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* 14
 #140662  
  angioplasty - 11/22/06 17:17
 
  14. A 42-year-old African-American man with hepatitis C is admitted to the hospital for evaluation of a 3-day history of fever and right upper quadrant abdominal pain. The pain is steady and does not change with position. He has had associated nausea but has not vomited. He has a history of alcohol dependence but has not had an alcoholic beverage since being diagnosed with hepatitis C 4 years ago. He does not take any medications. On admission, vital signs are: temperature 38.5°C (101.3°F), pulse 115/min, respirations 24/min and blood pressure 100/60 mm Hg. Physical examination shows scleral icterus. Abdominal examination discloses mild distention and right upper quadrant tenderness to palpation; the liver spans 25 cm. There is no rebound tenderness and bowel sounds are normal. Ultrasonography of the right upper quadrant shows three small gallstones, dilated right and left intrahepatic ducts and normal common bile duct. Laboratory studies show:


Serum



Blood



ALT

650 U/L

Hematocrit

35%

AST

442 U/L
22,000/mm3

Alkaline phosphatase

342 U/L

PT

14 sec

Bilirubin

7.0 mg/dL

PTT140 mEq/L

INR

1.2

K+

4.2 mEq/L





Cl-

104 mEq/L





HCO3-Fluid resuscitation is begun. Which of the following is the most appropriate next step?

A

) Biopsy of the liver

B

) Cholecystectomy

C

) CT scan of the abdomen

D

) Endoscopic retrograde cholangiopancreatography with st


23 mEq/L


28 sec

Na+

WBC
 
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* Re:14
#568385
  pk007 - 11/22/06 17:29
 
  c.  
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* Re:14
#568408
  knock_knock - 11/22/06 17:43
 
  As liver Bx is not appropriate at this time, cholecystectomy is usually done within 48 hr or after pain and inflammation resolves and there is no indication for ERCP as the CBD is normal on sono, I'll go for C as well.  
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* Re:14
#568506
  ekammaoffiong - 11/22/06 20:08
 
  I'II say C,
but I don't understand why the hepatic ducts are dilated except the stones could have by passed through the common hepatic duct upwards towards the liver. Can someone pls carify me on that,
 
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* Re:14
#569292
  tea - 11/23/06 13:55
 
  c
 
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