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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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An 18-year-old woman is admitted to the hospital for a 2-day history of fever, right upper quadrant abdominal pain, and jaundice. Her only medication is a daily oral contraceptive pill.

On physical examination, temperature is 37.9°C (100.2°F), blood pressure is 100/65 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. BMI is 22. Scleral icterus is present. Abdominal examination discloses tenderness in the right upper quadrant.

Laboratory studies:

Hematocrit

38%

Leukocyte count

11,500/μL (11.5 x 109/L)

Platelet count

450,000/μL (450 x 109/L)

Alkaline phosphatase

180 units/L

Alanine aminotransferase

80 units/L

Aspartate aminotransferase

65 units/L

Total bilirubin

3.0 mg/dL (51.3 μmol/L)

Abdominal ultrasound discloses a dilated common bile duct with a diameter of 20 mm. The liver is otherwise normal. The spleen is normal. Endoscopic retrograde cholangiopancreatography reveals fusiform dilatation of the common bile duct with smooth tapering at the distal common bile duct. No stones are noted.

Q.

Which of the following is the most appropriate next step in management?

The most likely diagnosis is a biliary cyst. Biliary cysts are often found incidentally when patients undergo imaging for nonspecific symptoms. The finding of fusiform dilatation of the common bile duct in the absence of obstruction or stones is characteristic of a type I biliary cyst. Intermittent chronic pain and episodic jaundice are the most common symptoms. Though biliary cysts are rare (1:10,000 to 1:15,000 births in the United States), recognition is important because a biliary cyst confers a risk for recurrent bouts of cholangitis and a high risk for biliary cancer (up to 75%). Extrahepatic dilatation of the common bile duct, as described in this patient, is the most common type of biliary cyst and is seen in 50% to 80% of cases.

Although cholelithiasis (gallstones) can result in obstruction of the bile ducts and subsequent dilatation of proximal bile ducts, this patient's abdominal imaging did not demonstrate findings of cholelithiasis.

The diagnosis of irritable bowel syndrome (IBS) is based solely on clinical grounds. Because no biochemical, radiographic, endoscopic, or histologic marker exists, several clinical indices have been published to aid in the diagnosis of IBS. IBS does not cause ascending cholangitis or fusiform dilatation of the common bile duct as seen in this patient.

Primary biliary cirrhosis (PBC) is a disease of the microscopic bile ducts that can result in jaundice, liver inflammation, and liver failure. However, the extrahepatic bile ducts are not dilated in PBC, and therefore this patient does not have PBC.

Key Point

  • A biliary cyst should be suspected when dilatation of the bile duct is found without evidence of an obstructing lesion.
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