A 45-yo woman presents to an outside hospital with several weeks of RUQ pain, especially worse after eating, with about 3 days of intense abdominal pain, nausea and vomiting, fever and chills, and a leukocytosis to 18. Suspecting cholelithiasis/cholecystitis and because of the sudden, recent change in her condition, a procedure is performed; after the procedure, the patient acutely worsens and is transferred to your hospital.

The patient appears to be in moderate distress, she is lethargic with a BP of 86/50, HR 114, RR 16, satting 96% on RA. She is markedly jaundiced, with no rashes, purpura or telangectasias. Her physical exam is remarkable for exquisite diffuse abdominal pain with mild guarding and rebound tenderness. The Emergency physician is about to call the surgeon to evaluate for emergent cholecystectomy, but you ask him to hold off in order to stabilize the patient and review the imaging. Imaging from the outside hospital is seen in the picture below.

Pertinent lab data that you have ordered include a WBC of 19.6 with 20% bands, a creatinine of 1.4 (unknown baseline), bicarb 18, AST 42, ALT 42, Total Bili of 3.2 mg/dl, alk phos 222.

Correct answers back to drdeshpande@gmail.com by Sunday @ midnight! Good luck!