![]() What tests should be used to confirm initial tests?Ĭholedocholithiasis detected on radiologic imaging usually does not warrant additional confirmatory testing. Air in the biliary tree seen on imaging is suggestive of choledochoenteric fistula or in the right clinical setting (fever, jaundice, abdominal pain, hypotension, mental status changes) for cholangitis. MRCP sensitivity is lower for smaller stones.Įndoscopic ultrasound (EUS) is a minimally invasive procedure and has higher sensitivity than MRCP, but it is not widely available on an urgent basis, requires sedation, and is operator dependent (Verma et al. MRCP image quality can significantly vary from institution to institution and is prone to motion artifact. Magnetic resonance cholangiopancreatography (MRCP) is a very good test for evaluation of main bile duct stones because it affords an excellent noninvasive visualization of the biliary tree. Transabdominal ultrasound is a good test to use for evaluating for gallbladder stones and bile duct dilation however, it is not very sensitive for main bile duct stones. Computed tomography (CT) can detect bile duct dilation but is suboptimal to evaluate for bile duct stones. Plain abdominal films are insensitive in detecting choledocholithiasis, but, in rare instances, they can visualize calcified stones or can detect air in the biliary tree. The noninvasive ones should be considered first. Several modalities exist for the evaluation of bile duct stones (Freitas et al. How can I confirm the diagnosis? What tests should be ordered first? Obstructive jaundice,intermittent elevation of liver chemistriesĬholestasis, leucocytosis, positive blood culturesĬholestasis, cholangitis, moderate elevation of CA 19-9Ĭholestasis, weight loss, elevated CA 19-9Ībnormal liver chemistries or elevated amylase/lipase, bile duct dilation Jaundice, palpable gallbladder, weight lossįever, right subcostal tenderness on inspiration (Murphy’s sign), palpable gallbladder, mild jaundiceĪbdominal tenderness, abnormal liver chemistries or amylase/lipase ![]() Jaundice, stigmata of disease contributing to formation of stricture Jaundice, fever with chillsīiliary colic usually lasting >6 hours, nauseaįever, right upper quadrant tenderness, jaundice, hypotension, or peritoneal signs Mental status changesĪsymptomatic, weight loss, jaundice, or abdominal pain (See Table I for signs, symptoms, and other features of choledocholithiasis and cholangitis, among others.)Īsymptomatic,biliary colic, orabnormal liver chemistryĪbdominal pain, fever, or jaundice. Patients can be asymptomatic, with or without the elevation of liver chemistries. ![]() ![]() Rapidly alternating elevation and decrease of liver chemistries can be seen with sequential passage of stones or of the floating of stones up and down the main bile duct, causing intermittent obstruction (ball valve effect). Liver chemistries can rapidly decline after passage of stones. Liver chemistry elevation is due to impediment of biliary flow and, early in the course of obstruction, the predominant pattern is elevation of the transaminases followed later by the elevation of the alkaline phosphatase and, finally, bilirubin. A fluctuating pattern of liver chemistries is typical. ![]() Liver chemistries may be elevated but can also be completely normal. The patients can present with one or more of these constellation of symptoms in various combinations, which can make the diagnosis difficult. There are no pathognomonic features for choledocholithiasis and cholangitis. A tabular or chart listing of features and signs and symptoms Are there pathognomonic or characteristic features? ![]()
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