ANSWER 77
This woman has a 5-year history of intermittent upper abdominal pain. Her current pain
has lasted longer than previous episodes and on examination she is jaundiced. The acute
pain on inspiration while palpating in the right upper quadrant is a positive Murphy’s sign
of inflammation of the gallbladder. The relative bradycardia in the presence of the acute
illness is likely to be related to the beta-blocker therapy (atenolol) rather than hypothy-
roidism or any other problem. The dark urine would fit with increased conjugated biliru-
bin because of obstruction. The conjugated bilirubin is water soluble and excreted in the
urine. Without conjugated bilirubin entering the bowel one would expect pale stools.
Her investigations show a raised bilirubin. The alanine aminotransferase is slightly raised
but the main abnormalities in the liver enzymes are high values of alkaline phosphatase
and gamma-glutamyl transpeptidase. This is the pattern of obstructive jaundicewhich
can be caused by mechanical obstruction by tumour or by gallstones, or by adverse effects
of some drugs, e.g. phenothiazines, flucloxacillin. The drugs she is taking are not likely
causes of liver problems.
The previous episodes of pain and fever over the last 5 years are likely to have been chole-
cystitis secondary to gallstones. If the gallbladder were to be palpable on examination this
would suggest an alternative diagnosis of malignant obstruction, since by this time these
previous episodes of cholecystitis would usually have caused scarring and contraction of
the gallbladder. In order to produce obstructive jaundice one or more of her gallstones must
have moved out of the gallbladder and impacted in the common bile duct. Migration of
gallstones from the gallbladder occurs in around 15 per cent of cases.
Her thyroid condition seems to be stable and not relevant to the current problem. Her angina
is indicative of coronary artery disease and needs to be considered when treatment is being
planned for her gallstones. An electrocardiogram (ECG) should be part of her management.
Only a minority of gallstones are radio-opaque and visible on a plain radiograph so the
next investigation should be an ultrasound of the liver and biliary tract. Ultrasound will
show dilatation of the biliary tree but is not so reliable for identifying common bile duct
stones. Endoscopic retrograde cholangiopancreatography (ERCP) is the best tool for this,
and sphincterotomy with or without stone retrieval may be possible to remove stones
obstructing the common bile duct.
- Obstructive jaundice with a dilated, palpable gallbladder is likely to be caused by carcinoma
at the head of the pancreas (Courvoisier’s sign). - Obstructive jaundice causes preferential elevation of alkaline phosphatase and gamma-
glutamyl transpeptidase. - When the main rise is in alanine aminotransferase, this indicates primarily hepatocellular
damage.