Yeah hypertension iron deficiency anemia now the reason I'm ringing you is because I've noticed his liver functions have been creeping up and essentially doubled over the last 3 days okay he is now jaundiced which he wasn't oh that's interesting and he does not have any abdominal symptoms mhmm right so his alk phos over the last week has gone from 1 80 80 to a thousand okay his bilirubin has gone from 8 to 47 okay and his alt has gone from 15 to 215 okay you know in terms of infection there's there's no real discernible infection his white cell count's fine his crp is 30 his renal function's fine there's essentially no reason why he should be jaundiced mhmm the only reason I potentially can think of is the fact that we gave him ferringect yesterday but quick I'm really sure yeah I'm not really sure whether that's such a rise and and he had slightly elevated lfts before the pharyngect as well so it's a bit it's a bit neither here nor there do you have a hospital number for him or a neighbor I do yes it's alpha16 9 mhmm 808 thanks john botterall that's right and I have I've spoken to the radiologist about getting an ultrasound liver done you know over the last overnight and yeah they're not they're not too keen on doing doing it this do they can yeah but essentially the if they're too busy it's not something that's bad they don't yeah so I'm aiming to try and get it done early tomorrow morning with the with the caveat that he's going for surgery tomorrow morning the pattern the pattern is much more like cholestasis like and stone disease you know that's what I thought the alt is classic of stone disease yeah and with this pattern you know with the alt increasing like that but with the alp high I mean I would think it's like very high very very high chance of having a stone fine I think I don't know what you I think obviously he's gonna lose his legs so having a stone is is kind of the least of his worries however yeah the anesthetists are usually very reluctant to anesthetize people who are jaundiced yeah that that's what I was thinking to get them round and stuff like that do you have an idea of anything I can or need to do overnight I mean if you want some imaging overnight mean you can do a ct mhmm like you can get that overnight with relative ease and it will in it they are very cent ct is very sensitive for ductal stones yeah so it's it's like it's if it's radiopaque stone which it probably will be in this age group it's almost you will you will almost certainly detect it yeah it's not sensitive for duct dilatation but we're kind of irrelevant really if we don't see a stone we don't see a stone yeah the alternative is I can come and try and scan him I'm 1 of the hepatology regs so oh I can have a look at his liver but my sensitivity of will be far lower than the ct because I'm not like it I understand I mean essentially all I'm trying to find out is is is it something that needs to be urgently treated before he has a bypass versus after the bypass if it's after the bypass we can deal with it afterwards it's just I'm just trying to I mean I've I've requested a liver ultrasound anyways and they said that potentially we can do it early do it tomorrow tomorrow what time are taking him to theater tomorrow well ideally he's first on the list so ideally we'd be sending for him around 9 to half past 9 I can potentially move things around and put another case above him but realistically so what we find he's got a stone he's still gonna be jaundiced he's gonna be more jaundiced tomorrow and you're not gonna take it out are you with an ercp yeah which is what we what we would need if you had a ductal stone yeah and so the issue here is if he's asymptomatic abdominally exactly would you still want to kind of push ahead with with taking it out does that fall under hpv surgery I'm I'm not entirely we so stone disease is managed by both us both hepatology and hpv surgery and it's a bit of a potluck who you end up under really classically these ductal stones will go to them initially but we usually get involved at some. Purely because they need to have their gallbladder taken out they've got a stone in their duct anyway so they need to take they need to be on their radar to take it out fine how are you planning to do this this thing so it's essentially it's a lower limb bypass it's basically he'll be under a ga mhmm for for about 4 hours mhmm and he'll he'll have he'll have a prosthetic graft done between between his common femoral artery and yeah his popliteal artery fine and it's and he's got chronic limb ischemia so this is limb saving surgery isn't it essentially limb salvage yeah yeah fine so I'm just wondering about the potential of trying to do it all in 1 anesthetic mhmm like the hpv surgeons do sometimes do a bile duct exploration yeah along with you know and and removal of stones and then a cholecystectomy at the same time and they do that laparoscopically but right I think you're very unlikely to be able to tee that up for tomorrow obviously getting it done getting his limb better is the most important thing I would think yeah yeah where is he on clearbrook is that right he's on clearbrook d 4 okay fine I'll bring my ultrasound machine and scan him and just for my interest really and see if I can see a stone oh you are a stone and then we and then what will we do I mean if he has a stone then he has a stone you're still gonna need some confirmatory imaging before anyone runs she's in with an with a endoscope and so I would suggest that regardless you you get your anesthetic team on board and say this is limb saving surgery this man's probably got a stone but we still need to take we still need to sort him out in terms of sorting his limb out and accept that he may have a slightly prolonged recovery time and then we'll once we've got confirmation there's a stone we can then talk about how we remove it whether that's with hpv or whether that's ercp and then later cholecystectomy depending on how well he is after the operation does that sound reasonable that sounds perfectly fine should I leave the notes for you to please do yeah I'll go find my ultrasound machine and then I'll be there in a minute fantastic awesome thank you so much no worries it was nice to chat to you thank you bye bye bye bye