Episode 5 - Yellowish Choledocholithiasis

From Rio Bravo qWeek · 00:19:38

Show by Rio Bravo Family Medicine Residency Program

Yellowish CholedocholithiasisThe sun rises over the San Joaquin Valley, California. BIG NEWS! Our program has relinquished our affiliation with UCLA and we have decided to join USC instead. Just kidding, April fools. Today is April, 1, 2020. This week the United States became the country with the most coronavirus cases in the world with over 213,000 confirmed cases, probably more by the time this podcast is over. COVID 19 continues to spread around the world, Italy being the country with the most casualties with over 12,000 deaths. It is difficult to talk about anything else during these times of turmoil. You may ask yourself, is this the result of a spontaneous viral mutation? Is it a conspiracy against Capitalism? Are extraterrestrials involved? Was the virus created for economic reasons? There are many theories, you can draw your own conclusion. What we can’t deny is that this pandemic has touched every aspect of our lives. "When there is a crisis, let your heart pray, but let your hands work” - John KramerI am reminded of another quote: “Pray as if everything depends on God, work as if everything depends on you”, attributed to Ignatius. Religious freedom is great, isn’t i? Today our guest is Gina Cha. Gina is known as “the intern” at Kern Medical by her inpatient team. I am glad she accepted the invitation to come and talk to us about a relevant topic today.As you know, Gina, we have 5 questions in our podcast. Let’s start with question number one.Who are you?My name is Gina Cha, I am called “the intern”. I was born and raised in a small town about one hour north east of here called Porterville. I am Hmong and I have 7 siblings. I went to the American University of the Caribbean, Saint Martin. What did you learn this week? This is case I’ve personally experienced this week in the hospital. We had a patient in her late 20s with no significant past medical history present with yellowing of the skin for 1 day. Other associated symptoms include right upper quadrant abdominal pain for one day that had since resolved. She also had episodes of nausea that had since resolved. She had noticed continual yellowing of the skin and reported to the ED. Comment: With the history that you obtained what did you think? Yellowing of the skin is called jaundice. Differential diagnosis of increased bilirubin, yellowing of the skin in this case including:Chronic alcohol use (indicative of chronic liver damage) Hepatitis (viral infections of the liver affecting liver function)Gallstones (that can be block bilirubin excretion) Hemolysis (increased break down of hemoglobin)Comment: Ascending cholangitis triad (Charcot’s): jaundice; fever, usually with rigors; and right upper quadrant abdominal pain. When the presentation also includes low blood pressure and mental status changes, it is known as Reynolds' pentad. How did you narrow down your differential?Physical exam: unremarkable, no abdominal guarding, no Murphy’s sign. Comment: What is the Murphy’s sign? Well this is a technique is highly sensitive for diagnosis of acute cholecystitis. The way we perform this is by having the patient lay down by gently press on the right upper quadrant of the abdomen and having the patient take a deep breath. We are essentially feeling for the gallbladder and with a patient taking a deep breath, it allows the gallbladder to descend and be palpated. Comment: The same principle applies when a technician is performing a RUQ US, if there is pain with inspiration, it is a positive Murphy sign. What is cholecystitis? In short this is infection and inflammation to the gallbladder that can be quite serious if left untreated. It can cause symptoms such as fever, chills, an increase in a patient’s WBC, and can lead to perforation of the gallbladder and sepsis. Comment: What are other things you looked for? It is important to take into consideration lab values. Lab findings remarkable on a comprehensive metabolic panel: elevated liver enzymes including AST, ALT, Alk Phos, total bilirubin. Interestingly enough a meta-analysis of 22 studies revealed that an elevated serum bilirubin has a sensitivity of 69% and specificity of 88% for diagnosis of a stone in the bile duct. Comment: With those findings, were you able to narrow down the diagnosis? With this clinical picture and laboratory findings were indicative of a blockage somewhere in the biliary duct as the patient had RUQ pain that were “colicky” in nature, she was not anemic, hepatitis panel was negative. With these findings we were able to rule out some of our suspected differential diagnosis. To be sure, we obtained an Abdominal US and the patient had a dilated Common bile duct, approximately 8 mm in diameter. The common bile duct is a tube-like structure that carries bile from the liver to be expelled into the intestines. Any CBD measuring more than 6mm with an elevated serum total bilirubin is highly predicative of a stone obstruction. Which leads to our patient’s diagnosis called…

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