A 35-year-old woman comes to the office with episodic abdominal pain. After dinner a day ago, she had intense epigastric pain that lasted 30-40 minutes, was dull with radiation to the back and right shoulder, and was accompanied by nausea and difficulty catching her breath. The pain resolved spontaneously after an hour and she did not seek medical care. The patient has had 2 similar episodes of lesser intensity in the past 6 months that resolved spontaneously. She has a history of migraine headaches treated with sumatriptan as needed. She does not use tobacco or illicit drugs. The patient has consumed 1 or 2 glasses of wine daily for the past 10 years. Her father died of pancreatic cancer at age 75, and her mother died of breast cancer at age 65. Vital signs are within normal limits. BMI is 35 kg/m². Abdominal examination reveals normoactive bowel sounds without tenderness or guarding. The liver span is 8 cm and there is no palpable spleen. The remainder of the examination is within normal limits. The patient refuses the suggested therapy and does not follow up with a health care provider. She returns to the emergency department 6 months later with recurrent persistent abdominal pain that has waxed and waned for the past 30 hours. She also has nausea and an episode of vomiting. Temperature is 36.7 C (98 F) , blood pressure is 136/80 mm Hg, and pulse is 100/min. She had mild icterus. The abdomen is tender in the right upper quadrant without guarding or rebound. Laboratory results are as follows:
Abdominal ultrasound shows a mildly distended gallbladder with multiple stones, no pericholecystic fluid, and an enlarged common bile duct of 1.1 cm (normal: <0.6) . Which of the following is the best next step in management of this patient?

Question

A 35-year-old woman comes to the office with episodic abdominal pain. After dinner a day ago, she had intense epigastric pain that lasted 30-40 minutes, was dull with radiation to the back and right shoulder, and was accompanied by nausea and difficulty catching her breath. The pain resolved spontaneously after an hour and she did not seek medical care. The patient has had 2 similar episodes of lesser intensity in the past 6 months that resolved spontaneously. She has a history of migraine headaches treated with sumatriptan as needed. She does not use tobacco or illicit drugs. The patient has consumed 1 or 2 glasses of wine daily for the past 10 years. Her father died of pancreatic cancer at age 75, and her mother died of breast cancer at age 65. Vital signs are within normal limits. BMI is 35 kg/m². Abdominal examination reveals normoactive bowel sounds without tenderness or guarding. The liver span is 8 cm and there is no palpable spleen. The remainder of the examination is within normal limits. The patient refuses the suggested therapy and does not follow up with a health care provider. She returns to the emergency department 6 months later with recurrent persistent abdominal pain that has waxed and waned for the past 30 hours. She also has nausea and an episode of vomiting. Temperature is 36.7 C (98 F) , blood pressure is 136/80 mm Hg, and pulse is 100/min. She had mild icterus. The abdomen is tender in the right upper quadrant without guarding or rebound. Laboratory results are as follows:

Abdominal ultrasound shows a mildly distended gallbladder with multiple stones, no pericholecystic fluid, and an enlarged common bile duct of 1.1 cm (normal: <0.6) . Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with prolonged abdominal pain and jaundice with liver function test abnormalities and a dilated common bile duct (CBD) likely has choledocholithiasis (CBD stones). Patients commonly have typical biliary colic symptoms (eg, right upper-quadrant pain, nausea, vomiting); however, unlike cholelithiasis, CBD stones cause accompanying biliary outflow obstruction, leading to cholestatic liver function abnormalities (elevated bilirubin, alkaline phosphatase out of proportion to aminotransferases), and more prolonged pain. Pancreatic enzymes, white blood cell count, and vital signs are typically normal. Choledocholithiasis is diagnosed by visualization of a stone within the CBD; however, ultrasound is insensitive for detecting distal stones. Endoscopic retrograde cholangiopancreatography (ERCP) allows for both diagnosis and treatment (stone removal) and is the best next step in management of patients with: Endoscopic retrograde cholangiopancreatography (ERCP) Visualized choledocholithiasis High-risk features (dilated CBD on imaging, elevated serum bilirubin) Evidence of acute cholangitis (fever, right upper-quadrant pain, jaundice, hypotension, confusion) - these patients also require intravenous antibiotics and treatment of sepsis. In patients in whom choledocholithiasis is suspected but who have none of the above criteria, a less invasive procedure (eg, MR cholangiopancreatography) should be considered. After ERCP, laparoscopic cholecystectomy is performed on a nonemergent basis to prevent future complications (Choice C). Although intraoperative (ie, during cholecystectomy) CBD stone removal is occasionally performed, it is technically challenging and rarely undertaken in the era of ERCP. Immediate cholecystectomy is usually reserved for patients with emergent indications (eg, hemodynamic shock, gallbladder perforation) who are at low risk for surgery (Choice E). laparoscopic cholecystectomy (Choice A) Cholescintigraphy uses technetium-labeled hepatic iminodiacetic acid (HIDA) to evaluate for patency of the cystic duct, CBD, and ampulla. It is useful for diagnosing suspected cholecystitis in patients with negative or inconclusive ultrasound findings. However, this patient's positive ultrasound findings would not require a HIDA scan. (Choice B) Patients with choledocholithiasis can develop gallstone pancreatitis, which can be evaluated with CT scan. However, the normal lipase value virtually rules out this diagnosis. Educational objective: Choledocholithiasis (common bile duct stones) causes prolonged biliary colic and cholestatic liver function test abnormalities. Endoscopic retrograde cholangiopancreatography is indicated for patients with visualized choledocholithiasis, high-risk patients (dilated common bile duct, elevated serum bilirubin), or those with evidence of acute cholangitis. References: Modern approach to cholecysto-choledocholithiasis. (http://www.ncbi.nlm.nih.gov/pubmed/24567790)

A 35-Year-Old Woman Comes to the Office with Episodic Abdominal