Case presentation A 64 years old Female with no past medical or surgical history presented with yellowish discoloration of skin for two days duration associated with vague and non-radiating abdominal pain. Patient also endorses 8 pounds unintentional weight loss over the past 2–3 months.
On physical exam; scleral icterus and jaundiced skin were noted. Abdominal exam was non-significant, no rash or discoloration on inspection, abdomen is soft with no tenderness or rebound tenderness, murphy sign is negative, no organomegaly, and bowel sounds are positive upon auscultation. No renal costo-vertebral angle tenderness noted.
Laboratory testing was significant for: Alanine Aminotransferase (ALT) 448 U/L; Aspartate Aminotransferase (AST) 330 U/L, Alkaline Phosphatase (ALK) 225, Gamma-Glutamyltransferase (GGT) 530 IU/L, Leukocyte Dehydrogenase (LDH) 328 U/L, Total Protein 7.1; Albumin 4; Total Bilirubin 9.3 6 mg/dL and Direct Bilirubin 6.2 6 mg/dL. Hepatitis serology showed previously infected with Hepatitis A infection, HbA total AB+ and negative for Hepatitis B Surface Ag (HBsAg), Hepatitis B Core AB (HBcAb), Hepatitis B Surface AB (HBsAb) and Hepatitis C AB (HC ab). Tumor marker (CA 19–9) level of 27.
Imaging studies including chest X-Ray were normal without any acute cardio-pulmonary event. Abdominal-Pelvic CT scan with oral and IV contrasts showed moderate dilated intrahepatic & extra hepatic bile ducts consistent with common bile duct obstruction with no mass or stones seen. There is no liver lesion or mass. No pancreatic lesion or mass. No Gall bladder identified.
Abdominal MRCP was recommended, procedure showed intra-extra hepatic and common bile duct dilatation of maximum diameter of 1.3 cm. An ovoid filling defect was identified on distal common bile duct consistent with choledocholithiasis. No gallbladder was identified figure 1A.
Patient developed Fever 102 F with elevated WBC count of 15,000/mm3 for which she was started on IV Antibiotics empirically. Urgent ERCP was attempted and revealed marked dilatation in the region of the proximal common bile duct after contrast injection and ballooning. Proximal to the balloon there was a marked dilatation of the CBD and mild dilatation of central intra-bililary ducts. Intra-pancreatic portion of distal common bile duct is of normal caliber without filling defects. Successful extraction CBD biliary stone biliary stent placed. No gall bladder was identified figure 1B.
Patient improved over the course of one to two days with normal WBC count and normal liver enzymes. Total Bilirubin dropped to 1.5. Patient's abdominal pain resolved. She remains afebrile more than two days and was able to tolerate oral diet. Patient was discharged home and was seen one month later in gastroenterology clinic with normal liver function test⇓.
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