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.