171) A 54 year old woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She denies any fever, nausea or vomiting.
On physical examination, there is mild tenderness in right upper quadrant. Her liver function tests reveal an AST (SGOT) 160U/L ( N= 5 to 40U/L) , ALT (SGPT) 240U/L( N= 8 to 55U/L) , Alkaline phosphatase 110 U/L ( 40 TO 130U/L) , Total Bilirubin 1.2mg%. An ultrasound of the gall bladder does not reveal any gall stones or pericholecystic fluid and shows a common bile duct diameter of 9mm (normal 6mm). The most appropriate next step in managing this patient:
A) Hepatitis Serology
B) Laparoscopic Cholecystectomy
C) HIDA scan
D) Endoscopic Retrograde Cholangiopancreatography (ERCP)
E) Magnetic Resonance CholangiOpancreatography ( MRCP)
Archer USMLE Step 3 Blog 
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ercp – either charcots triad lets us do it, or the fact that CBD is dilated 9mm(very close to the guideline that says 10mm)
Hello Dr Red,
This lady does not have fever, nl alk po4
+ findings only-ruq pain,cbd 9 mm
Isnt it safe /cheaper to do MRCP rather than ERCP as the patient is not septic?
Thanks
Bindu
The most appropriate next step is Hepatitis serology. Answer is (a).
This is not obstructive jaundice. Alkaline phosphatase is normal.
Transaminases are elevated 3 fold. It suggests liver cells are being damaged by a non obstructive cause. Why not check for viral etiology?
Gall bladder is normal by ultrasound – not inflamed, so no ‘cholecystitis’ and no ‘cholecystectomy’. Rules out option (b)
MRCP, ERCP, HIDA are good to detect obstruction. But this guy does not have an obstruction! Rules out option (c),(d),(e)
Also pls note that invasive imaging like ERCP or MRCP is not recommended by some authors if a cyst is detected in the common bile duct. It is proven that risk outweighs benefit. These procedures can convert an uncomplicated cyst into a complicated cyst. The patient could develop cholangitis, a deadly complication from such procedures.
Sorry, I was carried away by the normal ALP. ALP is normal 30% of the time in CBD obstruction and besides, this patient has a dilated common bile duct and symptoms of obstruction, (elevated bilirubin).This patient has symptomatic CBD obstruction. I think ERCP will be diagnostic and therapeutic for this patient.
I think I made a big mistake. This patient clearly has obstructive CBD from gall stone. (dilated CDB, elevated bilirubin, ALT > AST, elevated bilirubin). The first thing to go up is ALT in gall stone ; ALP can be normal in 30% of symptomatic choledocholithiasis. US showes dilated CBD. Please disregard my earlier post. I feel ERCP should be done for definitive diagnosis and therapy (D). Cholecystectomy will not help now because the obstruction is past the cystic duct. We already know where there is an obstruction so HIDA wont be my choice. MRCP is only imaging, it will not remove the stone from the CBD. It is non-invasive. This is obstructive jaundice, hepatitis serology will not be my most appropriate next step when there is a CBD obstruction that is affecting liver function.
what about total bili which not high for obstructive jaundice?
i still feel ans a
mrcp