1. FINAL DIAGNOSIS

2. PatientCholedocholithiasis Signs & symptoms -Painless jaundice -Tea-colored urine - (-) acholic stools - (-) fever - (-) weight loss -Non-tender abdomen -No palpable mass Laboratory findings ↑ ALT (165 IU/mL; N: 9-6 IU/mL) ↑ ALP (325 mg/dL; N: 50-75 mg/dl) ↑ TSB (3 mg/dL; N: 0.1-1 mg/dL) Signs & symptoms - Colicky RUQ pain associated with nausea and vomiting - Jaundice - Tea-colored urine, Acholic stools - RUQ tenderness - may present with fever if cholangitis occurs Laboratory findings ↑ ALP Normal/↑ Aminotransaminases ↑ Bilirubin usually >3mg/dL

3. PatientCholedocholithiasis Ultrasound dilate CBD (12mm; N:4mm) Dilated intrahepatic duct Possible risk factors: s/p cholecystectomy Ultrasound CBD stones are frequently missed CBD dilation Etiology -Benign CBD strictures - PSC - sphincter of Oddi dysfunction - gallstone migrated into the CBD

4. PatientMalignant CBD Obstruction Signs & symptoms -Painless jaundice -Tea-colored urine - (-) acholic stools - (-) pruritus - (-) fever - (-) weight loss -Non-tender abdomen -No palpable mass Laboratory findings ↑ ALT (165 IU/mL; N: 9-6 IU/mL) ↑ ALP (325 mg/dL; N: 50-75 mg/dl) ↑ TSB (3 mg/dL; N: 0.1-1 mg/dL) Signs & symptoms -Painless jaundice - tea-colored urine -Acholic stools -Pruritus -Anorexia -Weight loss -Courvoisier sign: palpable, nontender gallbladder Laboratory findings ↑ ALP Normal aminotransaminases ↑ Bilirubin usually >20mg/dL

5. PatientMalignant CBD Obstruction Ultrasound dilate CBD (12mm; N:4mm) Dilated intrahepatic duct Possible risk factors: s/p cholecystectomy Ultrasound CBD dilation Etiology -Liver fluke infection (ex. Clonorchis sinensis) -IBD -Chemical Exposures -Congenital diseases of the biliary tree

6. PatientBenign Bile Duct Stricture Signs & symptoms -Painless jaundice -Tea-colored urine - (-) acholic stools - (-) fever - (-) weight loss -Non-tender abdomen -No palpable mass Laboratory findings ↑ ALT (165 IU/mL; N: 9-6 IU/mL) ↑ ALP (325 mg/dL; N: 50-75 mg/dl) ↑ TSB (3 mg/dL; N: 0.1-1 mg/dL) Signs & symptoms - Features of obstructive jaundice - Painless jaundice - Tea-colored urine - Pruritus Laboratory findings Aminotransaminases <300 IU/mL ALP increased 3x than normal ↑ Bilirubin

7. PatientBenign Bile Duct Stricture Ultrasound Dilate CBD (12mm; N:4mm) Dilated intrahepatic duct Possible risk factors: s/p cholecystectomy Treatment for TB when he was in his 30s Ultrasound Dilated CBD Dilatation of intrahepatic and extrahepatic bile ducts Etiology -Postoperative injury after cholecystectomy - TB and histoplasmosis

8. Final Diagnosis Benign Bile Duct Stricture