A 68-year-old woman presents with a high fever and jaundice for 2 days, in a background of pain in the right upper abdomen for 5 days. She was diagnosed with type 2 diabetes mellitus 3 months ago, which is well controlled on 850 mg of Metformin daily. Her medical and surgical histories are otherwise unremarkable. She does not smoke, and only drinks socially. There is no history of recent travel.
WBC: 20,200/mm3 (4,600-11,000) Neutrophils: 97% Hb: 12.1 g/dL (11-16) Platelets: 310,000 (150,000-400,000)
AST: 101 IU/L (8 - 48) ALT: 98 IU/L (7 - 55) ALP: 230 IU/L (45 - 115) Total bilirubin: 33 mg/dL (0.1 - 1.2) Conjugated bilirubin: 31 mg/dL (0 - 0.3)
The common bile duct is dilated, with a maximum diameter of 12 mm. There are multiple small gallstones in the gallbladder. The walls of the gallbladder appear normal, and there is no pericholecystic fluid. The liver, pancreas and spleen appear normal.
The common bile duct is markedly dilated, with a maximum diameter of 13 mm. There are several gallstones in the distal common bile duct, as well as multiple small gallstones in the gallbladder. There is diffuse inhomogeneous enhancement of the liver parenchyma surrounding the bile ducts.