38 years
• living with his children at Toledo, Cebu
• non-smoker
• no history of illicit drug use
• no other sexual partner aside from his wife
• alcohol drinker for 44 years
• 4 bottles of hard liquor and 3 cases of 500ml beer together with
his co-workmates once a week
Personal and Social History
• usual diet includes fruits and vegetables
• seldom eats meat
• doesn’t eat street foods
• defecates 3x day with a soft brownish yellow stool
• yellow colored urine for 5-6 times a day, 200mL
Personal and Social History
• sleeps at 12am or 1am after work
• wakes up at around 6 am
• no routine exercises
Physical Assessment
General Survey
• conscious, alert and coherent
• oriented to time, place, and person
• cooperative, relaxed, no respiratory distress
General Survey
Vital Signs:
•Blood pressure: 120/80 mmHg
•HR: 85 bpm
•RR: 20 cpm
•Temp: 36.3ºC
• Pain Score: 10/10

•O2 Sat: 95%

•Height: 162.56 cm
•Weight: 54 kg
•BMI: 20.4
Skin:
• Brown complexion, warm, good mobility and turgor
• No central cyanosis, ecchymoses and petechiae; jaundice noted

Head:
• Normocephalic, no deformities, no fractures, masses, tenderness.
• Hair is of average texture, evenly distributed.
• No lumps, no scars, scalp without lesions.
Eyes:
• No ptosis, exophthalmos, and blurring of vision
• Equal convergence, (+) consensual and direct pupillary
reflexes
• Extraocular muscles intact, 20/40 Jaegar Eye chart
• Icteric sclerae

Ears:
• Symmetric, no discharges, lesions, and masses
• No mastoid tenderness, can hear whispered voice
Nose and Sinuses:
• Nasal septum is midline, no sinus tenderness
• No nasal discharge

Mouth and Throat:

• Tongue is midline, yellowish tongue
• No soreness, swelling, and ulcers

Neck:
• Trachea is midline, no thyroid enlargement, no lymphadenopathy
Respiratory:
•Symmetric, regular respiratory rate, no intercostal retractions
• no tenderness, symmetric respiratory excursion
•tactile fremitus present and equal bilaterally
• resonant throughout peripheral lung fields
• vesicular breath sounds throughout peripheral lung fields
bronchovesicular breath sounds over the sternum and between scapulae
• no adventitious breath sounds
Cardiovascular:
•Adynamic precordium, no thrills, no heaves or lifts
• PMI is tapping, 1cm lateral to the midclavicular line in the 5th ICS
• Regular rate and rhythm
• S2 louder at the base, S1 louder at the apex
• No murmurs and bruits
Abdomen:
• Flat, symmetric, skin is of brown color
• No presence of bruises, no erythema
• No jaundice, no striae
• No dilated veins or no scars
• Normoactive bowel sounds (11 clicks per minute)
Abdomen:
• No palpable masses
• Liver span is 10 cm, right midclavicular line
• Spleen and kidneys non-palpable
• Negative for fluid wave test
• Negative for shifting dullness
• Negative for Rovsing’s sign
• Negative for Murphy’s sign
Genitourinary:
• not assessed
• DRE not performed
Peripheral Vascular:
• Black discoloration on right & left forearm noted
• No edema or no varicosities noted
• No signs of cyanosis
• CRT < 2 seconds
Peripheral Vascular:
Pulses
• Right and Left radial: +2 (brisk, normal)
• Right and Left brachial: +2 (brisk, normal)
• Right and Left Dorsalis pedis: +2 (brisk, normal)
Musculoskeletal:
• Symmetric, no deformities
• ROM (upper and lower extremities) without assistance
• no atrophy, no fasciculation, no wasting
• No tenderness, no tremors
• no pain and no swelling on joints
Nervous System:
Cerebral:
• Alert and well-groomed
• Speech and words are clear
• Oriented to time, place, and person

Cerebellar:
• Able to perform rapid alternating movements
• Able to perform finger-to-nose test
Cranial Nerves
• CN I- able to identify the smell of coffee
• CN II- able to read letters at 14 inches using Jaegar chart; 20/40
• CN II, III- Intact direct and consensual pupillary light reflexes
• CN III,IV,VI- Intact EOM
• CN V-
• Sensory: able to identify light touch to forehead, cheeks and chin
• Motor: able to move jaw
Cranial Nerves
• CN VII – able to do facial expressions
• CN VIII – able to hear whispered voice
• CN IX, X – able to swallow
• CN XI – able to shrug shoulders against resistance
• CN XII – tongue is midline upon protrusion
Sensory
• Pain, temperature, light touch senses intact
• Able to identify number in stereognosis test
• Intact discriminative sensations
Motor
• No involuntary movements
• Muscle bulk: no muscle atrophy noted
• Muscle tone: intact
• Muscle strength: 5/5 in both extremities
Reflexes
Biceps Triceps Brachioradialis Quadriceps Achilles

Left
Not Assessed 2 2 2 2

Biceps Triceps Brachioradialis Quadriceps Achilles

Right
2 2 2 2 2
IMPRESSION:
Obstructive Jaundice probably secondary to
Choledocholithiasis
Basis:
• RUQ Pain, radiates to the back, occurs after meals and at night
• Icteric Sclerae
• Jaundice
• Yellowish mucous membranes
• Bilious vomitus
• Risk factor: Alcoholism
Differential Diagnosis
 Chronic Cholecystitis Acute Pancreatitis Acute Hepatitis
(Biliary Colic)
Basis for • RUQ pain, radiating to the • Jaundice • RUQ pain
ruling in: back, occurs after meals and • Icteric Sclerae • Jaundice
at night • Yellowish mucous • Icteric Sclerae
• Alcoholism membranes • Yellowish mucous
• Alcoholism membranes
• Alcoholism

Basis for • No jaundice • No RUQ pain • No bilious vomitus

ruling out: • no icteric sclerae
• no yellowish mucous
membranes
• no bilious vomitus
• do ultrasound
• order serum markers • do liver panel and
(pancreatic amylase & liver function tests
lipase
• do contrast -enhanced
CT scan
DIAGNOSTIC MODALITIES
Laboratory Tests
Liver Function Tests
• AST and ALT
• ALP & GGT
• Bilirubin

Amylase & Lipase

Complete Blood Count

• WBC Count, Atypical Lymphocytes
Blood Urea Nitrogen (BUN)

Creatinine

Urinalysis

Fecalysis
Hepatitis Panel
• Blood test used to find
markers of hepatitis
infection
• A blood sample drawn
from a vein in your arm
Imaging
Ultrasonography
• Initial investigation of suspected biliary tree disease
• Show stones in the gallbladder
• Sensitivity and specificity of >90%
• Determine the size of the common bile duct
• Determine the site and the cause of obstruction
 Advantages Disadvantages
• Non-invasive • Dependent upon the
• Painless skills and the experience
• No radiation of the operator
• Adjacent organs can be • May be difficult on:
examined at the same obese patients
time patients with ascites
patients with distended
bowel
Stones seen on Ultrasound
• Acoustically dense
• Reflect the ultrasound
waves back to the
ultrasonic transducer
• Move with changes in
position
• Produce an acoustic
shadow
• Extrahepatic bile ducts are well
visualized
• Obstruction caused by stones:

Dilated common bile duct

(>8mm in diameter)
small stones in the
gallbladder
MRI with magnetic resonance
cholangiopancreatography (MRCP)
• Single non-invasive test for
diagnosis of biliary and pancreatic
duct pathology
• Sensitivity and specificity of 95% &
89%
• Detects choledocholithiasis
>5 mm in diameter
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
• Gold standard for diagnosing CBD stones
• Success rate of CBD cannulation and cholangiography
is >90%
• Morbidity of <5% (mainly cholangitis and
pancreatitis)
• Requires intravenous (IV) sedation
Side-viewing Fluoroscopy
endoscope
• Advantages of ERCP
include:

Direct visualization of
the ampullary region
Direct access to the
distal CBD
• Diagnostic and therapeutic procedure of choice for:

Stones in the CBD, associated with obstructive

jaundice
Cholangitis
Gallstone pancreatitis

• Sphincterotomy and stone extraction can be

performed
TREATMENT
• Endoscopic Retrograde Cholangiopancreatography (ERCP)
- direct visualization of the ampullary region and
direct access to the distal common bile duct
• Laparoscopic Common Bile Duct Exploration
- cost effective, efficient, minimally invasive
• Open Common Bile Duct Exploration
- used when endoscopic and laparoscopic means are
not feasible for documented common duct stones
• Choledochoduodenostomy
• Roux-en Y choledochojejunostomy
- CBD > 2cm diameter