PGY 961012

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PGY?????????961012

• ReportR1???
• Supervisor?????

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• 25942164
• ??xx??
• ????
• 53?

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Chief complaints

• Epigastric pain for 1 day

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Present Illness

• Pattern dull pain with jaundice without
  radiation.
• Accompanying symptoms were fever, chills, nausea
  and anorexia.
• Denied tarry stool or ulcer history.
• No aggravating factor.
• No relieving factor.
• Threre was no BW loss, or weakness.

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Past History

• Smoking Hxdenied
• Alcoholic drinking Hxdenied
• Betel nut Hxdenied
• Allergy historydenied
• OP Hx cholecystectomy about 20 years ago

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Physical Examination

• Abdomen
• Inspection flat, OP scar
• Palpation soft, no tenderness, no hepatomegaly,
  no splenomegaly
• Percussion tympanic, no knocking pain, no
  shifting dullness
• Ausculation normoactive bowel sounds, no bruit,
  no friction rub

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Lab Data

• CBC-- WBC12600 Hb13.3 MCV92.8 PLT206K
  Seg91.2
• Bio-- BUN14 Cr0.8 Glucose146 GOT101
  GPT119 Na138.1 K3.69
• Others--- Lipase130 Bilirubin (T/D)
  6.31/5.91

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Abdominal sonography

• Parenchymal liver disease
• CBD stones with CBD dilatation
• Bilateral IHDs stones with IND dilatation
• Ascites and pleural effusion
• s/p Cholecystectomy

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Impression

• CBD stones and bil IHD stones with severe biliary
  tree dilatation.

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Treatment

• Antibiotic treatment
• Emergent PTCD
• OP Choledocholithotomy EHL T-tube drainage

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• ???????????PTCD???????????
• ??Post-cholecystectomy?pt,??????

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Diagnostic approach to the patient with jaundice
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INTRODUCTION

• Plasma elevation of predominantly unconjugated
  bilirubin due to the overproduction of bilirubin
  (such as with hemolysis), impaired bilirubin
  uptake by the liver, or abnormalities of
  bilirubin conjugation
• Plasma elevation of both unconjugated and
  conjugated bilirubin due to hepatocellular
  disease, impaired canalicular excretion, or
  biliary obstruction.

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• Pancreatic or biliary carcinoma accounted for 20
  gallstones for 13 and alcoholic cirrhosis
  for 10 . (Dutch)
• jaundice can reflect a medical emergency in a few
  select situations, such as massive hemolysis
  (eg, due to Clostridium perfringens sepsis or
  falciparum malaria), ascending cholangitis,
  unconjugated hyperbilirubinemia in the neonatal
  period (which can lead to kernicterus), and
  fulminant hepatic failure.

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History Physical examination

• A history of fever, particularly when associated
  with chills or right upper quadrant pain and/or a
  history of prior biliary surgery, is suggestive
  of acute cholangitis.
• Symptoms such as anorexia, malaise, and myalgias
  may suggest viral hepatitis

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Lab Screening

• Normal liver enzymes suggest that the jaundice is
  not due to hepatic injury or biliary tract
  disease.
• A predominant elevation in serum ALK-P in
  relation to aminotransferases (AST and ALT)
  usually reflects biliary obstruction or
  intrahepatic cholestasis. right upper quadrant
  pain, prolonged PT that corrects with vitamin K,
  recent history of pale (acholic) stools

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• Predominant elevation of serum transaminase
  activity suggests that jaundice is caused by
  intrinsic hepatocellular disease.

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• Serologic tests for viral hepatitis
• antimitochondrial antibodies (for primary biliary
  cirrhosis)
• antinuclear anti-smooth muscle (sm), and
  liver-kidney microsomal (LKM) antibodies (for
  autoimmune hepatitis)
• Serum levels of iron, transferrin, and ferritin
  (for hemochromatosis)
• Serum levels of ceruloplasmin (for Wilson's
  disease)
• alpha-1-antitrypsin activity (for
  alpha-1-antitrypsin deficiency)

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Image Study

• Ultrasonography (US) The sensitivity of
  abdominal US for the detection of dilated bile
  ducts and biliary obstruction ranges in various
  studies from 55 to 91 percent
• Endoscopic ultrasound (EUS) EUS has a similar
  accuracy to ERCP for detection of small common
  bile duct stones but does not carry the risk of
  inducing pancreatitis. EUS is also highly
  accurate for detecting pancreatic tumors,
  especially small (lt3cm) tumors which are
  difficult to see with helical CT.

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• Helical CT scan Compared to US, helical CT
  offers a more comprehensive analysis of the liver
  and extrahepatic abdomen and pelvis. CT is not as
  sensitive in detecting cholelithiasis because
  only calcified stones are visualized.

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• Endoscopic retrograde Cholangiopancreatography
  (ERCP)
• It is clearly superior to US and CT for the
  detection of extrahepatic obstruction and it is
  the procedure of choice when there is suspicion
  of choledocholithiasis.
• ERCP is more expensive than US and CT and, as an
  invasive maneuver, is associated with a finite
  rate of mortality (0.2 percent) and complications
  such as bleeding, cholangitis, and pancreatitis
  (3 percent)

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• Magnetic resonance cholangiopancreatography
  (MRCP)
• In patients with dilated ducts, a MRCP
  cholangiogram is diagnostic in 90 to 100 of
  patients it also reveals the level of
  obstruction in 80 to 100 of cases and has a
  sensitivity and specificity of 90 to 100 for
  the detection of choledocholithiasis and bile
  duct stenosis.
• Stones larger than 4 mm are readily seen as a
  signal void within the bright signal arising from
  bile, but cannot be differentiated from other
  filling defects such as blood clots, tumor,
  sludge, or parasites.

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• Percutaneous transhepatic cholangiography
• Injection of contrast media provides close to 100
  percent sensitivity and specificity for the
  diagnosis of biliary tract obstruction

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Thanks for your attention