ABSTRACT
Introduction: Choledocholithiasis, the presence of gallstones in the common bile duct (CBD), commonly presents as abdominal pain, jaundice, and an elevated bilirubin and is further evaluated with abdominal ultrasound and consideration of MRCP or ERCP based on clinical predictors. Herein, we describe a novel approach to abdominal pain and hyperbilirubinemia due to SARS-CoV-2 (Covid 19) which led to additional imaging and an incidental malignancy diagnosis. Case Description/Methods: A 52-year old man with a history of chronic hepatitis B virus presented with one week of abdominal pain and jaundice. Admission labs were significant for a total bilirubin of 4.1mg/dL, and positive screening for Covid 19. Abdominal ultrasonography demonstrated a dilated CBD to 1.7cm. His presentation was highly suggestive of choledocolithiasis by ASGE criteria, but ERCP was deferred to abide by hospital-wide precautions at the time. As a result, the patient underwent confirmatory testing with MRCP, which showed no choledocholithiasis but demonstrated a 4.1cm enhancing lesion abutting the pancreatic body. Subsequent abdominal computed tomography found a 3.3cm soft tissue density encasing the celiac axis, suggesting lymphoma. Endoscopic ultrasound (EUS)-guided biopsy of the pancreatic lesion demonstrated an unreported 3.1cm liver mass, which was biopsied. On further review of imaging, the liver mass was not appreciated on ultrasound, CT or MRCP. It was suspected that the hyperbilirubinemia was likely due to this intrahepatic mass, described as poorly differentiated adenocarcinoma. Due to the early diagnosis he was able to be discharged and follow up with oncology to better guide his future directed therapy. Discussion: The Covid 19 pandemic forced all aspects of healthcare to adapt. Given gastroenterology's invasive nature this also encouraged gastroenterologists to consider alternative pathways of treatment aside from the published algorithms in place. This case demonstrates how deviating from the ASGE guidelines resulted in a cascade of diagnostics which led to an eventual malignancy diagnosis which may have been otherwise missed or delayed. Guidelines are established on large sets of data and patient prognostic indicators which to our knowledge have not considered infection status or isolation needs. Further research in this area may result in amending guidelines to address isolation status and reminds practitioners to consider the patient before them and their unique patient needs. (Figure Presented) .