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Gastrointestinal: jaundice

Mrs Wood is a 45 year old lady in A&E who is experiencing abdominal pain. Earlier that day it was pointed out to her that her eyes looked yellow. Mrs Wood’s doctor sensibly decides to take a thorough history. In order to ensure that he doesn’t jump to conclusions as to the likely cause, he bases his questions around the broad classification system for the causes of jaundice. Which classes occur within this system?

Upon questioning Mrs Wood admits that she has been feeling tired lately and that her skin is rather itchy. She has been experiencing some severe pain lately in her upper abdomen that comes and goes after several hours, but has not noticed having a fever or shivering. She has been experiencing intermittent pain of 9/10 intensity. She’s not sure if her stools have changed colour, but her urine has been rather dark of late. She is a social smoker and drinker. Her most recent holiday was to South Africa to visit her sister, but she had taken “malaria pills” from the GP before and during her visit. Which of the following is now the most likely diagnosis?




He decides to perform a few blood tests. Which of the following would you expect given the likely diagnosis?

The doctor decides to admit Mrs Wood so that her pain can be managed and further management can be decided on. Which mode of imaging is the doctor likely to request to confirm the suspected diagnosis?

After imaging Mrs Wood’s diagnosis of gallstones is confirmed. One treatment option is ERCP (endoscopic retrograde cholangiopancreatography). What is the most common serious complication of this procedure?

In discussion with the surgeons, Mrs Wood considers the risks of ERCP too great. During her admission Mrs Wood is given PRN analgesia until her pain subsides. Amongst her other management the surgeon visits and advises Mrs Wood to return in a few months time to have her gallbladder removed. He explains that this should prevent the symptoms from recurring in the future.

A few months later Mrs Wood’s surgery is performed. During the procedure the surgeon is sure to identify Calot’s triangle to ensure that the cystic artery is localised and accounted for. What are the borders of Calot’s triangle?

Six months later Mrs Wood has recovered well from her laparoscopic cholecystectomy and is symptom free. Out of curiosity the surgeon sent Mrs Wood’s gallstones to the lab for analysis. Which of the following regarding the composition of the stones is most likely to have been concluded?

 
Mrs Wood has a speedy recovery (it is faster with laproscopic as opposed to open operations) and can barely find the scars. She is very pleased with the outcome and continues to host tea-parties.
 
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jaun.jpg

Obvious jaundice as seen by the yellowing of the scleara. With greater bilirubin concentration the skin becomes yellow as well. © 2011 Dr. Colin Tidy.





















us gallstones

The gallstone is indicated by the red arrow, whilst the S indicates the acoustic shadow. Note that the presence of gallstones in a patient's gallbladder can be normal and the technician needs to look for gallbladder and common bile duct dilatation. © Dr. Ruth E. Moran.



ERCP

ERCP visualises the biliary tree and any obstruction (such as impacted gallstones). During ERCP gallstones can also be removed. © 2009 Shahat AH.



cal

Calot's triangle. © 2011 Dr. Eranga Perera.



Laproscopic cholecystectomy.