NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Leak Figure 7-12: ERCP and cholangiogram showing extravasation of dye near the cystic duct remnant and along the undersurface of the liver.

Case 7.11 Painless Jaundice You are asked to evaluate and manage a 55-year-old with jaundice of recent onset. The patient denies pain but has marked pruritus. Blood studies reveal a direct biliru- bin of 6 mg/dL, normal aspartate aminotransferase (AST [serum glutamic-oxaloacetic transaminase]) and alanine aminotransferase (ALT [serum glutamate pyruvate trans- aminase]), and an alkaline phosphatase of six times normal. Q: What are the most common diagnoses? A: The laboratory tests indicate an obstructive process to the biliary tree . The differential diag- nosis is cancer of the head of the pancreas, periampullary carcinoma, cholangiocarcinoma (Klatskin tumor), stricture of the CBD, and, occasionally, a CBD stone impacted in the ampulla . Pancreatic adenocarcinoma and cholangiocarcinoma are usually accompanied by weight loss. In addition, these cancers may be accompanied by vague abdominal or back pain. Strictures of the CBD typically occur in chronic alcoholics who have chronic pancreatitis or patients who have had prior biliary surgery. CBD stones that are impacted in the ampulla typically result in intermittent symptoms of abdominal pain, jaundice, fever, and chills. However, on occasion, presenting features may be similar to those of patients with carcinoma. Q: How would you further define the problem? A: An abdominal ultrasound study is a good initial step to visualize the CBD as well as stones in the gallbladder or duct. An ultrasound study indicates a dilated CBD and no gallstones or pancreatic masses. SAMPLE