Question of the Week # 455

You are evaluating a 63-year-old female with a complaint of abdominal pain radiating to her back. She has diminished appetite and pruritus. Her past history is significant for a 40-year history of tobacco use. She has three glasses of wine once a week.

The patient is afebrile, with blood pressure of 123/85, and her heart rate is 74. She appears jaundiced, with scleral icterus. Her abdomen is tender to palpation in the epigastric region, and her liver is palpable 2 cm below the right costal margin. Laboratory tests reveal total bilirubin of 6.0. direct bilirubin of 4.8, alkaline phosphatase of 1000, and AST is 42, with and ALT of 40. Which of the following initial diagnostic test will you order?

A. Abdominal ultrasound

B. Percutaneous liver biopsy

c. Percutaneous transhepatic cholangiography

D. CT abdomen and pelvis

E. Endoscopic retrograde cholangio-pancreatography.

8 Responses

  1. E

    • Initial diagnostic test should be Abdominal ultrasound A

  2. A. Abdominal Ultrasound-most reliable non -invasive n quick technique to suggest obstruction

  3. A, I think this is the initial test

  4. A. Abdominal U/S

  5. A.
    Ultrasonography (US) is the least expensive, safest, and most sensitive technique for visualizing the biliary system, particularly the gallbladder. Current accuracy is close to 95%.
    http://emedicine.medscape.com/article/187001-workup#2

    • Plus the picture suggests chokestasis and a/c pancreatitis possibly from a CBD stone

  6. cholestatic jaundice is the clinical picture,obstruction of the biliary tree secondary to gall stones, or tumor..as patient has long smoking history, and other LFT’s are normal. U/S is the least expensive and most sensitive test and the BEST INITIAL step, a CT scan of the abdomen and pelvis would be the next most accurate and least invasive if diagnosis still cannot be made, the most accurate step would be the ERCP

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