So the next patient is james stroud foxtrot228722 41 year old man the past medical history autoimmune hepatitis established cirrhosis and portal hypertension and then additional cholangiopathy on imaging p anca positivity previously on triple therapy with tacrolimus 6 mercaptopurine and prednisolone 6 mercaptopurine well I'll copy all of this in actually because it's quite complicated investigations crp 73 paracetamol level 8 sodium 124 previously 137 urea 10.4 previously 4.3 creatinine 96 from a baseline of 60 albumin 20 from 21 previously bilirubin 232 from when previously was 64 alt 68 from 58 alp a 187 from a 181 add to the plan add on gamma gt inr 3.3 from 1.5 previously but note managed with warfarin currently white cells 8.2 with neutrophils 6.9 platelets 82 from 70 previously hemoglobin and a 134 when previously a 118 recent ct scan 07/03/2025 noted liver cirrhosis simple hypertension intrahepatic bile duct strictures 1.2 cm hypervascular lesion within segment 2 which is unchanged which does not wash out new pathological porta hepatis adenopathy largest node 2 cm in short axis reactive versus malignant ct significant progression of perihilar soft tissue mass and minor progression of the dilatation of the subsegmental bile ducts most recent mrcp in november 2024 lowly progressive diffuse cholangiopathy retracted portal vein clot is the impression so I just need to plug in yeah I'm gonna in I'm gonna syringe open that's just for choice how are you feeling really I'm sorry I'm trying to read about everything it sounds like you haven't we've not met before but you've had a real time in it yeah I was gonna say I'm not so I've seen most of the team yeah you have I'm so I'm I started on hepatology hepatology but now I'm moved to gastro because I'm sure you know we're the same doctors but we just can specialize in different things yeah so as we do our training we move around but yeah so you've I see you've got autoimmune hepatitis you've you've been seen by the or assessed by the king's team considered transplantation got people making thrombus for which you're on warfarin and other than that what's been going on lately so on tuesday mhmm I had probably 1 of the worst night I've ever had and it was due pain in in my sternum the sub ear area mhmm and then I took just some some normal painkillers I went up to the to the gp on wednesday get an inr because I was having a endoscopy biopsy got my duodenum on thursday and what was that for so they found something on the ct scan okay that they wanted to look at what it was is it duodenal thickening on their valve which will probably be nothing yeah no hope it is yeah so so I asked them about are there any pain pain meds yeah so was in I didn't sleep I was just chilling and they obviously instantly just checked I went for heart so ecg nothing okay and then I I went to the pharmacy and got some soda filling max capsules like the strongest painkillers that they could prescribe over okay and what are they they're simple they are paracetamol and codeine okay so 5 mg and 2.6 codeine okay so started taking those and something we just took took too much yeah how much is too long so I got them on wednesday mhmm out of 24 tablets I've got 4 left okay and then I supplemented that with some paracetamol as well so it wasn't out of you know did you know you were taking it at your dose I didn't know no I I did it purely because of the pain that was in sorry due to this yeah and then and then from thursday when the the wife picked me up from mhmm the procedure didn't happen didn't happen because you were in too much pain no because I the my inr was wasn't yeah it was too high yeah it went to be lower and then yeah it started turning yellow my urine is really really dark it's getting better now like browny like dark yellow really so it's like a covid 1 time yeah yeah and yeah just felt really really lethargic so I emailed who do I lisa fletcher yeah and just basically set my symptoms she's put me in we'll have a blood test this week yeah monday and then we're gonna look at it but I just couldn't couldn't hang on yeah that's just definitely hear yeah great since you've been here we've put up some fluid but not it have we given you any other treatment so they've given me neutlenium ct yeah and that's farxistiq yeah that's the 1 so I've had 2 hours of that excellent I've got 10 hours of this 1 so this is going this is nice nice brilliant yeah yeah so I've got that coming in and then they've done a x-ray they've just come back from a ct scan amazing so yeah so they I'm just like priority number 1 at it which is absolutely amazing as you should be and yeah so that's it really I'm I'm just trying to find out what this pain is here of course yeah because that's what drove me to take the meds I had before yeah I thought it was a muscular 1 mhmm but I don't well it may be have you had any fevers at all or anything like that nothing like that just yeah just really look I said to see correlate turning yellow with after the paracetamol not really the pain yeah yeah so I think different times yeah I think it's that yeah so I think the paracetamol overdose is related to the you know extra strain on the liver mhmm which is causing my ability to be really high it was high anyway mhmm and then cough cramp increased your hydrocortisone yeah to 2 to counteract that mhmm but obviously it's just and I guess I wonder thinking at it from the other way whether you've got a stone or obstruction in your infection around around the your bile ducts that caused you to have this pain and then get yellow yeah and the paracetamol is in the background yeah towards the loss of evidence yeah that's probably 1 of the edt officials as well yeah we should obviously have a scan because yeah the ct scan could be picking up stones and injection but scanning is usually a bit more sensitive so I've got some cold jelly here if that's okay and tell me about your life more generally you live with your wife you said yeah is that right live with the wife and my daughter emily lovely how old is your daughter she's 4 so I went to trathorn today lovely so yeah I'm still I spent many lovely childhoods in trathorn leisure park yeah no it's nice it's nice did you stay or should give it the day no just went for the day we we only are only a half hour away oh lovely so so yeah so she loved it mhmm really really tired yeah even a little sleep in the car I have memories of running around that you know park when I was with that playground and with the animals and stuff it's really lovely it like you must love it yeah we didn't really do the animals because it's just guinea pigs and stuff isn't it okay is it fine don't really remember that much no it's fine animals aren't aren't all that aren't all that no okay fine I seem to remember some goats or something like that yeah but maybe not anymore you know jen lives on a farm so she's just like not even now I've seen that I've been there done that yeah fair enough when's the last time you had some eat to eat I had cheesy chips lovely at about 12:00 ish after okay I've got a ham sandwich in there that I'm due to eat but eating just sort of causes a little bit of discomfort does it I think it just softly swells my stomach yeah and then obviously your bowel your gallbladder contracts and try to squeeze that bile through when you have fat so those things together yeah may. Towards something in the ducts you've got as you know you've got this diffuse cholangiopathy inflammation of your ducts we see the feeding of your bile ducts here where they kind of narrow and wide and narrow and wide and then there is a little narrowing here in your duct your stone clearly in that narrowing but there is something slightly shiny but it doesn't look like it's obstructing the duct my pain was in my sternum but now it's gone to where you are now really down to there so I can't quite work out the pain in the abdomen is so poorly localized yeah you know because you've got a coating over your whole abdomen can't really feel it but when the coating is irritated that's the cause of the pain so you can really essentially get pain anywhere yeah okay I'm seeing your gallbladder here a stone or a small polyp in your gallbladder yeah here yeah see shiny thing and obviously you haven't eaten which is great so we get a nice view of your big distended gallbladder and then we'll just try and initialize the duct which is with the eye of faith the duct that drains the gallbladder just here you'll have to trust me on that 1 yeah that's fine so I've seen the duct coming out here now yeah mhmm and then that should join the lumbar puncture it should be interesting yeah did you always see professor graham or do you see any of the other consultants see a lot of I see a lot of katie ramos to be fair lovely yeah she's really nice yeah she's lovely yeah that's good but he's been away on leave hasn't he professor has he yeah I haven't seen him in a while to be fair has he been off somewhere nice I don't know probably somewhere exotic no yeah no yeah on his stupidly massive salary probably yeah fair off his private island yeah maybe his wife's consultants are and she's I'm sure sure they do they're fine she's a nephrologist so the discussions at the cramped dinner table must be very cerebral too cerebral for me more yeah interested in pillow talk it's not doesn't bear thinking about it no it doesn't I think he's too busy on his cycling too yeah thanks anyway he'd been my consultant for like forever oh that's very good like even from like I was diagnosed this like at 11 years old he was up at king's and that's where I lived in I lived in kent oh great that's fine and you followed him down here he's followed you he followed me yeah you you and the friends so you're right yeah exactly I don't see any stones in your duct but there is that narrowing in your duct with that tiny bit of shininess there I mean with the eye it could be a stone in the duct now I'm looking at it a bit more it does look slightly separate from the wall and it's casting a slight shadow so it may be that you've got a stone causing all of these problems and ct scans are relatively good for picking up dilated ducts and I think if your ducts are dilated on the ct scan and we have evidence of this small stone then I think that will be what we treat you for an infection around the bile ducts yeah would be the most likely thing mhmm what can we do to get you feeling better are you in pain at the moment I am in pain at the moment like I've got up taking quite shallow breaths mhmm and then it doesn't satisfy my demand for oxygen yeah of then I take a big 1 and then that hurts and given that I'm in there for like 10 hours it's just gonna be miserable yeah so it's just there's pain meds really but I've had it's very difficult to have it when you've got the antidote and pump around me yeah of course I mean where it doesn't stop the pain meds working not like you know opiates and naloxone it just helps the liver deal with yeah I've got quite a big duct 12 millimeters is quite big for your age so which goes with the possibility of a duct infection or duct obstruction hi you're okay how are you yeah I'm fine thank you how are you yeah good do need to talk about more things yeah we just- I'd like to see 1 on the ct you're really fine I can just think I can see 1 in the gut your gallbladder looks quite enlarged in comparison to your previous okay we'll just- it's not been reported yet but we'll- I'm not gonna stain in the cbd just here yeah and there's biliary dilatation proximally and intrahepatic duct dilatation as well to my eye but obviously in ct you'll be mean very sensitive to duct dilatation is a big gallbladder and bright white shiny things is there a stone in the gallbladder is there yes yeah finally saw that is there a ductal stone there we go yeah that's fine it's cool we have a look seen it but that's that makes sense guess yes doesn't that is positive yeah what's the procedure for that does it can we dissolve it or was it so if you've got a stone in the duct we'd probably want to fish it out with an ercp but it's a procedure you haven't had 1 before by the looks so of camera test would go down your throat into the first part of the small intestine similar to the plant 1 you were getting out oh yeah okay instead of using a camera that looks forward we use a camera that looks sideways yeah and instead of lying on your side you lie on your yeah we make you a bit more sleepy than we normally would for an upper camera test mean you put a wire into the ducts oh wow and then use a balloon to fish it out oh right nice in an ideal world we would treat the infection and leave the stone in there yeah with the hope that would you have this transplanted at some time I don't know what you know about the plan for that what how far through it are we well katie said that until they can sort of work out what this this is this lump in my judy yeah potentially potentially I'll offer a transplant list if I like okay so you're poor you're suspended on the list at the moment think so yeah I think that's what katie said okay fine so yeah okay fine so yes obviously there's risks of ercp in the context of of course inflammation around the bile ducts thing so we need to weigh the risks and benefits mhmm but at the moment we need to just treat this treat this bile duct I would think okay causing and that will cause the brain to go away will it it should improve the pain but not as quickly as painful as well so we need to see painkillers for that in the shorter term yeah okay but the real problem is those high jaundice levels yeah yeah as we and that's to the the the if there's a stone in the dark looks like there is to me yeah probably it's because of this obstructing stone combined with an element of infection around it okay yeah alright do we want so you've had the effect on it yes I'm just mindful of the fact that we didn't wanna leave it too long clotting yeah if we're thinking about ercp I would yeah suspend the warfarin so so we'll hold your warfarin your therapeutic anyway yeah okay and bridge you on the injections yeah which wash out much quicker than the warfarin yeah so we can always stop them and is it more or more for it or or more yeah this isn't written up for much pain relief it's just all it's every 4 hours I've just got someone to come back thank you that's great thanks cheers thanks stacy stacy stacy I'll let you grab I'll wash your teeth out it'll be really sleepy and then it won't great we'll bridge you on the warfarin we'll so then we can go do an ercp and see if we do yeah biomarkers to treat infection around yeah okay and then john this the knack to treat the paracetamol overdose yeah yeah background yeah yeah yeah it's probably not causing all of this yeah and just be mindful that that's happened jaundice levels until the jaundice levels turn the corner and then we can stop them there okay okay so in terms of I suppose next steps of gonna be looking at antibiotics yeah to treat the infection and then maybe when I have that duodenum mhmm investigation they could probably also do the gallbladder removal yeah can't take the gallbladder out or maybe they just sweat it yeah exactly yeah okay that's absolutely fine so I think for now we need to get you're very sick yeah we need to get you better yeah you've got an infection somewhere probably around the gallbladder yeah and around the ducts yeah so that's done we'll treat you with some antibiotic yeah and get your jaundice levels back under control yeah cover you for the paracetamol and the dose at the same time yeah once that's better in a day or so once you're all better the jaundice levels are coming down we can be quite happy that we've stabilized things and then we can talk about what we do to fish that stone out or whether we talk to the transplant center or whether we do something different and sexy and we'll decide what we do I'll probably call the hepatology consultant just to let them know that yeah I'll send them an email actually to be able to send at least from katie an email that's great I'll drop you an email as well to let them know you're in and I'll just give them a call because it's not too late and I think it's worth them knowing yes okay you're amazing thanks for all cool it was really nice to meet you yeah and you and nice like that yeah and t t k of course yeah yeah and if you have any questions or queries or anything I get all night so so yeah don't know nothing unlucky you yeah I know you'd be but if you yeah have any questions just let me know alright thank you alright thank you you too and I'll get to the patient okay it's gonna be sore it's gonna it's gonna be sore having a stained neck yeah that's yeah it will be okay okay so this is today's it's dope and it's yeah yeah in comparison to the most recent 1 what's happening what's yeah I don't know I was trying to work out what that was hepatitis load isn't it I guess then it's a concern about gastric outlet obstruction even really think they commented on his like but like I remember being like what's going on here yeah with the air fluid level like blood pressure yeah and so like pneumatosis like it's thickened is that the gallbladder thickened gallbladder that looks like gallbladder yeah they're in there's we have tiny staining that back in it and then but the ducts aren't big there no but now there's a fluorine intraoperative implantation what do you think about his electrolytes I've seen it so he's newly gave him a 100 of hydrochloric you by alison's hip he's got autoimmune hepatitis okay I was I odd and he needed sick day rules anyway for his bread of course because he's on press sorry well we might as have done a reasonable amount and then I suspect that's because of related to aki and all the other bits but this is I think it's based on a creatinine I did see the sublibrary think it's based on a creatinine site 56 yes so I reckon it's d drive yeah but but a good thought and I think you're right we'll keep him on high dose steroids I'm just gonna check so he's I've put him on some comox mhmm and then I gotta retreat it yeah so okay duct dilatation and he's got jaundice I think to treat hemorrhoiditis yeah so a 100 I do 400 he's a 100 and then who do I am ma'am no yes I'll be just looking the the looking at the I'm just looking the the squeeze your just have a message hospital please mhmm they told you what this lump around the liver might be what the new 1 no they haven't yeah don't think I don't really know I don't know what it is no just getting in the notes no that's fine and then there's a little bit where the move that the socks down oh yeah like around the middle of the bed but that's the funny thing yeah but moving in can you put your hand out in front of you like this and just copy the stuff start scratch oh it's a cheapie it's not it's not a it annoys me because when you hook it up to the bluetooth all of the like reels that you watch all the sound come out of the the watch the watch I know damn I'm annoyed the first 1 and I need the second 1 and listen to your chest in minute let's see yeah okay thank so on examination no asterixis no encephalopathy orientated gcs 15 ecteric sclera pale sweaty abdomen soft with right upper quadrant tenderness and sonographic murphy's heart sounds normal no asterixis dry mucous membranes that's clear impression new duct dilatation and gallstone most likely cholangitis lesion to jaundice staggered accidental paracetamol overdose suspended on transplant list due to portal hepatis nodes possibility of the obstruction secondary to this node or disease plan number 1 antibiotics to treat cholangitis number 2 iv fluids number 3 repeat inr and post nac bloods number 4 n acetyl cysteine to continue until hepatology review number 5 chest x-ray number 6 msu number 7 septic screening with blood cultures number 8 analgesia number 9 suspend warfarin and bridge on low molecular weight heparin to facilitate ercp if felt indicated number next bloods tomorrow including crp fvc une inr venous blood gas number next hepatology ward only number next call hepatology consultant to inform of her presentation number next full escalation number next in power output monitoring number next level 1 care number next can go straight to avon ward for post take ward down there