A 45 yr old lady, presented with history of pain abdomen for 4 weeks and jaundice for 5 days. USG revealed gallstones and a dilated CBD. Bilirubin was 5mg%, and SGOT/SGPT 102/88. Alkaline phosphatase was 481. The patient underwent MRCP, which also revealed dilated CBD till lower end, however, no CBD stone could be seen. What could be the diagnosis? How to proceed with the case?

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R/o ex cbd compression ie peri pancreatic or periportal lymphadenopathy may be simple or malignant
Thanx dr Avinashkumar Shrivastav
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Kindly do CT abdomen Please ruleout carcinoma of head of pancreas Sphinter of oddi dysfuction, impaction of stones by sphinterotomy to be done. Radionuclide scanning .
Majority of the time such situation is due to a secondary stone impacted at the ampulla which has slipped or passed down, best is to wait for some time till CBD dilatation decreases or lft derangement returns back to normal, usually a mass lesion large enough to cause such cbd dilatation and LFT derangement will also be easily detected in MRCP, My suggestions will be to 1. Wait for 15days for LFT & CBD to settle down 2. If conditions further detioriate do ERCP + CBD stenting
Later Lap cholecystectomy needs to be done
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As the CBD is dilated till the lower end and no stone the pathology must be at the distal part at the ampulla of vater. It can be malignancy ampulla of vater or may be cholangitis though it is not mentioned wheather pt is having temperature or not. Endoscopy can be done to to see the periampullary region fo any pathology.
If clinically there is suspecion of Cholangitis or pancreatitis then better do EUS . As its dilated CBD till lower end the pathology must be distal where EUS can help to diagnose stricture, Malignancy, Parasitic infection.. Before EUS side viewing endoscopy can help for periampullary abnormality.
As Dr Sanglodkar said, CBD dilation till lower end and no stone detection on MRCP should lead to teo ways to approach ...First is EUS which is costly and unavailable at most centres and Second is to manually see the pathology by doin ERCP....and find out whats going on...
One could think of SOD sphincter of oddi dysfunction , stricture , CP with groove pancreatitis ( not the kind of patient ), autoimmune pancreatitis , parasitic infection , Cholesocal cyst, HIV biliopathy Probably an EUs and then blood investigations in this line
I agree
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What is the patients general status? performance status ?did she loose weight? is she having goo symptoms...?what is the amylase or lipase level..? what is the ct abdo.en picture? whats the medical history? sphincter of oddi dysfunction should be ruled out...
If it is a case CA head pancreas then to have jaundice there must be pressure symptom on the CBD but CBD is although dilated till the end distallyso I don't think as a case of CA head pancreas.
This may be .ca head of pancreas investigate for tomou head of pencreas or ampulla of vatour if cnfirmed then whipples operation is advised
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