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

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

3. 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.

4. 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

5. 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

7. 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.

8. 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

9. Clinical Manifestations
Fever
Loss of appetite
Jaundice
Nausea
Vomiting

10. 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.

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

12. 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.

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

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

15. Fluoroscopy