ZSFG Hospitalist Report Pearls 7.12.17

Post Created by Dr. Amanda Johnson:
Thank you, Emily Tsanotelis, for presenting the perplexing case of a middle-aged man who presented with nausea, vomiting, and painless jaundice found to have a direct hyperbilirubinemia of unclear etiology…not to mention severe hyponatremia, concern for an upper GIB, and AKI on CKD.

Top Pearls
  • Jaundice on exam
  • Use the anatomy of the biliary system to organize your differential diagnosis for direct hyperbilirubinemia.
  • An abdominal ultrasound is the test of choice for biliary pathology.
  • There is emerging evidence to (re-)support the use of pre-hydration and bicarb to prevent renal injury due to CT contrast.

Our patient’s conjugated hyperbilirubinemia was most considering for extrahepatic causes of obstruction, though intrahepatic and hepatocellular causes will help us round out the differential.
Extrahepatic
Intrahepatic
Hepatocellular
  • Cholelithiasis or choledocholithiasis
  • Mass lesion
    • Cancer: pancreas, galllbladder, ampulla, biliary tree
    • Lymphadenopathy
    • Cyst
  • Infection
    • AIDS cholangiopathy (HIV, CMV, Cryptosporidia)
    • Parasites (Ascaris)
  • Post-procedural stricture
  • Primary biliary cirrhosis
  • Primary sclerosis cholangitis (though extrahepatic stricture also possible)
  • Infection (Clonorchis sinensis)
  • Total parenteral nutrition
  • Cholestasis of pregnancy
  • Hepatic crisis of sickle cell disease
  • Injury (viral, toxin)
  • Defects in excretion (Dubin-Johnson)
  • Defects in sinusoidal reuptake (Rotor syndrome)

In most cases, abdominal ultrasound is the imaging modality of choice for suspected biliary obstruction, though we discussed several alternatives.  Here’s how these modalities stack up for evaluation for one type of biliary obstruction, choledocholithiasis:
Modality
Sensitivity
Specificity
Comments
Abdominal ultrasound
73%
91%
  • cheap
  • no radiation
  • no contrast
ERCP
80-93%
99-100%
  • diagnostic & therapeutic procedure
  • requires technical expertise
  • risk of perforation, bleeding, and post-procedure pancreatitis
EUS
94%
95%
  • Invasive
  • Able to detect biliary sludge
MRCP
93%
94%
  • Noninvasive
  • Lower sensitivity for small stones
CT abdomen/pelvis with contrast & helical cholangiography protocol
93%
100%
  • Contrast required to be effective

*BONUS EBM Update on contrast-induced nephropathy from Dr. Pallabi Sanyal-Dey! [links below]
    • In patients having procedures with contrast media, several drug categories combined with hydration prevent contrast-induced acute kidney injury more than hydration alone. High-dose statins plus N-acetylcysteine and high-dose statins alone had the greatest risk reductions.
    • This is a meta analysis, so not the strongest type of study, but the first to indirectly compare treatments that haven’t been studied head to head.

Post Created by Dr. Amanda Johnson
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