The emergency department ordered a CT scan that showed a dilated common bile duct, no pancreatic masses, a mass in the duct – stone versus other.
Twelve hours after admission, he developed a temperature of 101 and a repeat CBC showed an elevated WBC with left shift.
Therefore, GI did an ERCP the next day – revealing a large gallstone – not easily removable. The placed a stent and drained pus.
So this man had painless jaundice from a common duct stone.
As an intern in 1976 I had a patient with ascending cholangitis. His internist told me that he had pancreatic cancer, but had declined surgery. In 1976, we had no ultrasound, CT or MRI. As a medical student, I had learned that ascending cholangitis was a surgical emergency (now with either IR or ERCP we have less invasive options). So I called surgery, who convinced the patient to do palliative surgery. The pancreatic cancer diagnosis was an assumption because the patient had painless jaundice. In that case, at surgery they found a common duct stone.
This story therefore has several important lessons. Few things in medicine are absolute. While most gallstones cause significant pain, this symptom’s sensitivity is less than 100%. Fever and elevated WBC with a dilated common duct requires aggressive measures. Even very nice patients sometimes do not have the worst diagnostic possibility. The man is a wonderful guy and we could not be any happier with his result. As I told my team, telling a story like this is a highlight of being a teaching attending physician.
