Episode 5 - Yellowish Choledocholithiasis

Yellowish Choledocholithiasis

The sun rises over the San Joaquin Valley, California. 

 

BIG NEWS! Our program has relinquished our affiliation with UCLA and we have decided to join USC instead. Just kidding, April fools. Today is April, 1, 2020. This week the United States became the country with the most coronavirus cases in the world with over 213,000 confirmed cases, probably more by the time this podcast is over. COVID 19 continues to spread around the world, Italy being the country with the most casualties with over 12,000 deaths. 

 

It is difficult to talk about anything else during these times of turmoil. You may ask yourself, is this the result of a spontaneous viral mutation? Is it a conspiracy against Capitalism? Are extraterrestrials involved? Was the virus created for economic reasons? There are many theories, you can draw your own conclusion. What we can’t deny is that this pandemic has touched every aspect of our lives.

 

"When there is a crisis, let your heart pray, but let your hands work” - John Kramer

I am reminded of another quote: “Pray as if everything depends on God, work as if everything depends on you”, attributed to Ignatius. Religious freedom is great, isn’t i?  Today our guest is Gina Cha. Gina is known as “the intern” at Kern Medical by her inpatient team. I am glad she accepted the invitation to come and talk to us about a relevant topic today.

As you know, Gina, we have 5 questions in our podcast. Let’s start with question number one.

Who are you?

My name is Gina Cha, I am called “the intern”. I was born and raised in a small town about one hour north east of here called Porterville. I am Hmong and I have 7 siblings. I went to the American University of the Caribbean, Saint Martin.

 

What did you learn this week? 

This is case I’ve personally experienced this week in the hospital. 

We had a patient in her late 20s with no significant past medical history present with yellowing of the skin for 1 day. Other associated symptoms include right upper quadrant abdominal pain for one day that had since resolved. She also had episodes of nausea that had since resolved. She had noticed continual yellowing of the skin and reported to the ED. 

Comment: With the history that you obtained what did you think? 

Yellowing of the skin is called jaundice. Differential diagnosis of increased bilirubin, yellowing of the skin in this case including:

Chronic alcohol use (indicative of chronic liver damage) Hepatitis (viral infections of the liver affecting liver function)Gallstones (that can be block bilirubin excretion) Hemolysis (increased break down of hemoglobin)

Comment: Ascending cholangitis triad (Charcot’s): jaundice; fever, usually with rigors; and right upper quadrant abdominal pain. When the presentation also includes low blood pressure and mental status changes, it is known as Reynolds' pentad. How did you narrow down your differential?

Physical exam: unremarkable, no abdominal guarding, no Murphy’s sign. 

Comment: What is the Murphy’s sign? 

Well this is a technique is highly sensitive for diagnosis of acute cholecystitis. The way we perform this is by having the patient lay down by gently press on the right upper quadrant of the abdomen and having the patient take a deep breath. We are essentially feeling for the gallbladder and with a patient taking a deep breath, it allows the gallbladder to descend and be palpated. 

Comment: The same principle applies when a technician is performing a RUQ US, if there is pain with inspiration, it is a positive Murphy sign. What is cholecystitis? 

In short this is infection and inflammation to the gallbladder that can be quite serious if left untreated. It can cause symptoms such as fever, chills, an increase in a patient’s WBC, and can lead to perforation of the gallbladder and sepsis. 

Comment: What are other things you looked for? 

It is important to take into consideration lab values. Lab findings remarkable on a comprehensive metabolic panel: elevated liver enzymes including AST, ALT, Alk Phos, total bilirubin. Interestingly enough a meta-analysis of 22 studies revealed that an elevated serum bilirubin has a sensitivity of 69% and specificity of 88% for diagnosis of a stone in the bile duct. 

Comment: With those findings, were you able to narrow down the diagnosis? 

With this clinical picture and laboratory findings were indicative of a blockage somewhere in the biliary duct as the patient had RUQ pain that were “colicky” in nature, she was not anemic, hepatitis panel was negative. With these findings we were able to rule out some of our suspected differential diagnosis. 

To be sure, we obtained an Abdominal US and the patient had a dilated Common bile duct, approximately 8 mm in diameter. The common bile duct is a tube-like structure that carries bile from the liver to be expelled into the intestines.  Any CBD measuring more than 6mm with an elevated serum total bilirubin is highly predicative of a stone obstruction. Which leads to our patient’s diagnosis called Choledocholithiasis. 

Comment: Choledocholithiasis is a mouthful.  

[Chole] stands for “bile”, [doch] stands for duct. [lith[ stands  for stone. So choledocholithaisis is a fancy way of saying stone in the the bile duct. 

What makes up the biliary tree is the left and right hepatic duct coming together to make the common HEPTATIC DUCT that meets with the cystic duct to make up the command bile duct, which meets the pancreatic duct and drains into the duodenum via the ampulla of Vater. 

Cholelithiasis is a stone in the gallbladder, and Choledocholithiasis is a stone anywhere in the biliary out of the gallbladder.

Question Number 3: Why is that knowledge important for you and your patients? 

According to the national health and nutrition examination survey there are over 20 million Americans who reported that they have either gallstones or a history of cholecystectomy. It is important to recognize the common signs and symptoms of anyone with gallbladder disease, that way proper work up can be ordered and proper management can be performed.  

Question number 4: How did you get this knowledge? 

Most of the knowledge that I have is from my clinical experience. I’m much more of a hands-on learner than obtaining information from text books. During my rotations in surgery and in during my GI rotation I saw many of these cases. It made it much easier to go home and review in literature cases that I saw in the hospital.  

Question number 5: Where did this knowledge come from? 

There are multiple resources that we have access to including American Academy of Family Physicians and Up to date and multiple questions that I’ve reviewed on USMLE world. For this particular case, I reviewed the articles by Arain, Mustafa and Zakko , Salam F, and Nezam H Afdhal in Up to Date.

 

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Speaking Medical 
by Lisa Manzanares

The word of the day is amblyopia.  This is a non-lazy way of saying “lazy eye.” Amblyopia is the functional reduction in visual acuity caused by abnormal visual development early in life, up to age 6 years.  Amblyopiais decreased vision in an eye that otherwise typically appears normal.  Amblyopia is THE most common childhood cause of monocular vision loss.  In Greek, amblyopia means “dullness of vision.” It occurs in 2-6% of U.S. children. 

Causes of amblyopia include strabismus, which is the most common, followed by refractive amblyopia, and then depravation amblyopia such as that caused by a scar or mass, which is the least common.  Methods of treatment include: patching, atropine, and Bangter filter applied to glasses lens of the good eye, depend on what type and how severe the amblyopia is.  

If there is suspicion for Amblyopia, don’t think, “That’s all Greek to me,” place pediatric ophthalmology referral because amblyopia is nearly irreversible by 9 years of age.

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Espanish Por Favor (Spanish Word of the Day) 
by Roberto Velazquez 

Hi this is Dr RAVA on our section Espanish por favor. This week’s Spanish word is “angina”, which it is spelled the same as angina. Although, angina in Spanish means tonsils. People usually use this word in its plural form anginas referring to both tonsils. This word comes from the Latin root angina which means strangling or choking or narrowing of the throat. So you can have a patient coming to you saying, “Doctor, me duelen las anginas,” and literally it sounds “Doctor, I have angina pain”. If you hear this, don’t panic, your patient is not having a heart attack. He or she is telling you that they have a sore throat.  Now you know the Spanish word of the day, angina or anginas, all you need to do is to assess your patient’s tonsils. Have a great week and take care. 

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[Music] For your Sanity (Medical joke of the day)
by Lisa Manzanares and Roberto Velazquez

Q: Did you hear about the optometrist that fell into his lens grinding machine?
A: He made a spectacle of himself

Q: Does an apple a day keep the doctor away?
A: Only if you aim it well enough

Q: Why did Dracula go to the doctor?
A: He couldn't stop his coffin

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During this episode we talked about Choledocholithiasis. Remember, think about the liver, alcohol, gallbladder, hemolysis, and infections when you see a yellow-skin patient. A millimetric stone obstructing the biliary tree can cause a big trouble if it is not diagnosed and treated on time. Don’t forget the medical word of the day Amblyopia or “lazy eye”, and the Spanish word “Angina”, which has little to do with the English word Angina. See you next week! 

 

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email [email protected], or by visiting our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Lisa Manzanares, Roberto Velazquez, and Gina Cha. Audio edition: Suraj Amrutia. 

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References

Arain, Mustafa A, et al. “Choledocholithiasis: Clinical Manifestations, Diagnosis, and Management.” UpToDate, 2 Mar. 2020, www.uptodate.com/contents/choledocholithiasis-clinical-manifestations-diagnosis-and-management?search=choledocholithiasis&source=search_result&selectedTitle=1~112&usage_type=default&display_rank=1.

Zakko , Salam F, and Nezam H Afdhal . “Acute Calculous Cholecystitis: Clinical Features and Diagnosis.” UpToDate, Uptodate, 8 Nov. 2018, www.uptodate.com/contents/acute-calculous-cholecystitis-clinical-features-and-diagnosis?search=cholecystitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.