Title: The Oxbow (View from Mount Holyoke, Northampton, Massachussetts, after a Thunderstorm)

Artist: Thomas Cole

Date: 1836

Source/ Museum: The Metropolitan Museum of Art, New York

Medium: oil on canvas

Size: 51 1/2 x 76" (1.31 x 1.94 m)

HC MORNING REPORT

Cathy Larrain, MD, PGY2Cooper University Hospital

November 4, 2009

75 y.o. M with a history of DM, HTN, HPL, BPH presents with 5 days of painless jaundice, nausea, epigastric fullness, and tactile fever/chills.

ROS:(+)tactile fever/chillsunspecified weight loss over the past 4-5 mos.mild dyspneashoulder painepigastric fullness and sensation of tightnessadmits to using acetaminophen for URI and HA

Denies tobacco or illicit drug use, (+)social alcohol use

Works at a post office No known drug allergies Home medications: antihypertensives,

Metformin, medication for cholesterol

Family history: Mother died @75 y.o. from lung cancer. Otherwise noncontributory

Differential Diagnoses

Infectious Disorders (Specific Agent) Viral hepatitis Leptospirosis Yellow fever Cirrhosis, syphilitic (Hepar

lobatum)

Neoplastic Disorders Adenocarcinoma, ampulla of

Vater Metastatic liver disease Adenocarcinoma, pancreatic Carcinoma, gallbladder Carcinoma, biliary tree

Allergic, AutoImmune Disorders Autoimmune hepatitis (Plasma

cell) Cirrhosis, Primary Biliary

Hereditary Disorders Cirrhosis/childhood Indian type

Reference to Organ System Cirrhosis Cirrhosis, cryptogenic

Drug Induced Toxic hepatitis

Physical Examination T 98.6, HR 67, BP 88/58, RR 12, SaO2 96% on RA

NAD, AAOx3 with diffuse jaundice and scleral icterus, PERRLA, NC/AT

No palpable LAD, supple neck, depressed JVP

CTAB bilaterally no r/r/w, RRR no m/r/g

Abd soft (+)BS (-)Murphy’s (+)hepatomegaly, ND, NT

No c/c/e, no asterixis

Laboratory and Imaging

Albumin 3.2 {3.5-5.3} AlkPhos 495 {39-117} Totalprot 6 {5.9-8.3} SGPT (ALT) 118 {0-40} SGOT (AST) 122 {0-37} Totalbili 27.4 {0-1} Directbili 20.3 {0-0.3} Indirectbili 7.1

Influenza A&B (-)

AG 16.8

Amylase 60 {15-120} Lipase 30 Ammonia 75 {28.2-80.4} GGT 199 {8-69}

CK 180 {40-172} TnI 0.24 {0.01-0.4}

12.7

36.2

18.2 322127

2.8

92

21

37

1.32125

Ca 8.2

1.5

38.217.8

10/28 Blood culture E.coli 10/29 Blood culture E.coli 10/29 Urine culture <10,000 cfu/ml mixed

gram positive organisms, probable contamination

UA negative UDS negative

Electrocardiogram: NSR 80 bpm, left axis deviation

CT abdomen and pelvis: severe heterogeneity of liver consistency with hepatocellular disease vs infiltrating malignancy. Intrahepatic & extrahepatic biliary duct dilation with possible calculus in distal CBD. Limited evaluation of gallbladder with possible pericholecystic fluid. Enlarged prostate.

UnderaerationPatchy parenchymal opacities may represent atelectasis. Infectious vs inflammatory process cannot be excluded

Sludge and tiny stones presumably filling GB lumen and extending into normal caliber CBD. Top size normal liver with mildly heterogeneous echogenicity. Trace perinephric fluid on left. Bilateral pleural effusions.

CBD 5-6 mm distal CHD 8 mm

6 mm impacted calculus within the distal duct

Biliary sphincterotomy was performed with stone removal

10-Fr 7 cm biliary endoprosthesis was placed for complete drainage of contrast

Normal pancreatic duct

Acute Cholangitis

Charcot’s triad: RUQ pain, fever with chills, jaundiceUsually in the setting of biliary obstructionBacteremia and shock are common

Medical emergency with high morbidity and mortality

ERCP is an established mode of treatment The cause of biliary obstruction may influence the

outcome, with malignant biliary obstruction having a worse prognosisMalnutrition, weakened immunity, effects of

chemotherapy and the malignancy itself

Primary Sclerosing Cholangitis

Cholestatic liver disorder characterized by inflammation, fibrosis, eventual obliteration of the extrahepatic and intrahepatic bile ducts

Middle aged men Presentation of jaundice, hepatomegaly, pruritis,

weight loss, and fatigue Associated with IBD (70% with UC) and

cholangiocarcinoma (6-20% patients) May progress to cirrhosis and ESLD

Should be considered in individuals with IBD and increased AP

Confirmation by ERCP or MRCP +/- liver biopsy

Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6. Acute cholangitis associated with bile duct stones

carries a considerable morbidity and mortality. Conservative treatment with antibiotics is effective in

only 80% of cases. 20% of patients who developed suppurative cholangitis

do poorly without drainage. This is because complete bile duct obstruction affects the

excretion and penetration of antibiotics into bile. Retrospective analysis, as well as prospective

randomized controlled trials, have shown that urgent endoscopic drainage is an effective treatment for suppurative cholangitis and is superior to surgical drainage with a better clinical outcome

Siegel JH, Rodriguez R, Cohen SA, Kasmin FE, Cooperman AM. Endoscopic Management of Cholangitis: Critical Review of an Alternative Technique and Report of a Large Series. American J Gastroenterology. 2008; 89 (8): 1142-46. Objective: To assess the outcome of endoscopic techniques as the solitary treatment

modality for the complete management of ascending, bacterial cholangitis, compared with results of radiological and surgical methods as historical controls.

Methods: Endoscopic techniques were used to decompress bile ducts obstructed by stones (898 patients) or stenosis (49 patients).

Endoscopic sphincterotomy (ES) was performed in 839 patients with either 7-Fr stents or nasobiliary tubes.

Of these latter patients, 68 subsequently underwent ES and stone removal, 17 had ES, litho-tripsy, and stone removal, 18 were left with stents in place, and 5 were lost to follow-up. Follow-up was conducted by direct patient contact, by telephone, or through the referring physicians.

Results: All patients were managed by endoscopic techniques. There were four deaths (0.42%) in the first 30 days (none before 2 wk); no deaths were related to the procedures but were attributed to intercurrent medical problems. Two patients underwent surgery: one pancreatitis, one perforation. Complications were infrequent, occurring in 6% of patients. Bleeding occurred in 3%, pancreatitis in 2.8%, and perforation 0.2%.

Conclusions: Endoscopic management of cholangitis is as effective as surgical or radiological methods for managing bacterial cholangitis, a potentially fatal syndrome, but ERCP and ES have been shown to be safer. Endoscopy is the preferred index technique both for establishing a definitive diagnosis and providing therapy.

Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest. Endosc. 1991; 37: 383-91. Despite its relative safety (in comparison with

surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy not without risk.

Complications occur in about 10% of patients

2 to 3% have a prolonged hospital stay, with a risk of mortality

Emphasis on the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues

Mirizzi syndrome is a rare complication of cholelithiasis, characterized by the narrowing of the common hepatic duct as a result of mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct

Polson J, Wians FH Jr., Orsulak P, et al. False positive acetaminophen concentrations in patients with liver injury. Clinica Chimica Acta. 2008; 391 (1-2): 24-30. False positive acetaminophen tests may

result when enzymatic-colorimetric assays are used, most commonly with bilirubin concentrations > 10 mg/dl, leading to potential clinical errors in this setting.

References Cotton PB, Lehman G, Vennes J et al. Endoscopic

sphincterotomy complications and their management: an attempt at consensus. Gastrointest. Endosc. 1991; 37: 383-91

Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6.

Polson J, Wians FH Jr., Orsulak P, et al. False positive acetaminophen concentrations in patients with liver injury. Clinica Chimica Acta. 2008; 391 (1-2): 24-30.

Washington Manual pp. 385, 460-61, 489-90.

The End

Title: Under the Birches

Artist: Pierre-Étienne-Théodore Rousseau

Date: 1842-1843

Source/ Museum: Toledo Museum of Art, Ohio

Medium: oil on wood panel

Size: 16 5/8 x 25 3/8" (42.2 x 64.4 cm)

John AR, Haghighi KS, Taniere P, Esmat ME, Tan YM, Bramhall SR. Is a raised CA 19-9 level diagnostic for a cholangiocarcinoma in patients with no history of sclerosing cholangitis ? Dig Surg. 2006; 23 (5-6): 319-24.

The aim of this study is to assess the role of CA 19-9 in patients with a cholangiocarcinoma without PSC.

METHODS: The prospectively collected information on patients with biopsy-proven cholangiocarcinomas who had the CA 19-9 level measured was obtained (n = 68) from our computer database and medical records. These patients were compared with patients who had benign liver tumors (n = 25) and benign bile duct strictures (n = 13) who also had their CA 19-9 concentration measured.

RESULTS: Sensitivity and specificity of CA 19-9 in the diagnosis of a cholangiocarcinoma were 77.9 and 76.3%, respectively, when using a cut-off value of 35 kU/l, while sensitivity and specificity were 67.5 and 86.8%, respectively, when the cut-off value was raised to 100 kU/l. The specificity was found to be higher in patients with peripheral cholangiocarcinomas (96%) using a CA 19-9 cut-off value >100 kU/l. A CA 19-9 value >600 kU/l was associated with non-resectable tumors (p = 0.05).

CONCLUSIONS: This study demonstrates that CA 19-9 is a useful adjunct in the diagnosis of cholangiocarcinomas without primary sclerosing cholangitis, especially in the diagnosis of peripheral cholangiocarcinomas. However, it does not provide a reliable guide for the pathological staging of these tumors