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Case 165: Urine discolouration

This is a specimen of urine taken from a man who complained recently of epigastric pain radiating through to his back.

1. What physical sign does the urine demonstrate?

The dark urine of cholestatic jaundice. This man says that 'it was much worse yesterday - almost like Coca-Cola.'

2. How would you manage this problem in the emergency department?

First confirm the diagnosis with a thorough history, physical examination and then a biliary ultrasound.

Liver function blood tests would also be needed. Other tests required are full blood examination for white cell estimation, clotting parameters, amylase or lipase to exclude gallstone pancreatitis.

The urgency of intervention then depends primarily on the degree of biliary sepsis. The septic and hypotensive patient will require urgent biliary decompression.

3. Biliary ultrasound shows stones in the gallbladder. The common bile duct was 8mm in diameter with no stones seen. Next move - MRCP or straight to ERCP?

Some would say that if this was a young man then the duct being 8mm is above the upper limit of normal and probably obstructed distally.
Combined with a good story for obstructive jaundice, then proceeding straight to ERCP would be reasonable. However this approach would high negative rate of having the stones already passed.

MRCP is preferable to save some patients the morbidity (and mortality) of ERCP.

Related Cases
Case 48: Dark Urine Case 50: Right upper quadrant abdominal pain, fever and jaundice Case 51: Jaundice