INFORMATION SHEET FOR CANDIDATE:

You are working as a locum GP. The next patient is a 60

year old Mr. Johnson who had a cholecystectomy about 3
years ago because of biliary colic secondary to
cholelithiasis. Over the last 2 to 3 weeks he developed
increasing abdominal pains and in the last few days fever
and yellowing of his skin.
Your tasks are to:
1. take a focused further history
2. examine the patient (youll have to tell the examiner
what you want to examine and how you do it)
3. explain your most likely diagnosis to the patient and
outline your management

HOPC:
Mr. Johnson has been generally in very good health until about 2 or 3 weeks ago Mr.
Johnson noticed some non specific abdominal pains like indigestion and he did not
think much about it. The pains seemed to be more pronounced in the right
hypochondrium and intensified in the last week with colicky attacks. The pain is
different from the biliary colic he had in the past, it seems to be deeper in his
abdomen and radiates into his back.
The last couple of nights he could not sleep well because he felt hot and cold,
sweating a lot with now generalised aches and pains and he noticed a generalised
yellowing of his skin with an urge to scratch his skin and his urine has turned dark
over the last few days.
He lost his appetite and he thinks he has lost a bit of weight in the last 2 weeks.
PHx:
Except for the cholecystectomy 3 years ago, unremarkable,
FHx and SHx : NAD
EXAMINATION:
The patient looks quite unwell, sclera icteric and generalised jaundice with a few
scratch marks.
Vital signs: BP 115 / 70, P 120 (SR), RR 20, T 39.5.
Abdo: previous laparoscopy scars, tenderness under right rib cage on deep palpation
with slightly enlarged liver palpable.
PR reveals pale stool
Urine is dark and shows bilirubin +++ on multistix examination
DIAGNOSIS: cholestatic/obstructive jaundice with cholangitis
Most likely due to a recurrent stone in the common bile duct.
In acute cholangitis, bile duct obstruction allows bacteria to ascend from the
duodenum. Most (85%) cases result from common bile duct stones, but bile duct
obstruction can result from tumors or other conditions.
Common infecting organisms include gram-negative bacteria (eg, Escherichia coli ,
Klebsiella sp, Enterobacter sp); less common are grampositive bacteria (eg,
Enterococcus sp) and mixed anaerobes (eg, Bacteroides sp, Clostridia sp). Symptoms
include abdominal pain, jaundice, and fever or chills (Charcot's triad). The abdomen
is tender, and often the liver is tender and enlarged (often containing abscesses).
Confusion and hypotension predict about a 50% mortality rate and high morbidity.
DDx: Neoplasm (head of pancreas, bile duct, liver, including metastases
Hepatitis
MANAGEMENT:
Immediate referral to the hospital for:
INVESTIGATIONS:
FBE, LFT, Lipase, coagulation screen, blood cultures
Ultrasound
ERCP (often therapeutic!!!)
CXR
CT
THERAPY:
PAIN relief,
NPO
Iv antibiotics covering gram negatives,eg. ampicillin plus gentamycin
iv. fluids
ERCP or surgery