1. Differential Diagnosis
Farie

2. Differential Diagnoses

3. TB Lymphadenitis
Chronic specific granulomatous inflammation of the lymph node with caseation necrosis
Right hypochondriac pain, epigastric pain and tenderness, jaundice, weight loss, icterisia
Philippines is endemic for Tuberculosis
Involvement of abdomen (one of the common sites of extrapulmonary TB)
No associated or antecedent pulmonary TB (Majority of patients do not have associated or antecedent pulmonary TB)
No splenomagaly or ascites

4. Peribiliary Cancer
Tumor arising from the distal common bile duct, duodenum and ampulla of Vater
Jaundice - presenting symptom; intermittently wax and wanes because of necrosis and sloughing or pressure opening of minimally obstructed duct
Progressive weight loss
Abdominal pain - midepigastric or right hypochondriac
Loss of appetite

5. Choledocholithiasis Epigastric pain that come and go, cramping.
The presence of stones in the common bile duct
Epigastric pain that come and go, cramping.
Jaundice, tea-colored urine and light-colored stools
Female
64 y/o
It is the presence of gallstone in the common bile duct. This might have resulted from passage of gallstones into the CBD in ~ 10-15% of patients with cholelithiasis. Bile-duct stones can also be formed in the absence of gallbladder stones, and such primary bile-duct stones are more common in East Asian countries than in the Western world. Choledocholithiasis may remain asymptomatic for years, may pass spontaneously into the duodenum, or (most often) may present with biliary colic or a complication such as in this case.
Epigastric pain that come and go, cramping.
Jaundice, tea-colored urine and light-colored stools (Gradual obstruction of the CBD over a period of weeks initially manifests as jaundince. As biliary obstruction causes progressive rise in intrabiliary pressure, hepatic bile flow is suppressed, and reabsorption and regurgitation of conjugated bilirubin in to the bloodstream occur.
Female (women are more likely to develop cholesterol gallstones than men and this appears to be attributable mainly to estrogen, which increases biliary cholesterol secretion. pigment gallstones affect men and women equally)
64 y/o (incidence of common duct stones increases with increasing age of the patient, so that up to 25% of elderly patients may have calculi in the common duct at the time of cholecystectomy)
Inc. bilirubin levels (Serum bilirubin level >85.5 umol/L (5mg/dL)
Inc. SGPT, SGOT (2- to tenfold elevation especially in association with acute obstruction)
Alkaline phosphatase (almost always elevated in biliary obstruction)

6. HIV infection increases likelihood
Condition
Ruling Out Parameters
Other Tests
Tuberculous Lymphadenitis
Low incidence
2:1 male predominance
HIV infection increases likelihood
Palpable liver
Bilirubins
Ultrasound/CT Scan
ERCP
CEA, Ca 19-9
Peribiliary Cancer
Choledocholithiasis
TB:
Low incidence (Biliary obstruction from enlarged TB lymph node as a cause of jaundice is very rare)
2:1 male preponderance with the majority falling within the year-old age group with a peak age incidence in the second decade of life in both sexes .
HIV infection (increases susceptibility)
Palpable liver below the costal margin
Inc. bilirubin levels, inc. SGPT, SGOT, alkaline phosphatase, dec. hgb
UTZ – hypoechgenic lesion, enlargement of lymph nodes, dilation of CBD
CT scan – low density mass with a contrast enhancing solid rim
ERCP – narrowing of distal CBD
This diagnosis be considered in the context of a mass in the head of the pancreas, after the exclusion of malignancy and other biliary inflammation
FNAB – may be useful but not definitive
Cytology of CBD aspirate by ERCP – may be confirmatory in the presence of AFB
PCR of the aspirate may be diagnostic
Histological findings of a granuloma with caseation necrosis
Normal CEA and c 19-9

7. Bleeding and clotting times Urinalysis CA 19-9
Condition
Ruling Out Parameters
Other Tests
Tuberculous Lymphadenitis
Dyspepsia and vomiting
Diarrhea
Pruritus
Gastrointestinal bleeding
Acute Pancreatitis
Couvosier sign
Hepatomegaly
Palpable fixed epigastric mass
SGPT and SGOT
Alkaline phosphatase
CBC
Prothrombin time
Bleeding and clotting times
Urinalysis
CA 19-9
Peribiliary Cancer
Choledocholithiasis
Dyspepsia and vomiting - compromise of duodenal lumen leads to gastric outlet obstruction
Diarrhea - due to pancreatic duct obstruction
Pruritus
Gastrointestinal bleeding - more common in unresected patients
Acute Pancreatitis - more common in unresected lesions
On PE,
Couvosier sign - severe jaundice with a palpable, non-tender gallbladder; indicating obstruction of biliary passages from something other than a gallstone, possibly a tumor
Hepatomegaly
Palpable fixed epigastric masses
Findings on laboratory work up would show:
Elevated SGPT and SGOT
Elevated alkaline phosphatase
CBC - anemia
increased prothrombin time
prolonged bleeding and clotting times
urinalysis - may show bile pigments
elevated CA 19-9

8. No signs of cholecystitis
Condition
Ruling Out Parameters
Other Tests
Tuberculous Lymphadenitis
No signs of cholecystitis
Not totally ruled out by history and PE
Serum bilirubins
Ultrasound
CT Scan
ERCP
Peribiliary Cancer
Choledocholithiasis
The maximum bilirubin level is seldom >256.5 umol/L (15.0 mg/dL) in patient with choledocholithiasis unless concomitant hepatic disease or another factor leading to marked hyperbilirubinemia exists.
Serum bilirubin levels > umol/L (20 mg/dL) should suggest the possibility of neoplastic obstruction.
In patients with persistent jaundice, the first test will usually be an UTZ which may show dilated bile ductsd dependin on the degree of obstruction or gallbladder stones.
Radioopaque gallstones may be seen on plain CT scans.
The lesion may be further delineated by ERCP. ERCP is preferable when the lower end of the duct is thought to be obstructed (eg, suspected carcinoma of the pancreas or other periampullary tumors). THC is usually preferred for proximal lesions (eg, biliary stricture, neoplasm of the bifurcation of the hepatic ducts), because it gives better opacification of th educts proximal to the obstruction and therefore provides more information that can be used in planning.
CT scan is preferred for clinical presentation suggestive of neoplastic obstruction.
Based on the previous slides, we have been able to enumerate the ruling in and ruling out parameters of our differential diagnoses based on history and PE. In order for us to investigate further on the underlying condition of our patient, we now move on to the other tests that can aid us in either proving or disproving our diagnosis. Laboratory workup will be discussed by Ms. Unica Francisco.