Hey this is Dr K from imedicalschool.
Today we are going to discuss a step 1 practice question.
So lets get started.
The question is a 56 year old male with a past medical history of hypertension, diabetes,
and hyperlipidemia presents with new onset painless jaundice without associated abdominal
pain.
Vitals signs are normal.
Basic labs are drawn and are shown.
The total bilirubin is 9.2, Direct 7.8, albumin is 3.8, ALT is 130, AST is 146, and alkaline
phosphatase is 405.
What is the next best step for this patient.
Is it A Hida Scan, B right upper quadrant ultrasound, C ERCP, D IV antibiotics, or E
emergent cholecystectomy.
Take a few moments and pause here to think about the question and come up with your answer.
Alright let's talk about the correct answer.
The correct answer is right upper quadrant ultrasound.
Let's talk about why B is the best answer.
Whenever someone presents with painless jaundice it is cancer until proven otherwise.
To identify the cause we need imaging.
A HIDA scan is a very good test to identify obstruction but given that it has greater
specificity and less sensitivity we generally do a RUQ ultrasound.
If the RUQ ultrasound is negative but the clinical suspicion is high then we could consider
a HIDA scan.
In terms of urgent surgery there is no need for an emergent cholecystectomy as the patient
is normotensive and has no red flag signs to indicate a cholecystectomy.
IV antibiotics would be indicated if the patient had cholangitis.
Cholangitis usually presents wight the symptoms and signs in Charcot's triad or Reynold's
pentad.
Charcot's triad is fever, right upper quadrant pain and jaundice.
Reynold's pentad is chariot's triad plus hypotension and altered mental status.
Given the patient does not meet these criteria antibiotics should not be administered
Finally lets talk about ERCP.
ERCP is a procedure that can identify blockages of the biliary tract from stones or masses
and then open up those blockages.
Before obtaining an ERCP you need an ultrasound to identify the location and the likely cause
of the obstruction.
This is why before doing an intervention we generally obtain a RUQ ultrasound given it
is a cheap non interventional test that can provide a great deal of information.
So when anyone presents with jaundice we generally know that the biliary tract or liver is being
affected in some way so the first step is almost always to obtain a RUQ ultrasound.
Lets talk about how to interpret abnormal liver function tests.
If a patient has a transaminitis, that is an elevated AST and ALT, we need to determine
if the patient has a cholestatic or noncholestatic liver pattern.
Cholestatic means there is an obstruction, either from a gall stone, mass, stricture
or inflammation.
Noncholestatic generally indicates a process that is affecting the liver and not the biliary
tract.
Let's briefly review the biliary tract.
The liver empties into the hepatic duct and the gallbladder empties into the cystic duct,
with both creating the common bile duct.
The pancreas empties into the common bile duct which empties into the duodenum.
When there is an obstruction in the CBD or hepatic duct this can lead to a transaminitis
with an elevated alkaline phosphatase.
Now the biggest question is how to differentiate between a noncholestatic and cholestatic liver
pattern.
To differentiate between these patterns look at the alkaline phosphatase.
If a alkaline phsophatase is significantly higher than the levels of transaminases I
generally consider this to be a cholestatic picture.
If not then it is noncholestatic.
Now remember biliary obstruction is not the only part of the body that can cause an elevation
in alkaline phosphatase.
ALP can be increased by anything that affects gut, bone, and uterus.
We can identify biliary versus other causes by obtaining a GTT.
If the GGT is high this indicates that the ALP is likely due to biliary obstruction.
In addition we can also identify if the ALP is of biliary origin if we fractionate the
ALP.
Fractionating the ALP identifies how much ALP comes from bone, gut, uterus,or the biliary
tree.
Lets briefly review the biliary anatomy.
In todays' s case we have elevated ALT and AST with an elevated ALP higher than the transaminases
with jaundice indicating a cholestatic pattern.
So remember jaundice workup almost always begins with a RUQ ultrasound.
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This is Dr K i will see you next time.