Shaharia Uddin
ER- QHC
August 29, 2018 17:11
Name: R.B.
CC: yellow eyes, generalized itchiness and dark urine x3-4 wks
HPI:73 year old Male with pmhx of CAD s/p CABG 18 years ago, DM, HTN, HLD and BPH presents to ED c/o yellow eyes, generalized body itching and dark urine x3-4 weeks. Pt also reports having intermittent, dull and localized RUQ abdominal pain lasting4-6 hrs; denies alleviating/aggravating factors. Complaints are also accompanied with yellow stools, decreased appetite, indigestion, nausea and fatigue. Pt also notes that his fingernails are shiny. Reports that he used to drink alcohol occasionally but not daily, and generally consumes large meals. Reports he traveled to Canada to see his daughter therefore could not come to ED earlier. States has had labs done by PMD last week and was told that LFTs were high. At this time, Pt denies fever, chills, CP, SOB, abdominal pain, back pain, vomiting, constipation, diarrhea, dysuria, black stools or blood in stool.
PMH: CAD, DM, HTN, HLD and BPH
PSH: CABG 18 years ago, TURP 6 yrs ago
Allergies: NKDA
Meds:
Metformin 500 MG BID
Gliclazide 5 MG QD
ASA 81 MG QD
Atorvastatin 20 MG QD
Amlodipine 5 MG QD
Losartan 50 MG QD
FHx: deceased parents both with DM, HTN, HLD
SHx: denies tobacco or illicit drug use;quit drinking ETOH 2 mos ago- previously occasional drinker
ROS
GEN:Positive for decreased appetite and fatigue; Negative for: weight loss or gain, weakness, fever
SKIN:Positive for: itching; glossy fingernails; Negative for rash
HEENT:Positive for: scleral icterus; Negative for: headache, vision problems, discharge, redness, puffiness, Ear pain, frequent ear infections, hearing loss, ringing, runny nose, sinus infections, epistaxis, sneezing, swollen neck glands, stiffness, masses, sore throat, stuffy nose, difficulty swallowing
CARDIO: Negative for: palpitation, abnormal murmurs, heart defect, chest pain, dyspnea upon exertion, orthopnea, PND, edema, cyanosis
VASC: Negative for: leg edema, claudication, varicose veins, thromboses
RESP: Negative for: SOB, wheezing, cough, stridor, URI, croup, asthma, bronchitis, hoarseness
MSK:Negative for:, muscle pain, joint pain, stiffness, backache, visible injury/bruising, redness or heat in joint, decreased range of motion, muscle weakness, muscle atrophy, muscle cramps, difficulty walking, difficulty climbing stairs, knee pain
GI:Positive for: jaundice, yellow stool, RUQ abdominal pain, decreased appetite, indigestion, abdominal distention, nausea; Negative for: heartburn/reflux, vomiting, hematemesis, constipation, diarrhea, rectal bleeding
GU:Positive for dark urine;Negative for: sores, rash, increased urgency/frequency, bedwetting, hesitancy, dribbling, dysuria, nocturia, hematuria, incontinence
ENDO: Negative for: frequent hunger, urination, or thirst, or hot/cold intolerance
NEURO: Negative for: fainting, blackouts, seizures, weakness, numbness, paralysis, tingling, tremor, lack of coordination, difficulty with memory/speech
DDX
- Acute hepatitis
- Jaundice, decreased appetite, RUQ abdominal pain, abdominal distension due to ascites, fatigue/weakness, pruritus, alcohol use
- Gallstones
- RUQ pain, nausea, scleral icterus, jaundice, pruritus, age, weight, DM
PHYSICAL EXAM
Wt: 215 lb | Ht: 5’10” | BMI: 30.85
BP: 138/70 L arm, sitting| HR: 92 | Temp: 97.7 °F (Oral) | RR: 17 | SpO2: 97% Room Air
GEN: overweight male, well-nourished, A&Ox3, in NAD
EYES:scleral icterus; EOMI bilat; PERRLA; conjunctiva clear; no strabismus; no discharge, no nystagmus
HEENT: NC/AT; cerumen in ear canal; TMs pearly b/l; clear nose; clear rhinorrhea; no sinus tenderness, normal tonsils; no exudates; neck supple; no thyromegaly; no lymphadenopathy; no carotid bruit; trachea midline
CV: RRR, normal S1 S2, no murmurs, clicks or rubs, normal PMI, no chest wall tenderness, cap refill <2 sec
RESP: CTA b/l; no wheezes. rhonchi/rales; no crackles or stridor; no SOB or retractions
ABD:no evidence of scars, striae, caput medusae or abnormal pulsations; soft, moderately distended abdomen, tympanic; no masses appreciated; no rebound or guarding;positive shifting dullness; nontender to palpation; BS present in all 4 quadrants; No bruits noted over aortic/renal/iliac/femoral arteries; no hepatosplenomegaly; no CVAT; negative Murphy’s sign
RECTAL: good tone w/o masses, lesions, tenderness; no occult stool
SKIN:generalized jaundice;glossy fingernails b/l; healed midline CABG incision over the chest; no rash or skin lesions, moist, warm
EXT: no clubbing, cyanosis, or edema, pulses 2 + bilaterally, sensations normal
MSK: no swelling or deformity , FROM, no effusions, no evidence of scoliosis
NEURO: alert and oriented x 3, CN’s II-XII grossly intact, normal sensation and strength, motor strength – 5/5 upper and lower extremities, DTR’s 2+ bilaterally and symmetric, normal gait
PSYCH: affect normal, affect flat, appropriate mood and affect , good eye contact, normal speech, no thought disorder
LABS
| REFERENCE RANGE | VALUE | |
| POC Glucose | 70 – 105 mg/dL | 204 |
| UA w/Rflx Micro | ||
| Urine pH | 5.0 – 7.5 | 6.0 |
| Color | Yellow | Dark Yellow |
| Appearance | Clear | Cloudy |
| Glucose, Qual Urine | Negative mg/dL | Negative |
| Bilirubin | Negative | Large |
| Ketones | Negative mg/dL | Negative |
| Specific Gravity | 1.005 – 1.030 | 1.021 |
| Blood | Negative | Negative |
| Protein | Negative mg/dL | 30 |
| Urobilinogen | 0.2 – 1.0 mg/dL | 0.2 |
| Nitrite | Negative | Positive |
| Leuk Est | Negative | Small |
| White Blood Cells Urine | 0 – 4 HPF | 7-10 |
| Red Blood Cells Urine | HPF | 7-10 |
| Urine Bacteria | Negative | Few |
| Squamous Epithelial Cells | 0 – 4 HPF | 5-6 |
| U HYAL CST | 0 – 4 /lpf | 0-4 |
| Mucus, UA | Negative | Negative |
| CBC w/ diff | ||
| WBC | 4.5 – 11.0 K/mcL | 9.2 |
| RBC | 4.50 – 5.90 M/mcL | 3.84 |
| HGB | 13.5 – 17.5 gm/dL | 12.1 |
| HCT | 41.0 – 53.0 % | 34.6 |
| MCV | 80.0 – 100.0 fL | 90.2 |
| MCH | 26.0 – 34.0 pg | 31.6 |
| MCHC | 31.0 – 37.0 g/dL | 35.1 |
| MPV | 7.4 – 10.4 fL | 8.4 |
| RDW | 11.5 – 14.5 % | 15.9 |
| PLT | 130 – 400 K/mcL | 287 |
| Neutrophil % | 40.0 – 70.0 % | 37.5 |
| Lymphocyte % | 22.2 – 43.6 % | 53.9 |
| Monocyte % | 2.0 – 11.0 % | 5.2 |
| Eosinophil % | 0.0 – 8.0 % | 0.8 |
| Basophil % | 0.0 – 2.0 % | 2.6 |
| Neutrophil Abs | 1.8 – 7.7 K/mcL | 3.4 |
| Lymphocyte Abs | 1.0 – 4.8 K/mcL | 5.0 |
| Monocyte Abs | 0.3 – 1.1 K/mcL | 0.5 |
| Eosinophil Abs | 0.0 – 0.7 K/mcL | 0.1 |
| Basophil Abs | 0.0 – 0.2 K/uL | 0.2 |
| NRBC Abs | <=0.00 K/mcL | 0.01 |
| NRBC % | <=0.0 % | 0.1 |
| BMP | ||
| Sodium | 136 – 145 mmol/L | 134 |
| Potassium | 3.5 – 5.1 mmoL/L | 4.1 |
| Chloride | 98 – 108 mmol/L | 96 |
| CO2 | 22 – 29 mmol/L | 24 |
| Glucose, Serum | 74 – 110 mg/dL | 175 |
| BUN | 6 – 23 mg/dL | 17 |
| Creatinine | 0.70 – 1.20 mg/dL | 1.10 |
| Calcium, Serum | 8.6 – 10.0 mg/dL | 9.1 |
| Anion Gap | 8 – 16 mEq/L | 14 |
| Indices | Gross Icteris | |
| eGFR, Non African-American | >=60 ml/min/1.73m2 | >60 |
| LFTs | ||
| Albumin | 3.5 – 5.2 g/dL | 3.3 |
| Total Protein | 6.6 – 8.7 g/dL | 5.7 |
| Total Bilirubin | 0.0 – 1.2 mg/dL | 27.6 |
| ALK PHOS | 40 – 129 U/L | 249 |
| ALT (SGPT) | 0 – 41 U/L | 83 |
| AST (SGOT) | 5 – 40 U/L | 66 |
| Indices | Gross Icteris. | |
| Direct Bilirubin | 0.0 – 0.3 mg/dL | 19.9 |
| PT/INR | ||
| PT | 10.0 – 13.0 second(s) | 18.3 |
| INR | ratio | 1.6 |
| APTT | 27.0 – 36.0 second(s) | 32.0 |
| HEPATITIS PANEL | ||
| Hep B Surface Ag | Nonreactive | Nonreactive |
| Hepatitis A Ab IgM | Nonreactive | Nonreactive |
| HCV S/CO Ratio | S/CO | 0.20 |
| HCV Interpretation | Nonreactive | Nonreactive |
| Hepatitis C Ab | S/CO | N/A |
| Hepatitis B Core IgM Antibodies | Nonreactive | Nonreactive |
| BLOOD CULTURE | No growth |
EKG: NSR, old inferior infarct
IMAGING
CT abd/pelvis (7/2/2018) showed “Multiple hepatic cysts the largest cyst involves the right lobe of liver posteriorly measuring 3.5 cm. Gallbladder and bile ducts: Cholelithiasis with gallbladder wall thickening noted as well as large stone in the gallbladder. Acute acute cholecystitis should be considered”
CT Abdomen and Pelvis With Intravenous Contrast
LUNG bases: Unremarkable. No mass. No consolidation.
ABDOMEN:
Liver: Multiple hepatic cysts the largest cyst involves the right lobe of liver posteriorly measuring 3.5 cm
Gallbladder and bile ducts: Cholelithiasis with gallbladder wall thickening noted as well as large stone in the gallbladder. The acute cholecystitis should be considered Gallbladder ultrasound may be helpful
Pancreas: Unremarkable. No mass. No ductal dilation.
Spleen: Unremarkable. No splenomegaly.
Adrenals: Unremarkable. No mass.
Kidneys and ureters: Unremarkable. No solid mass. No hydronephrosis.
Stomach and bowel: No evidence for bowel obstruction No mucosal thickening.
PELVIS:
Appendix: Normal appendix right lower quadrant
Bladder: Unremarkable. No mass.
Reproductive: Enlarged multinodular prostate gland
ABDOMEN and PELVIS:
Intraperitoneal space: Unremarkable. No free air. No significant fluid collection.
Bones/joints: No acute fracture. No dislocation.
Soft tissues: Unremarkable.
Vasculature: Unremarkable. No abdominal aortic aneurysm.
Lymph nodes: Unremarkable. No enlarged lymph nodes.
IMPRESSION: Cholelithiasis with gallbladder wall thickening noted as well as large stone in the gallbladder. Acute cholecystitis should be considered. Gallbladder ultrasound may be helpful. No evidence for bowel obstruction.
RUQ Sonogram:
Comparison is prior scan done on July 3, 2018. Liver appears to have increased echogenicity. Suspect fatty liver and/or liver and femoral disease. Clinical correlation is suggested. 32 mm x and smaller cysts noted in the liver.
Thickening of the gallbladder wall is noted and is a nonspecific finding. 6 mm cyst noted in the wall of the gallbladder. The gallbladder also shows tumefactive sludge and gallstones.
Common duct is not dilated. Visualized part of pancreas and right kidney appear unremarkable.
IMPRESSION: Abnormal gallbladder with gallstones. Remaining findings as above.
DDX
- Cholelithiasis
- Overweight, age, HLD, US findings
- Choledolithiasis
- Gallstones, RUQ pain, nausea, scleral icterus, jaundice, age, weight, DM, conjugated hyperbilirubinemia, elevated LFTs
- ETOH/viral/autoimmune hepatitis
- Jaundice, decreased appetite, RUQ abdominal pain, nausea, abdominal distension due to ascites, fatigue/weakness, pruritus, acholic stools, ETOH use, elevated LFTs, conjugated hyperbilirubinemia
- Order albumin, GGT, LDH, HAV, HBV, HCV, HEV, CMV, EBV, HSV, VZV, ANA, smooth muscle Ab, IgG levels
- Pancreatic carcinoma
- >60 y, ETOH, DM, males, obesity, jaundice, pruritus, dark urine, acholic stools
- Order CEA, CA 19-9
- Primary biliary/sclerosing cirrhosis
- Elevated ALP, fatigue, pruritus, RUQ discomfort, jaundice, hyperbilirubinemia, elevated LFTs
A:RB is a 73 y.o. male with PMH of CAD s/p CABG (18 years ago), DM2, HTN, BPH, HLD presents to ED ℅ generalized pruritus, scleral icterus, intermittent abdominal pain, dark urine and stool discolorations x3-4 weeks. CT of abdomen and pelvis and RUQ sono suggest cholelithiasis. Medicine consulted for further possible ERCP to locate the cause of generalized icterus.
P:
Generalized icterus likely 2/2 choledolithiasis vs hepatitis vs pancreatic carcinoma
- GI consult for possible ERCP
- Order albumin, GGT, LDH, HAV, HBV, HCV, HEV, CMV, EBV, HSV, VZV, ANA, smooth muscle Ab, IgG levels, CEA, CA 19-9
Cholelithiasis
- Surgery consult- ursodeoxycholic acid vs. surgical intervention
DM
- check BS
- Continue home meds
HTN
- continue home medications
CAD
- Continue home meds
UTI
- ciprofloxacin 400mg IV
- repeat UA/ UC
Nausea
- Zofran inj 4 mg IM
PATIENT EDUCATION
Mr. B, after running some tests, we found that your liver function levels are abnormal and the CT showed you have gallstones and some cysts in your liver. You are feeling very itchy because of the overproduction of bile salts in your body. However, we do not have a clear indication as to why you are jaundiced or having dark urine and yellow stool. Therefore, We still want to rule out things like hepatitis and see if the stones have traveled elsewhere in the biliary system that might actually be causes for these symptoms. For now, I am awaiting a consult from medicine to see what other blood tests and/or imaging we can add on to give us a more detailed picture of what is going on. Things like hepatitis or gallstones that have obstructed the biliary system could be causes for your symptoms. Additionally, I will get a consult from surgery to determine if the gallstones need to be surgically or medically removed, or left alone completely. As we wait on them, I will give you your regular medications. In addition, I will give you 4 mg of Zofran, an injection for nausea. I also see that you have a urine infection so I will give you 400 mg of an antibiotic called Ciprofloxacin via IV so we can get that treated before you leave the ED.
SENSITIVITY AND SPECIFICITY OF MRCP VS EUS AGAINST ERCP IN DIAGNOSING CHOLEDOCHOLITHIASIS
- Choledocholithiasis is the MCC of obstructive jaundice (54%)
- Despite high sensitivity of TUS in dx’ing cholelithiasis, difficult in identifying choledocholithiasis and low sensitivity (15-40%)
- CT more sensitive than TUS for dx’ing choeldocholithiasis but cost and radiation keeps it from being 1st line tool in dx
- ERCP = gold standard for dx’ing choledocholithiasis
- Cons of ERCP
- highly dependent on operator skill and experience
- Complications like pancreatitis, cholangitis, bleeding and bowel perf
- Therefore reserved for therapeutic purposes
- Makes EUS and MRCP modalities of choice for dx’ing choledocholithiasis
- MRCP
- Noninvasive
- Used when there is CBD dilatation
- Cons: contrast needed and no histological dx
- EUS
- Provides bx samples → stages malignancy
- When MRCP inconclusive, able to explain CBD dilatation
- METHOD
- 62 suspected choledocholithiasis pts (based on RUQ/epigastric pain, jaundice, elevated LFTs and TUS showing dilated extrahepatic and intrahepatic bile ducts) undergo ERCP
- 31 underwent EUS and other 31 MRCP then both went for ERCP
- RESULTS
| EUS | MRCP | |
| Sensitivity | 96% | 81% |
| Specificity | 57% | 40% |
| Accuracy | 87% | 68% |
| PPV | 88% | 74% |
| NPV | 80% | 50% |
- Of 26 who underwent EUS, 23 pts found to have choledocholithiasis using ERCP
- EUS stone detection rate = 88%
- Of 23 who underwent MRCP, 17 found to have choeldocholithiasis by ERCP
- MRCP stone detection rate = 73.4%
- ** EUS > MRCP for detecting choledocholithiasis, confirmed using ERCP
- COMPARATIVE STUDIES bc sample size too small to draw confident conclusions
- 45 pts → MRCP: 88.8% accurate, 91.9% sens, 75% spec, PPV 94.4%, NPV 66.7%; EUS: 93.3% accurate, 97.3% sens, 75% spec, PPV 94.7%, NPV 85.7%
- Verma et. al performed syst review of 5 RCTs comparing MRCP and EUS with ERCP or intraoperative cholangiography as gold standard
- Results: EUS and MRCP had high diagnostic performance and both didnt differ from one another significantly.
- Convenient approach: EUS should be considered when MRCP is neg in pts with moderate or high pretest probability, and ERCP should be performed immediately after stones are detected by EUS while pts remain sedated
