A patient with abdominal pain and markedly elevated transaminase levels after cholecystectomy.

BACKGROUND

A 33-year-old white female with a history of cholecystectomy presented to the emergency department with intermittent severe abdominal pain radiating from the left upper quadrant to the right upper quadrant, associated with nausea and emesis. Three weeks previously the patient had presented to the emergency department with similar pain in the abdomen. Laboratory investigations had revealed elevated bilirubin, transaminase, and alkaline phosphatase levels. At that time, pain and liver chemistry test results improved and the patient was discharged on hospital day 3. She denied a history of alcohol use, new medications, or the ingestion of other toxins.

INVESTIGATIONS: History and physical examination, liver chemistry tests, viral hepatitis serology tests, autoimmune serology tests, abdominal ultrasound, liver biopsy, and an endoscopic retrograde cholangiopancreatogram.

DIAGNOSIS: Choledocholithiasis.

MANAGEMENT: Endoscopic retrograde cholangiopancreatogram with sphincterotomy, removal of an 8 mm distal common bile duct stone, and pancreatic stent placement.