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Matias; Maulion; Medenilla; Medina; Medina; Matias; Maulion; Medenilla; Medina; Medina; Mejino; Melgarejo; Mendoza, Alvin, Diana and Mejino; Melgarejo; Mendoza, Alvin, Diana and Donn Donn

Matias; Maulion; Medenilla; Medina; Medina; Mejino; Melgarejo; Mendoza, Alvin, Diana and Donn

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Matias; Maulion; Medenilla; Medina; Medina; Mejino; Matias; Maulion; Medenilla; Medina; Medina; Mejino; Melgarejo; Mendoza, Alvin, Diana and DonnMelgarejo; Mendoza, Alvin, Diana and Donn

K.F.K.F. 80 year old80 year old femalefemale

Informant: patientInformant: patient

   Chief Complaint:Chief Complaint:

yyeelllloowwiisshh ddiissccoolloorraattiioonn ooff tthhee sskkiinn

2 months PTC2 months PTC gradual loss of weightgradual loss of weight decrease in appetitedecrease in appetite

dull abdominal pain in the epigastric dull abdominal pain in the epigastric areaarea

No consult was done, no medications No consult was done, no medications takentaken

1 week PTC1 week PTC yellowish discoloration of skin & scleraeyellowish discoloration of skin & scleraeprogression of the abdominal painprogression of the abdominal pain

acholic stoolsacholic stools

Persistence prompted present consultation.Persistence prompted present consultation.

BP 140/90, PR 89 bpm, RR 20 cpmBP 140/90, PR 89 bpm, RR 20 cpm Temp 36.5 Temp 36.5 °°CC Warm moist skin, (+) jaundiceWarm moist skin, (+) jaundice Pale palpebral conjunctivae, icteric scleraePale palpebral conjunctivae, icteric sclerae No naso-aural dischargeNo naso-aural discharge Moist buccal mucosa, yellowish frenulumMoist buccal mucosa, yellowish frenulum Supple neck, no palpable cervical lymph nodesSupple neck, no palpable cervical lymph nodes Flabby, soft and non-tender abdomenFlabby, soft and non-tender abdomen Normoactive bowel soundsNormoactive bowel sounds Pulses full and equalPulses full and equal No cyanosis, no edemaNo cyanosis, no edema

SALIENT FEATURESSALIENT FEATURES 80- year old80- year old FemaleFemale Gradual weight loss Gradual weight loss Decrease in appetiteDecrease in appetite Dull abdominal pain in the epigastric area, which Dull abdominal pain in the epigastric area, which

later progressedlater progressed Yellowish discoloration of the skin and scleraeYellowish discoloration of the skin and sclerae Yellowish frenulumYellowish frenulum Acholic stoolsAcholic stools

CholedocholithiasisCholedocholithiasis

Presence of a gallstone in the common bile ductPresence of a gallstone in the common bile duct The stone may consist of bile pigments or The stone may consist of bile pigments or

calcium and cholesterol saltscalcium and cholesterol salts About 15% of people with gallstones will develop About 15% of people with gallstones will develop

stones in the common bile ductstones in the common bile duct Risk factor: a previous medical history of Risk factor: a previous medical history of

gallstonesgallstones However, choledocholithiasis can occur in However, choledocholithiasis can occur in

people who have had their gallbladder removed.people who have had their gallbladder removed.

Clinical ManifestationsClinical Manifestations

Abdominal painAbdominal pain

- sharp, cramping, or dull - sharp, cramping, or dull

- may spread to the back and - may spread to the back and subscapular area subscapular area

- get worse after eating fatty or - get worse after eating fatty or greasy greasy foods foods

- may occur within minutes of a meal - may occur within minutes of a meal

Clinical ManifestationsClinical Manifestations

FeverFever Loss of appetiteLoss of appetite JaundiceJaundice NauseaNausea VomitingVomiting

UltrasoundUltrasound

Abdominal ultrasound scans show a mildly dilated common bile duct measuring 8 mm in diameter (arrow). An echogenic calculus with acoustic shadowing is visible in the distal portion of the common bile duct (arrow). There is no intrahepatic biliary dilatation. The gallbladder appears contracted (arrow). These findings are consistent with choledocholithiasis resulting in early or incomplete biliary obstruction.

UltrasoundUltrasound

ultrasound findingsultrasound findings

- dilated common - dilated common bile duct (cbd) with small bile duct (cbd) with small stone located distally stone located distally ((arrowarrow).).

posterior acoustic posterior acoustic shadowing (shadowing (arrowheadarrowhead))

CT ScanCT Scan

Common bile duct stoneCommon bile duct stone

- target sign- target sign

On On contrast-enhanced helical CT contrast-enhanced helical CT scanscan, choledocholithiasis is , choledocholithiasis is represented as represented as central density central density ((arrowheadarrowhead) surrounded by ) surrounded by hypoattenuating ampulla of hypoattenuating ampulla of Vater Vater ((arrowarrow).).

In this particular scan, stone is In this particular scan, stone is seen as heterogeneous with seen as heterogeneous with center showing lower density.center showing lower density.

CT ScanCT Scan

Stone in distal common bile ductStone in distal common bile duct

- - rim signrim sign

Faint rim of increased density Faint rim of increased density ((arrowarrow) along peripheral margin ) along peripheral margin of low-density calculusof low-density calculus

CT ScanCT Scan

Common bile duct stoneCommon bile duct stone

- crescent and target - crescent and target signssigns

stone (stone (arrowarrow) completely ) completely surrounded by bilesurrounded by bile