Jaundice/ choledocholithiasis
May 23, 2019

CASE

54y/o female patient , k/c of HTN and DM , presented with Jaundice and abdominal pain for 3days.

 


 

QUESTIONS

  • What are important history points ?
  • What are you going to look for on examination?
  • What are DDx?

 


 

HISTORY

  • Onset , course , duration, previous similar hx
  • History of fever, itching
  • Associated symptoms of abdominal pain , N/V, change in stool or urine color
  • Constitutional symptoms
  • Previous history of hepatitis , liver disease , GB stones , hematological disease
  • History of alcohol , drugs

 


 

EXAMINATION

  • Vitals
  • Mental status ( ? Hepatic Encephalopathy)
  • Stigmata of chronic liver disease
  • Signs of acute cholecystitis ( RUQ tenderness, Murphy sign
CLD
http://qncobatliver.com/tanda-penyakit-liver-sudah-parah/ciri-liver/

 


 

DDX

  • Jaundice classified to either ( pre-hepatic, hepatic, post-hepatic) or ( Unconjugated vs conjugated )

CASE CONT.

Patient had associates RUQ pain , that increase with fatty food , with no previous history of fever , hepatitis , CLD, no alcohol or drug history

Examination; vitally stable , -ve Murphy sign and no signs of CLD Labs ; had high bilirubin ( mainly conjugated) and ALP , with normal other LFT, normal CBC imaging : US showed CBD of 8mm with stones inside. GBS

QUESTIONS

  • What is the management ?
  • Would you do MRCP ?

CHOLEDOCHOLITHIASIS RX

  • First need to classify patient into ( high , intermediate , low risk )
  • High risk = ERCP
  • intermediate = MRCP / ERCP
  • Low risk = none
  • Classification is based on evidence , which are also classified into ( very strong , strong , and moderate )
  • High = 1 very strong / or 2 strong
  • Intermediate = [ ( all evidence ) – ( high ) ]
  • Low risk = 0 evidence
Predictors of choledocholithiasis