Uncontrollable itching – the denouement

The emergency department ordered a CT scan that showed a dilated common bile duct, no pancreatic masses, a mass in the duct – stone versus other. Twelve hours after admission, he developed a temperature of 101 and a repeat CBC showed an elevated WBC with left shift. Therefore, GI did an ERCP the next day – revealing a large gallstone – not easily removable.  The placed a stent and drained pus. So this man had painless jaundice from a common duct stone. As an intern in 1976 I had a patient with ascending cholangitis.  His internist told me that he had pancreatic cancer, but had declined surgery.  In 1976, we had no ultrasound, CT or MRI.  As a medical student, I had learned that ascending cholangitis was a surgical emergency (now with either IR or ERCP we have less invasive options).  So I called surgery, who convinced the patient to do palliative surgery.  The pancreatic cancer diagnosis was an assumption because the patient had painless jaundice.  In that case, at surgery they found a common duct stone. This story therefore has several important lessons.  Few things in medicine are absolute.  While most gallstones cause significant pain, this symptom’s sensitivity is less than 100%.  Fever and elevated WBC with a dilated common duct requires aggressive measures.  Even very nice patients sometimes do not have the worst diagnostic possibility.  The man is a wonderful guy and we could not be any happier with his result.  As I told my team, t...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs