10 March - Obstructive Jaundice

This morning's case was a brief discussion of a patient that presented with painless jaundice.  In this case the workup eventually led to ERCP with with biopsy specimen positive for adenocarcinoma at the ampulla.  Importantly, a recent CT scan did not reveal a mass in this case, which is often the case with cholangiocardinoma.  MRCP/ERCP is essential to diagnose these lesions.  The first step in the differential is to determine whether the bilirubin is primarily unconjugated or conjugated.  Unconjugated suggests diseases such as Gilbert's or hemolysis, whereas conjugated suggests hepatocyte dysfunction or obstruction. 

Read this NEJM case discussion for a nice breakdown of how to evaluate painless jaundice in a systematic way.  Had this one in my file from when I was an R2.... If you want to learn diagnostic medicine and refine your illness scripts and differential diagnoses you should be reading the Case Records of the Massachusetts General Hospital every week!