Question of the Week # 109

109) A 35 year old HIV positive male patient comes to your office with complaint of anorexia, nausea and vomiting and abdominal pain. His anti-retroviral medications include Stavudine and Didanosine. On physical examination, his temperature is 100F. His abdomen is tender in the epigastric area.  Laboratory results reveal WBC count of 20k/µl, Serum amylase 500 IU/L ( N =  25 to 160 U/L) , Lipase 590 units/liter (Normal = 25 to 300U/L), AST  120 IU/L, ALT 200 IU/L, Total bilirubin 3.6gm% and  Alkaline phosphatase 200IU/L . Ultrasound reveal gallstones with no cystic duct obstruction and no evidence of cholecystitis and a  common bile duct diameter of 1.5cm. The most important step that will help improve the patient’s acute pancreatitis is :

a)    Intravenos Imipinem/ Cilastatin
b)    Endoscopic Retrograde Cholangiopancreatography ( ERCP)
c)    Stop Didanosine
d)    Stop Stavudine
e)    Exploratory Laporotomy

4 Responses

  1. ccc

  2. when you have a patient with pancreatitis, there can be many causes – Drugs, ETOH, GALL STONES. It is important to identify the cause from their labs so we can select next suitable step. A gall stone pancreatitis often has elevated ALT more than AST along with increased ALP and total bili. If alcoholic pancreatitis, LFT are typically normal but if there is concomitant ETOH hepatitis you will still have AST > ALT but not ALT > AST. ALT > AST in this q gives the clue. Remember, in gall stone CBD obstruction, ALT tends to rise first. Then do ultrasound to confirm this and increased CBD diameter > 1.0 cm is indicative of obstruction and therefore, should be followed by ERCP for confirmation of diagnosis as wella s to relieve CBD obstruction by stone removal and/ or stent placement .
    ( ref: Dr.Red Gastroenterology lecture)

  3. B

  4. B: Common bile duct dilation more than 7 mm is needs further invastigation.

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