80 yo M presents to the ED w/ 1 week of intermittent epigastric pain w/ nausea and vomiting. On ED arrival he is febrile and exam shows epigastric tenderness. His labs show a transaminitis with bilirubin 3.3 and lipase >2300. A CT a/p is done and shown below. What's the diagnosis? (scroll down for answer)

Answer: Choledocholithiasis with gallstone pancreatitis and concern for cholangitis

• Choledocholithiasis = stones within common bile duct
• In the US, most CBD stones are due to passing gallbladder stones (10-15% of patients w CBD stones have gallstones)
• Signs/symptoms- epigastric pain/RUQ pain, fever, jaundice  (Charcot's triad)
• Complications of CBD stones include= gallstone pancreatitis and cholangitis
• Treatment
• IVF, broad spectrum antibiotics
• ERCP to remove stone and decompress bile duct

References:

Attasaranya S, Fogel EL, Lehman GA. Choledocholithiasis, Ascending Cholangitis and Gallstone Pancreatitis. Med Clin North Am. 2008;92(4):925-60.