drk1980
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Following is a UW Q
A 52 yr old male presents to his primary care physician c/o dark urine and 'feeling itchy all over'. Further inquiry reveals that he also has been experiencing episodes of RUQ pain awakening him from sleep and lasting 2-4 hours. He says the pain radiates to the right scapula and is severe, dull and constant. His medical history is significant for hypothyroidism managed with medication and a remote cholecystectomy. He has smoked half a pack of cigs/day since school, drinks alcohol occasionally. No illicit drug use.
Labs: Total Bil: 5.2, Direct Bil: 4.1; Alkaline Phosphatase: 455; AST: 80; ALT: 101
A sphincter of Oddi spasm is suspected based on Sx and Hx. An ERCP with sphincterotomy is performed. Two days later, the patients bilirubin begins to decrease, but imaging reveals air within the biliary tree. What is the most likely cause of this finding?
A) Normal finding after ERCP
B) Acute pancreatitis
C) Biliary infection with gas-forming bacteria
D) Gangrenous cholecystitis
E) Biliary enteric fistula
There was another Q that I wanted to compare this one with...but couldnt find it! Anyhow...will explain my confusion about it after this discussion.
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| cyra
Moderator
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Air in the biliary tree especially postendoscopy would be a normal finding after ERCP. C,D and E may show the same finding but there would have to be some clues to the presence of an infection(like fever)if it were due to C or D.With E....not too sure but since an internal incision is all thats needed at ERCP to relieve the spasm a biliary enteric fistula doesn't seem likely.
p.s:I am getting this nagging feeling that I just may be wrong on this one.....cos I remember being stuck on this question too and I can't for the life of me remember the answer(and the reasoning) they gave for it in UW!
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| drk1980
Forum Guru
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i think i know why the nagging feeling. Coz there was another similar Q, with a similar presentation and radiograph findings, post-ERCP + papillosphincterotomy (iam assuming this a slightly bigger version of a sphincterotomy). In that Q the answer was Normal finding.
This one though, sposed to be E! :-s
here is the expln-
..."Some complications of ERCP include pancreatits, perforation(resulting in biliary enteric fistula, especially after sphincterotomy), bililary peritonitis, sepsis, Hge etc. Given this patients presentation its most likely BEF secondary to perforation during ERCP procedure."
About why its not normal finding: "Certian procedures(eg air insufflation test for infertility) can result in the finding of free air under the diaphragm, but not the case with ERCP." (actually even the last part of the expln doesnt make sense!)
I fail to see the reason for two different answers. Unless, iam missing some vital clue from the other Q that i cant find....
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| cyra
Moderator
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Posts: 844
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Ughh!!How annoying is this?I remember now....I just thought the UW ppl had flipped and moved on cos there can be air in the biliary tree after ERCP.Also...what do you look for in such a case to suggest a biliary enteric fistula?I know pancreatitis is a well known complication of ERCP....I am just not too sure about perforation leading to a biliary enteric fistula... do you think UW is being nit picky here just to put across a possible(but uncommon) complication across?
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| drk1980
Forum Guru
Topics: 147
Posts: 1,038
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hopefully the USMLE examiners dont pick up the nitpickiness!!
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| achilles
Forum Guru
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i had the same confusion and was confused between A and E. but just wondering if air would still be there after 2 days.
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