Title: The Oxbow (View from Mount Holyoke, Northampton, Massachussetts, after a Thunderstorm) Artist: Thomas Cole Date: 1836 Source/ Museum: The Metropolitan Museum of Art, New York Medium: oil on canvas Size: 51 1/2 x 76" (1.31 x 1.94 m)
HC Morning Report Cathy Larrain, MD, PGY2 Cooper University Hospital November 4, 2009
75 y.o. M with a history of DM, HTN, HPL, BPH presents with 5 days of painless jaundice, nausea, epigastric fullness, and tactile fever/chills. ROS: (+)tactile fever/chills unspecified weight loss over the past 4-5 mos. mild dyspnea shoulder pain epigastric fullness and sensation of tightness admits to using acetaminophen for URI and HA
Denies tobacco or illicit drug use, (+)social alcohol use Works at a post office No known drug allergies Home medications: antihypertensives, Metformin, medication for cholesterol Family history: Mother died @75 y.o. from lung cancer. Otherwise noncontributory
Infectious Disorders (Specific Agent) Viral hepatitis Leptospirosis Yellow fever Cirrhosis, syphilitic (Heparlobatum) NeoplasticDisorders Adenocarcinoma, ampulla of Vater Metastatic liver disease Adenocarcinoma, pancreatic Carcinoma, gallbladder Carcinoma, biliarytree Allergic, AutoImmuneDisorders Autoimmune hepatitis (Plasma cell) Cirrhosis, Primary Biliary Hereditary Disorders Cirrhosis/childhood Indian type Reference to Organ System Cirrhosis Cirrhosis, cryptogenic Drug Induced Toxic hepatitis
Physical Examination T 98.6, HR 67, BP 88/58, RR 12, SaO2 96% on RA NAD, AAOx3 with diffuse jaundice and scleralicterus, PERRLA, NC/AT No palpable LAD, supple neck, depressed JVP CTAB bilaterally no r/r/w, RRR no m/r/g Abd soft (+)BS (-)Murphy’s (+)hepatomegaly, ND, NT No c/c/e, no asterixis
Electrocardiogram: NSR 80 bpm, left axis deviation CT abdomen and pelvis: severe heterogeneity of liver consistency with hepatocellular disease vs infiltrating malignancy. Intrahepatic & extrahepaticbiliary duct dilation with possible calculus in distal CBD. Limited evaluation of gallbladder with possible pericholecystic fluid. Enlarged prostate.
Underaeration Patchy parenchymal opacities may represent atelectasis. Infectious vs inflammatory process cannot be excluded
Sludge and tiny stones presumably filling GB lumen and extending into normal caliber CBD. Top size normal liver with mildly heterogeneous echogenicity. Trace perinephric fluid on left. Bilateral pleural effusions.
CBD 5-6 mm distal CHD 8 mm 6 mm impacted calculus within the distal duct Biliarysphincterotomy was performed with stone removal 10-Fr 7 cm biliaryendoprosthesis was placed for complete drainage of contrast Normal pancreatic duct
Charcot’s triad: RUQ pain, fever with chills, jaundice Usually in the setting of biliary obstruction Bacteremia and shock are common Medical emergency with high morbidity and mortality ERCP is an established mode of treatment The cause of biliary obstruction may influence the outcome, with malignant biliary obstruction having a worse prognosis Malnutrition, weakened immunity, effects of chemotherapy and the malignancy itself
Primary SclerosingCholangitis Cholestatic liver disorder characterized by inflammation, fibrosis, eventual obliteration of the extrahepatic and intrahepatic bile ducts Middle aged men Presentation of jaundice, hepatomegaly, pruritis, weight loss, and fatigue Associated with IBD (70% with UC) and cholangiocarcinoma (6-20% patients) May progress to cirrhosis and ESLD Should be considered in individuals with IBD and increased AP Confirmation by ERCP or MRCP +/- liver biopsy
Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6. Acute cholangitis associated with bile duct stones carries a considerable morbidity and mortality. Conservative treatment with antibiotics is effective in only 80% of cases. 20% of patients who developed suppurativecholangitis do poorly without drainage. This is because complete bile duct obstruction affects the excretion and penetration of antibiotics into bile. Retrospective analysis, as well as prospective randomized controlled trials, have shown that urgent endoscopic drainage is an effective treatment for suppurativecholangitis and is superior to surgical drainage with a better clinical outcome
Siegel JH, Rodriguez R, Cohen SA, Kasmin FE, Cooperman AM. Endoscopic Management of Cholangitis: Critical Review of an Alternative Technique and Report of a Large Series. American J Gastroenterology. 2008; 89 (8): 1142-46. Objective: To assess the outcome of endoscopic techniques as the solitary treatment modality for the complete management of ascending, bacterial cholangitis, compared with results of radiological and surgical methods as historical controls. Methods: Endoscopic techniques were used to decompress bile ducts obstructed by stones (898 patients) or stenosis (49 patients). Endoscopic sphincterotomy (ES) was performed in 839 patientswith either 7-Fr stents or nasobiliary tubes. Of these latter patients, 68 subsequently underwent ES and stone removal, 17 had ES, litho-tripsy, and stone removal, 18 were left with stents in place, and 5 were lost to follow-up. Follow-up was conducted by direct patient contact, by telephone, or through the referring physicians. Results: All patients were managed by endoscopic techniques. There were four deaths (0.42%) in the first 30 days (none before 2 wk); no deaths were related to the procedures but were attributed to intercurrent medical problems. Two patients underwent surgery: one pancreatitis, one perforation. Complications were infrequent, occurring in 6% of patients. Bleeding occurred in 3%, pancreatitis in 2.8%, and perforation 0.2%. Conclusions: Endoscopic management of cholangitis is as effective as surgical or radiological methods for managing bacterial cholangitis, a potentially fatal syndrome, but ERCP and ES have been shown to be safer. Endoscopy is the preferred index technique both for establishing a definitive diagnosis and providing therapy.
Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest. Endosc. 1991; 37: 383-91. Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliarysphincterotomynot without risk. Complications occur in about 10% of patients 2 to 3% have a prolonged hospital stay, with a risk of mortality Emphasis on the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues
Mirizzi syndrome is a rare complication of cholelithiasis, characterized by the narrowing of the common hepatic duct as a result of mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct
Polson J, Wians FH Jr., Orsulak P, et al. False positive acetaminophen concentrations in patients with liver injury. Clinica ChimicaActa. 2008; 391 (1-2): 24-30. False positive acetaminophen tests may result when enzymatic-colorimetric assays are used, most commonly with bilirubin concentrations > 10 mg/dl, leading to potential clinical errors in this setting.
References Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest. Endosc. 1991; 37: 383-91 Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6. Polson J, Wians FH Jr., Orsulak P, et al. False positive acetaminophen concentrations in patients with liver injury. Clinica ChimicaActa. 2008; 391 (1-2): 24-30. Washington Manual pp. 385, 460-61, 489-90.
Title: Under the Birches Artist: Pierre-Étienne-Théodore Rousseau Date: 1842-1843 Source/ Museum: Toledo Museum of Art, Ohio Medium: oil on wood panel Size: 16 5/8 x 25 3/8" (42.2 x 64.4 cm)
John AR, Haghighi KS, Taniere P, Esmat ME, Tan YM, Bramhall SR. Is a raised CA 19-9 level diagnostic for a cholangiocarcinoma in patients with no history of sclerosingcholangitis? Dig Surg. 2006; 23 (5-6): 319-24. The aim of this study is to assess the role of CA 19-9 in patients with a cholangiocarcinoma without PSC. METHODS: The prospectively collected information on patients with biopsy-proven cholangiocarcinomas who had the CA 19-9 level measured was obtained (n = 68) from our computer database and medical records. These patients were compared with patients who had benign liver tumors (n = 25) and benign bile duct strictures (n = 13) who also had their CA 19-9 concentration measured. RESULTS: Sensitivity and specificity of CA 19-9 in the diagnosis of a cholangiocarcinoma were 77.9 and 76.3%, respectively, when using a cut-off value of 35 kU/l, while sensitivity and specificity were 67.5 and 86.8%, respectively, when the cut-off value was raised to 100 kU/l. The specificity was found to be higher in patients with peripheral cholangiocarcinomas (96%) using a CA 19-9 cut-off value >100 kU/l. A CA 19-9 value >600 kU/l was associated with non-resectabletumors (p = 0.05). CONCLUSIONS: This study demonstrates that CA 19-9 is a useful adjunct in the diagnosis of cholangiocarcinomas without primary sclerosingcholangitis, especially in the diagnosis of peripheral cholangiocarcinomas. However, it does not provide a reliable guide for the pathological staging of these tumors