Advanced Endoscopy Fellows Program | September 2024-Draganov

Draganov_Clinical Cases Advanced Fellow Course

Pdf Summary

A 54-year-old female patient presents with jaundice, fatigue, nausea, and vomiting for the past month, with no abdominal pain, recent medication changes, travel, sick contacts, blood transfusions, or use of illicit drugs. Her lab results show significantly elevated total bilirubin (26.6), direct bilirubin (18.9), alkaline phosphatase (1966), AST (105), ALT (59), and total cholesterol (1059), along with low sodium (114), potassium (3.2), and albumin (2.6). Serum osmolality is normal at 285.<br /><br />A CT abdomen scan was performed. An ERCP (Endoscopic Retrograde Cholangiopancreatography) was requested but anesthesia staff wanted to cancel due to low sodium levels. Diagnostic steps include additional tests, physical exams focusing on edema, initiating oral fluid restriction, and IV 3% saline, along with a nephrology consult.<br /><br />The differential diagnosis includes pseudo-hyponatremia, which can happen due to markedly elevated lipids and cholesterol levels, as well as conditions such as multiple myeloma or amyloidosis. Detection involves identifying predisposing conditions, normal serum osmolality, and utilizing Direct Ion-Selective Electrode Potentiometry (DISE).<br /><br />ERCP was performed and revealed an Anomalous Pancreaticobiliary Junction (APBJ). This condition can be categorized into:<br />- Normal anatomy with a short common channel<br />- Abnormal junction type I (long common channel and dominant common bile duct)<br />- Abnormal junction type II (long common channel and dominant pancreatic duct)<br /><br />APBJ without Type I choledochal cyst is associated with gallbladder cancer, indicating the need for prophylactic cholecystectomy. If associated with a Type I choledochal cyst, the patient has an increased risk of cholangiocarcinoma, warranting surgical resection of the extrahepatic biliary tree.<br /><br />Key takeaways include:<br />1. APBJ is a significant risk factor for gallbladder and biliary tree cancers.<br />2. Pseudo-hyponatremia is common in the context of obstructive jaundice and can present with normal serum osmolality, typically not requiring specific therapy.

Keywords

jaundice

fatigue

pseudo-hyponatremia

Anomalous Pancreaticobiliary Junction

ERCP

elevated bilirubin

cholangiocarcinoma

gallbladder cancer

choledochal cyst

nephrology consult