Thread: what's the cuz of her obstruction??

hiii everybody...
last week, a young lady was admitted to our hospital with a simple obvious history, but we still couldn't diagnose her appropriately!!! so i need your opinion plz...

She's an 18 yr old lady came to ER at Sunday 12-8-2007AD, C/O abdominal
pain of 1 week duration.
the pain started suddenly, located in the RHQ, not radiating, colicky, sever progressive, no aggravating factors, not relieved by analgesics, associated with anorexia, nausea, vomiting several times everyday.
H/O yellowish discoloration of sclera started 2 days prior to admission, with diarrhea & pale colored stool difficult to flush, dark tea colored urine, pruritis.
H/O fever for one day b4 admission, not documented.
systemic review:
H/O drowsiness
otherwise unremarkable.
Past History:
no previous similar attack.
no H/O chronic diseases or bleeding disorder.
no H/O surgeries or BT or prior hospitalization.
no H/O drug intake or allergy.
no family history of similar problem or contact with febrile or jaundiced patient.
she's single & sexualy inactive...

O/E:
only jaundice & febrile 38C, tenderness felt on palpating the RUQ...
otherwise normal.

Investigations:

CBC - WBC = 13.000 otherwise Nl

Chem - glu = Nl
elect & renal function = Nl
AST = 195
ALT = 198
APh = 200
t Bil = 5.53
d Bil = 4.01
albumin = Nl
amylase = NL

PT / PTT = Nl

hepatitis markers = -ve

US Abd = GB dilated lumen
IHBR & proximal biliary tree dilated
CBD dilated (14 cm)
NO STONEs seen
otherwise Nl.

CT abd = same findings. NO MASSES seen around the CBD & pancreas is Nl.

MRCP = IHBR + proximal biliary tree + proximal CBD = dilated
distal CBD = NOT SEEN (complete obstruction interrupting the dye)

ERCP = selective cannulization of the CBD was extremely difficult, sphincterotomy & papillotomy done & the dye was introduced showing the same findings as MRCP - dilated proximal biliary tree with complete obstruction & NO stone - so balloon dilatation done to relieve the retention cholangiogram but the obstruction persisted.

So... if u were me ... how will u further manage this patient ???

what do u think the possible causes of obstruction in this young lady ???

SAP is not elevated much..

Which country?

I would think of Viral Hepatitis..

she's from saudi arabia ...
why viral hepatitis ??? markers were negative & CBD is obstructed & we still don't know why..!!!

Obstructive Jaundice Differential Should Include Wandering Ascaris +acalculous Cholecystitis
Charcot Triad Is There Fever Jaundice And Ruq

Really A Interesting Case

Originally Posted by leesa

hiii everybody...
last week, a young lady was admitted to our hospital with a simple obvious history, but we still couldn't diagnose her appropriately!!! so i need your opinion plz...

She's an 18 yr old lady came to ER at Sunday 12-8-2007AD, C/O abdominal
pain of 1 week duration.
the pain started suddenly, located in the RHQ, not radiating, colicky, sever progressive, no aggravating factors, not relieved by analgesics, associated with anorexia, nausea, vomiting several times everyday.
H/O yellowish discoloration of sclera started 2 days prior to admission, with diarrhea & pale colored stool difficult to flush, dark tea colored urine, pruritis.
H/O fever for one day b4 admission, not documented.
systemic review:
H/O drowsiness
otherwise unremarkable.
Past History:
no previous similar attack.
no H/O chronic diseases or bleeding disorder.
no H/O surgeries or BT or prior hospitalization.
no H/O drug intake or allergy.
no family history of similar problem or contact with febrile or jaundiced patient.
she's single & sexualy inactive...

O/E:
only jaundice & febrile 38C, tenderness felt on palpating the RUQ...
otherwise normal.

Investigations:

CBC - WBC = 13.000 otherwise Nl

Chem - glu = Nl
elect & renal function = Nl
AST = 195
ALT = 198
APh = 200
t Bil = 5.53
d Bil = 4.01
albumin = Nl
amylase = NL

PT / PTT = Nl

hepatitis markers = -ve

US Abd = GB dilated lumen
IHBR & proximal biliary tree dilated
CBD dilated (14 cm)
NO STONEs seen
otherwise Nl.

CT abd = same findings. NO MASSES seen around the CBD & pancreas is Nl.

MRCP = IHBR + proximal biliary tree + proximal CBD = dilated
distal CBD = NOT SEEN (complete obstruction interrupting the dye)

ERCP = selective cannulization of the CBD was extremely difficult, sphincterotomy & papillotomy done & the dye was introduced showing the same findings as MRCP - dilated proximal biliary tree with complete obstruction & NO stone - so balloon dilatation done to relieve the retention cholangiogram but the obstruction persisted.

So... if u were me ... how will u further manage this patient ???

what do u think the possible causes of obstruction in this young lady ???

hey man good case plz post the diagnsis of this case wheneve you get it

really interesting...

so u repeated the Ix and couldn't find anything obstructing the duct?

acalculous jaundice should be considered. it could happen in critically ill patient, such as in sepsis. what about the charcot's triad mentioned for ascending cholangitis? the bug could have spread from there.

should we do a blood culture here?

What do these abbr. mean H/E O/H etc?

Was the head of pancreas normal in ERCP or in MRCP?

some thing like primary sclerosing cholangitis.ithink it could be possible ,,extra hepatic biliary tree of cbd might b involved look 4r ulcerativ colitis in her .check it if possible....dont skip the case vith out the answer pls....

features are suggestive of an obstructive cause. Why not repeating the ct scan with iv and oral contrast