Female 77 years old Reason: Evaluation of biliary system; evidence of pancreatic mass? GI CONCERNED FOR ASCENDING CHOLANGITIS History: Jaundice, fever ABDOMEN:LIVER, BILIARY TRACT: Liver is normal in morphology. No suspicious hepatic lesions. Hepatic and portal veins are patent. There is moderate intrahepatic biliary ductal dilatation. There is mild hyperenhancement of the bile duct walls.Gallbladder contains gallstones. There is mild perihepatic and pericholecystic fluid. There is dilatation of the common bile duct measuring up to 11 mm and contains several stones. The largest stone is impacted in the distal common bile duct near the ampulla.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: Bilateral pleural effusions, right greater than left with basilar atelectasis and consolidation
1.Cholelithiasis with choledocholithiasis causing biliary obstruction. Mild hyperenhancement of the ducts suggests cholangitis.Findings discussed with clinical service at the time of dictation.