Thank you to Kapil for presenting the case of an elderly male with a history of cholecystitis s/p cholecystectomy and ERCP with sphincterotomy for retained stones presenting with 3 days of nausea and generalized abdominal pain found to have recurrent choledocholithiasis. Thank you to our GI colleagues for their participation and teaching!
- Murphy sign along with its sonographic variant is a useful (LR 2-3) and cost effective tool for diagnosis of acute cholecystitis. Be careful as this sign can be negative in elderly (more specific and less sensitive) or patients without a gallbladder!
- Patient’s with hx of cholecystectomy are at high risk for ascending cholangitis (obstruction of CBD) and should be empirically treated with antibiotics when presenting with recurrent abdominal.
- Acute cholecystitis – remember most common bugs are GNRs including E. Coli.
- Per Dr. Ostroff you are allowed to have ~ 1mm additional dilation of your CBD for every decade of life.
Evaluation of Jaundice
- Is the elevation of bilirubun real?
- Is the elevation Direct or indirect?
|Direct Bilirubin||Indirect Bilirubin|
|Obstruction (intra or posthepatic)
o Sclerosing cholangitis
o Hepatocellular carcinoma
o Pancreatic cancer
– Enzyme mediated
– Hepatitis (viral)
– Sepsis/Systemic Disease
|Gilberts – unconjugated|
– Alcoholic, NAFLD, ischemia, infiltration, TPN (long list)
Check out this evernote for more details and images regarding anatomy and causes of obstruction!
Murphy’s sign Test Characteristics
- A review of 17 studies found Murphy test to be useful positive LR: 2.8; 95% confidence interval (CI): 0.8 to 8.6 (Trowbridge RL, et al. 2003).
- Ralls and colleagues reviewed 497 patients of suspected acute cholecystitis and found that 98.8% of the patients in their series had a positive ultrasonographic Murphy sign. More, a combination of gallstones and a positive Murphy sign had a positive predictive value of 92.2% for acute cholecystitis, while the absence of gallstones together with a negative Murphy sign had a 95% negative predictive value.