Thank you to Dr. Cohen for a very interesting case of a woman presenting with "30/10" abdominal and back pain with initial concern for symptomatic choledocholithiasis found to have vertebral osteomyelitis. A few key learning points from today's case:
- Not all "abdominal pain" is from the abdomen. If the description does not fit your illness script, then start to think about other causes. For example, bilateral "band-like" abdominal pain does not fit the classic description of choledocholithiasis but could fit with pain radiating from the vertebra (think osteo or compression fracture, etc).
- Post-cholecystectomy common bile duct (CBD) dilatation can be normal and asymtomatic generally up to 10mm according to a 1-year prospective study out of Korea. Additionally, methadone maintenance therapy can increase the CBD diameter an average of 2.39mm according to a study out of Boston.
- Don't forget to review the primary data yourself! On outside hospital transfers, have the images pushed to our system and review them yourself and/or with Radiology. Some findings can be missed and the clinical history may change when you see them prompting evaluation of different features.
- In a clinically stable individual with vertebral osteomyelitis, obtain blood cultures, ESR, CRP, consider an Echo (especially if there is a new murmur) and consult your surgical colleagues to obtain tissue before starting antimicrobials.
- Be leary of the spinal cord stimulator. Look out for complications which include hardware malfunction such as lead migration or fracture, infection or tolerance. For more information on spinal cord stimulators, please refer to the systematic review and meta-regression analysis in Pain Practice.