RUQ Pain

Presentation:  46 yo M with 2 day hx of RUQ pain and n/v.  Taking Tylenol for pain. 

 PE:  VS NL, appears distressed, + TTP in RUQ and epigastrium


RUQ US:  showing sludge in gall bladder, no stones, no pericholecystic fluid and the wall was not thickened.  However, the common bile duct was dilated to 8mm without appreciable stones. 

Labs: Bilirubin and alk phos elevated to 8 and 950, respectively.  AST and ALT moderately elevated. 

 Teaching Point:  Choledocholithiasis:  According to ASGE Guidelines, this patient was at moderate to high risk of having a stone in the common bile duct, but not visualized on transabdominal ultrasound.  After the brief argument “He must have just passed a stone, surgery should admit him”, he was admitted to the hospitalist for GI consult and ERCP versus MRCP depending on GI recommendations. 

 Bonus Teaching Point:  He had taken 4.5 grams of Tylenol over the past 24 hours.  Despite a NL Tylenol level, he was started on NAC given his ingestion amount, lack of visualized stone on US, and his  LFT elevation. 

Leave a Reply

Your email address will not be published.