Interactive Case 4B Matias; Maulion; Medenilla; Medina; Medina; Mejino; Melgarejo; Mendoza, Alvin, Diana and Donn

K.F. 80 year old female Informant: patient Chief Complaint:   Chief Complaint: yellowish discoloration of the skin

HISTORY OF PRESENT ILLNESS 2 months PTC gradual loss of weight decrease in appetite dull abdominal pain in the epigastric area No consult was done, no medications taken 1 week PTC yellowish discoloration of skin & sclerae progression of the abdominal pain acholic stools Persistence prompted present consultation.

PERTINENT PHYSICAL EXAMINATION BP 140/90, PR 89 bpm, RR 20 cpm Temp 36.5 °C Warm moist skin, (+) jaundice Pale palpebral conjunctivae, icteric sclerae No naso-aural discharge Moist buccal mucosa, yellowish frenulum Supple neck, no palpable cervical lymph nodes Flabby, soft and non-tender abdomen Normoactive bowel sounds Pulses full and equal No cyanosis, no edema

SALIENT FEATURES 80- year old Female Gradual weight loss Decrease in appetite Dull abdominal pain in the epigastric area, which later progressed Yellowish discoloration of the skin and sclerae Yellowish frenulum Acholic stools

Choledocholithiasis Presence of a gallstone in the common bile duct The stone may consist of bile pigments or calcium and cholesterol salts About 15% of people with gallstones will develop stones in the common bile duct Risk factor: a previous medical history of gallstones However, choledocholithiasis can occur in people who have had their gallbladder removed.

Clinical Manifestations Abdominal pain - sharp, cramping, or dull - may spread to the back and subscapular area - get worse after eating fatty or greasy foods - may occur within minutes of a meal

Clinical Manifestations Fever Loss of appetite Jaundice Nausea Vomiting

Ultrasound Abdominal ultrasound scans show a mildly dilated common bile duct measuring 8 mm in diameter (arrow). An echogenic calculus with acoustic shadowing is visible in the distal portion of the common bile duct (arrow). There is no intrahepatic biliary dilatation. The gallbladder appears contracted (arrow). These findings are consistent with choledocholithiasis resulting in early or incomplete biliary obstruction.

Ultrasound ultrasound findings - dilated common bile duct (cbd) with small stone located distally (arrow). posterior acoustic shadowing (arrowhead)

CT Scan Common bile duct stone - target sign On contrast-enhanced helical CT scan, choledocholithiasis is represented as central density (arrowhead) surrounded by hypoattenuating ampulla of Vater (arrow). In this particular scan, stone is seen as heterogeneous with center showing lower density.

CT Scan Stone in distal common bile duct - rim sign Faint rim of increased density (arrow) along peripheral margin of low-density calculus

CT Scan Common bile duct stone - crescent and target signs stone (arrow) completely surrounded by bile

Fluoroscopy