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Image of the Month—Quiz Case FREE

Muhammad F. Dawwas, MRCP; Asif Jah, FRCS; William J. H. Griffiths, MRCP, PhD; Andrew P. Winterbottom, FRCR; Emmanuel L. Huguet, FRCS, PhD; Alexander E. Gimson, FRCP
[+] Author Affiliations

Author Affiliations: Cambridge Hepatobiliary Service (Drs Dawwas, Jah, Griffiths, Huguet, and Gimson), and Department of Radiology (Dr Winterbottom), Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.

Section Editor: Carl E. Bredenberg, MD

Arch Surg. 2011;146(4):483. doi:10.1001/archsurg.2011.54-a.
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An 89-year-old man presented with recurrent upper abdominal pain, jaundice, rigors, and vomiting. His medical history included type 2 diabetes mellitus, myocardial infarction, and an abdominal aortic aneurysm that had been under regular ultrasonographic surveillance. On examination, a nontender pulsatile mass was palpable midabdomen. Laboratory investigations on admission disclosed the following results: bilirubin, 3.4 mg/dL; alkaline phosphatase, 735 U/L; alanine transaminase, 120 U/L; amylase, 127 U/L; C-reactive protein, 77 mg/L; white blood cell count, 10 400/μL; and hemoglobin, 11.1 g/dL. (To convert bilirubin to micromoles per liter, multiply by 17.104; alkaline phosphatase, alanine transaminase, and amylase to microkatals per liter, multiply by 0.0167; C-reactive protein to nanomoles per liter, multiply by 9.524; white blood cell count to cells ×109 per liter, multiply by 0.001; and hemoglobin to grams per liter, multiply by 10.) Abdominal ultrasonographic and computed tomographic scans showed multiple stones within a dilated common bile duct and an uncomplicated 9-cm infrarenal abdominal aortic aneurysm. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the presence of 2 large stones that had impacted at the distal end of the common bile duct. A periampullary duodenal diverticulum was also noted. Sphincterotomy was performed, and, because stone extraction was infeasible, a 5-cm 7F pigtail plastic biliary stent was inserted. However, his jaundice and cholangitis failed to improve during the ensuing week, and another ERCP was performed, revealing no evidence of a stent in situ. A 15-cm 10F straight plastic stent was inserted into the common bile duct, with initial clinical improvement. A week later, however, the patient developed severe acute abdominal pain accompanied by peripheral neutrophilia (16 680/μL [to convert neutrophil count to cells ×109/L, multiply by 0.001]). An urgent computed tomographic scan was obtained, preceded by an anteroposterior scout radiograph (Figure 1).

Place holder to copy figure label and caption
Figure 1.

Anteroposterior computed tomography scout radiograph of the abdomen and pelvis.

Graphic Jump Location


A.  Acute pancreatitis

B.  Biliary stent occlusion

C.  Jejunal perforation

D.  Portal pyemia


Place holder to copy figure label and caption
Figure 1.

Anteroposterior computed tomography scout radiograph of the abdomen and pelvis.

Graphic Jump Location




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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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