As we heard the history we stopped, prior to hearing the exam and labs, and developed a differential diagnosis. With the combination of itching, probable jaundice and pale stools we assume either intrahepatic or extrahepatic obstruction. Our differential diagnosis with commentary:
Primary biliary cirrhosis – much more common in women then men – but does often present at this age with uncontrollable itching Primary sclerosing cholangitis – no history of ulcerative colitis or diarrhea symptoms, but still possible Gallstone – not all common duct stones cause pain Cholangiocarcinoma – could clearly cause extrahepatic obstruction Pancreatic cancer – probably the number one consideration from history alone.
Physical exam – positive Murphy’s sign
Labs:
CBC and basic metabolic panel unremarkable
Test Value AST 163 ALT 220 Alk phos 604 T Bili 5.9 GGT 1500Helical CT ordered – will report tomorrow
What is your best guess? Have we left anything out of the differential?
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