PA 526 Week 8 Hepatobiliary Case Paper Example

Hepatobiliary Case Paper: One Shared Drainage System Behind N.R.'s Jaundice, Fever and Back Pain, Each Lab Value Assigned to Liver, Bile Duct or Pancreas, and the Diagnoses That Lost to a Stone in the Common Duct

Student Name

Chamberlain University

PA 526: Comprehensive Clinical Module Gastroenterology

Instructor Name

Month Day, Year

Hepatobiliary Case Paper: One Shared Drainage System Behind N.R.'s Jaundice, Fever and Back Pain, Each Lab Value Assigned to Liver, Bile Duct or Pancreas, and the Diagnoses That Lost to a Stone in the Common Duct

Introduction

Seven weeks after the bleeding ulcer was treated, and two weeks before the scheduled gallbladder operation, N.R. arrived at the emergency department with a day of right upper quadrant pain, shaking chills, a temperature of 38.9 C and yellow eyes, plus a band of pain through to the back. This paper reasons through the case around the anatomy the three organs share: the liver's bile ducts, the gallbladder's cystic duct and the pancreatic duct all drain through the common channel at the ampulla into the duodenum.

One Exit, Three Organs

Bile from the liver flows through the hepatic ducts into the common bile duct, which the cystic duct joins from the gallbladder. Near its end, the common bile duct runs through the head of the pancreas and usually joins the pancreatic duct before both empty at the ampulla. A stone can sit in the cystic duct and inflame the gallbladder, in the common bile duct and block bile from the liver, or at the ampulla and block both bile and pancreatic juice. The location of one stone therefore decides which organ shows the injury, and the paper is organized around that single exit rather than three separate organs.

Chemistry Assigned to an Organ

For the liver and its ducts: total bilirubin 5.8 mg/dL, mostly direct; alkaline phosphatase 410 U/L and GGT 610 U/L, a cholestatic pattern showing bile backing up into the liver. ALT 180 U/L reflects liver cell irritation from the back pressure. Albumin 3.8 g/dL and INR 1.1 show that liver function is preserved.

For the pancreas: lipase 1,240 U/L, more than three times the upper limit, with back pain, which meets two of the three criteria for acute pancreatitis.

For the blood and infection: white cells 16.8 × 10^9/L, C-reactive protein raised, two sets of blood cultures drawn before antibiotics.

For the gallbladder itself: no specific laboratory marker; its state comes from imaging.

What Imaging Is Asked to Show

Ultrasound was asked one question: is the common bile duct dilated, and are there stones in it or in the gallbladder? It showed multiple gallbladder stones without wall thickening, a common bile duct of 9 mm (dilated for age) and a possible echogenic focus near its lower end, partly hidden by bowel gas. CT was not ordered first, because ultrasound answers the duct question with no radiation, and contrast would add little within the first 72 hours of pancreatitis.

Acute Cholangitis

Under the Tokyo Guidelines, a definite diagnosis of acute cholangitis needs three things together: an inflammatory response in the body, laboratory signs that bile is backing up, and a scan showing the duct widened or the thing widening it (Kiriyama et al., 2018). N.R. has fever with raised inflammatory markers, jaundice with abnormal liver tests and a dilated duct: a definite diagnosis. The guidelines grade severity by organ dysfunction; N.R.'s blood pressure, kidney function, platelets and mental status are normal, but the white count above 12 places N.R. in the moderate grade, which calls for early drainage.

The Plan

Intravenous fluids and broad antibiotics after blood cultures. The ASGE guideline places a patient with cholangitis in the high-probability group for a common duct stone and recommends proceeding to ERCP rather than further imaging (Buxbaum et al., 2019). ERCP was done the next morning: a 7 mm stone was removed from the lower common duct after a sphincterotomy, and pus drained from the duct. Gallbladder removal is planned during the same admission once the pancreatitis settles, because leaving the gallbladder in place after gallstone pancreatitis carries a high risk of recurrence.

The Versions That Lost

Acute cholecystitis alone: would cause right upper quadrant pain, fever and a positive Murphy sign, but rarely a bilirubin this high and not a dilated duct; the ultrasound showed no wall thickening. It lost.

Hepatitis from drugs or viruses: would raise ALT far more than alkaline phosphatase, with no duct dilation. The R ratio here is below 2, the cholestatic range in the liver chemistry guideline (Kwo et al., 2017), and the duct is dilated. It lost.

Pancreatic head tumor: can block the duct and cause jaundice, but usually without fever or such sudden pain, and a stone was found. It lost for now, although the ERCP findings and later imaging will confirm the pancreas head is normal once the inflammation has passed.

A complication of the healed ulcer: a posterior duodenal ulcer can penetrate the pancreas, but would not dilate the bile duct or explain the jaundice. It lost.

Connecting the Year

Looking back, N.R.'s first visit described biliary colic, the liver panel after the fourth attack suggested a stone that passed, and this admission is the stone that did not. The bleeding ulcer, treated endoscopically and followed by a confirmed healing exam as the bleeding guideline supports (Laine et al., 2021), and the dysphagia, found to be a peptic stricture on endoscopy and dilated after healing, were separate problems in the same patient. Each was handled at its own point along the gut, which is the lesson of the course.

Conclusion

A stone at the lower end of the common bile duct, the shared exit, explains every finding: obstructed bile flow, infection behind the blockage and pancreatic inflammation from the shared channel. Assigning each value to the organ it reports for, and reading imaging as an answer to a specific question, led directly to ERCP. The case also shows the cost of delay: a gallbladder with known stones awaiting surgery can produce a duct stone at any time.

References

Buxbaum, J. L., Abbas Fehmi, S. M., Sultan, S., Fishman, D. S., Qumseya, B. J., Cortessis, V. K., Schilperoort, H., Kysh, L., Matsuoka, L., Yachimski, P., Agrawal, D., Gurudu, S. R., Jamil, L. H., Jue, T. L., Khashab, M. A., Law, J. K., Lee, J. K., Naveed, M., Sawhney, M. S., . . . Wani, S. B. (2019). ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointestinal Endoscopy, 89(6), 1075-1105.e15. https://doi.org/10.1016/j.gie.2018.10.001

Kiriyama, S., Kozaka, K., Takada, T., Strasberg, S. M., Pitt, H. A., Gabata, T., Hata, J., Liau, K.-H., Miura, F., Horiguchi, A., Liu, K.-H., Su, C.-H., Wada, K., Jagannath, P., Itoi, T., Gouma, D. J., Mori, Y., Mukai, S., Gimenez, M. E., . . . Yamamoto, M. (2018). Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis (with videos). Journal of Hepato-Biliary-Pancreatic Sciences, 25(1), 17-30. https://doi.org/10.1002/jhbp.512

Kwo, P. Y., Cohen, S. M., & Lim, J. K. (2017). ACG clinical guideline: Evaluation of abnormal liver chemistries. American Journal of Gastroenterology, 112(1), 18-35. https://doi.org/10.1038/ajg.2016.517

Laine, L., Barkun, A. N., Saltzman, J. R., Martel, M., & Leontiadis, G. I. (2021). ACG clinical guideline: Upper gastrointestinal and ulcer bleeding. American Journal of Gastroenterology, 116(5), 899-917. https://doi.org/10.14309/ajg.0000000000001245