A 45 Year Old Woman presents To ER With Epigastric pain, Nausea, Vomiting & Jaundice

A 45-year-old woman presents to the emergency room when you are on call. She complains of epigastric pain, radiating to the back. She also has nausea and vomiting. She states that she has had similar symptoms for many years but has never felt this bad. She does not use tobacco or alcohol. You suspect obstruction of the common bile duct because the patient is jaundiced. The optimal diagnostic study is:

A. Ultrasound evaluation
B. Computerized tomography (CT) scan of the abdomen
C. Plain abdominal films, flat and upright
D. HIDA scan
E. Endoscopic retrograde cholangiopancreatography

 Answer : E.  Endoscopic retrograde cholangiopancreatography

Discussion: Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in diagnosing choledocolithiasis. It has the added benefit of being therapeutic because sphincterotomy and removal of impacted stones is possible. If biliary pancreatitis is present, early ERCP may reduce morbidity and mortality. 

The complications of ERCP are:

•  pancreatitis, 
• infection, 
• biliary duct perforation, and 
• hemorrhage. 

Ultrasound is an excellent choice for gallstones in the gallbladder and has a high sensitivity for acute cholecystitis. However, up to half of biliary duct stones are missed, likely due to abdominal gas. Also, small stones (less than 2 mm) are easily missed on ultrasound. CT scan can be helpful in determining if there is evidence of pancreatitis. 

High-resolution CT scans that provide three-dimensional images of the biliary duct may be comparable to ERCP but do not offer therapeutic options. 

Abdominal films are unlikely to be helpful, although there may be a sentinel loop of duodenum seen in acute pancreatitis. 

A HIDA scan uses technetium-labeled iminodiacetic acid that is injected intravenously. Because it is excreted by the liver into the bile, the gallbladder and ducts should be seen within 30 to 45 minutes of administration. Nonvisualization of the gallbladder is usually due to obstruction of the cystic duct. Repeating the scan 4 hours after initial administration will reduce the false-positive rate for gallbladder nonvisualization. 

Ninety-five percent of common bile duct stones originate in the gallbladder. The complications are acute pancreatitis and cholangitis. 

The classic presentation of cholangitis, called Charcot's triad, consists of chills, pain, and jaundice. If there is hypotension and altered mental status as well, the presentation is called Reynold's pentad and is indicative of ascending cholangitis and sepsis. Pancreatitis may be difficult to differentiate from cholangitis in that symptoms are similar. However, enzyme levels, particularly lipase and amylase, are higher in pancreatitis.