Syncope with Jaundice

Department of Radiology
Henry Ford Health System
Detroit, Michigan
Syncope with Jaundice
Nena A. Stanley, MS IV
Wayne State University School of Medicine
December 19, 2008

History
HPI: 83
83 yo male with a PMH dementia, DMII, HTN, atrial fibrillation
presented to ER after episode of syncope. Pt. stated he became
dizzy in the bathroom and lost consciousness. Patient stated had
experienced one past episode of syncope two weeks prior which
he sought no treatment. Associated symptoms (+)loss
incontinence (+)clay-colored colored stool, (+) coluria,
, (+)dizziness,
(+)jaundice, (+)HA, (+)30 lb wt loss, (-)fever,(
chills, nt. sweats, (-(
)recent head trauma, (-)nausea,(
(-)vomiting,(
(-)blurred(
vision, (-(
)tinnitus, (-)palpitations,(
(-)dyspnea(
on exertion, (-)orthopnea(
orthopnea, , (-(
)edema, (-)SOB,(
(-)hemoptysis(
hemoptysis, , (-)loss(
of appetite, (-(
)melena,, (-)hemetemesis(
hemetemesis, , (-)hematuria(
hematuria, , (-)dysuria(
dysuria, , (-)(
anemia, (-)numbness/tingling(
of extremities

History continued
PMH/PSH: : Dementia, DMII, HTN, a-fib, a
MI, mitral valve replacement
FH:
Noncontributory
SH: Married with 3 adult children, lives at home, (-)smoking,(
(-)EtOH,, (-)recent(
travel, (-)illegal(
drug use
MEDS: Coumadin, Digitoxin, Humulin (70/30), Motrin
ALL:
NKDA
ROS:
Per HPI
PE:
Gen: Oriented, A&Ox3, NAD
HEENT: EOMI, PERRLA
Cardio: RRR, S1/S2 (-)mrg(
Resp: : Lungs CTA bilaterally
Abd: : Soft NT, (-)masses,(
)masses, (+)BS
Rectal: (-)FOBT(
Ext. (-)skin(
excoriation, (-)bruising(
Neurological: CN II-XI grossly intact

History continued
• Labs: INR 6.45, elevated liver enzymes
(SGOT: 498.0 U/L; SGPT:306 U/L; T.Billi
22.2 mg/dl; Bili D 11.6 mg/dl; Alk Phos:
1,281 U/L)
• A/P
• Abdominal US to rule out obstructive jaundice

Findings
• Ultrasound with Doppler
• Intrahepatic duct and common bile duct
dilation
• Slightly distended gallbladder with visible
sludge
• Unable to visualize pancreas
• CT of abdomen recommended to visualize
pancreas and further evaluation of biliary
ducts

• CT of Abdomen
Findings continued
• Nodular intrahepatic biliary dilation greater in left
hepatic lobe
• Diffuse fusiform dilation of the common hepatic
and bile duct measuring up to 3.9 cm
• Findings compatible to type Iva choledochal cysts
• No pancreatic cyst
• ERCP and/or MRCP recommended to exclude an
underlying biliary or ampullary lesion

• ERCP
Findings continued
• Significant intra and extrahepatic duct dilation
• Recognized stricture within the mid-common
bile duct

Differential Diagnosis
• Hepatic Cysts
• Choledochal Cysts
• Cholangiocarcinoma
• Choledocholithiasis
• Cholangitis
• Duplicated Gallbladder

• Choledochal Cysts
Diagnosis

Discussion
• Classification
• Type I is the most common and is a dilation of the common bile ductd
• Type II is the rarest and is a diverticulum of the extrahepatic bile duct
proximal to duodenum
• Type III is a choledochal from embryological origin and cystic dilation of
intraduodenal portion of the distal common bile duct
• Type A bile duct and pancreatic duct converge on the cysts
• Type B is diverticulum of the intraduodenal bile duct or common bile duct
• Type IV multiple cysts
• Type IVA multiple intra and extrahepatic cysts
• Type IVB multiple extrahepatic parenchyma
• Type V multiple cysts limited to intrahepatic parenchyma

• Frequency
Discussion continued
• Rare in U.S.
• More prevalent in Asia
• Mortality/Morbidity
• Age dependent
• Cholangiocarinoma malignancy 9-28% 9
• Sex
• Female prevalance 3:1

Discussion continued
• Management/Treatment
• Stent placement to correct stricture within the
mid-common bile duct
• Surgical excision of cysts and resection of
common biliary tract and duodenum
• Biopsy of cystic tissue to evaluate for
dysplastic changes

References
DeGroen, Piet C., Biliary Tract Cancers, NEJM,
1999, Vol 341, No. 18 1368-1377
1377
Novelline, , Robert A. Novelline, Squires’s
Fundamentals of Radiology, 6 th Ed., Harvard
University Press, Cambridge, MA: 2004
Sawyer, Michael AJ, Choledochal Cyst, e-e
medicine: April 13, 2007
Topazian, , Mark, Biliary Cysts, Up to Date, v. 16.3:
Oct. 1, 2008