This 72-year-old man was admitted with a hip fracture after falling. He developed abnormal liver chemistries on the day of his hip repair. He had mild upper abdominal discomfort and nausea but denied vomiting, dysphagia, weight loss, jaundice, and gastrointestinal bleeding.
Past history is positive for chronic renal insufficiency and atrial fibrillation. He has been on chronic treatment with anticoagulation. He has a pacemaker.
He has been afebrile with normal vital signs. Physical examination revealed right upper quadrant tenderness without rebound.
Laboratory evaluation showed mild leukocytosis, creatinine level of 2.0 mg/dL, and mild anemia. Liver chemistry abnormalities included moderate elevation of the alkaline phosphatase level, normal amylase level, and mild elevations of the ALT and AST levels. Ultrasonography revealed gallstones without thickening of the gallbladder wall. There was mild dilation of the biliary ducts.
1) Appropriate evaluation of this patient includes:
a) Abdominal CT scan with oral and IV contrast
b) Hepatobiliary scan
c) Liver biopsy
d) MRCP (magnetic resonance cholangiopancreatography)
e) ERCP (endoscopic retrograde cholangiopancreatography)
2) The photographs reveal findings noted at the time of a diagnostic and therapeutic procedure. The photographs demonstrate:
a) Coffee beans
c) Duodenal mass
d) Pigmented stones
e) None of the above