What specialist should I consult for abdominal pain with a dilated common bile duct (CBD) on CT imaging, suspected acute cholecystitis, and elevated lipase and transaminases?

Consult General Surgery First, Then GI as Needed

You should consult General Surgery immediately as the primary service, with GI consultation to follow for likely ERCP once the patient is stabilized. This clinical presentation suggests acute cholecystitis with possible concomitant choledocholithiasis (CBD stones) and/or acute cholangitis, which requires urgent surgical evaluation and potential operative intervention 1.

Clinical Reasoning

Your patient presents with a complex biliary picture that requires surgical expertise:

• Acute cholecystitis is primarily a surgical disease requiring cholecystectomy, typically within 72 hours of symptom onset for optimal outcomes 1
• Dilated CBD with elevated transaminases and lipase suggests possible choledocholithiasis (CBD stones), which occurs in 15-50% of acute cholecystitis patients even without direct biliary obstruction 1
• Elevated lipase raises concern for gallstone pancreatitis, another surgical emergency requiring coordinated management 1

Why Surgery First

General Surgery should be the primary consulting service because:

• Acute cholecystitis requires definitive surgical management (cholecystectomy), and early surgical consultation allows for optimal timing of intervention 1
• The surgeon needs to assess for complications such as gangrene, perforation, or gangrenous cholecystitis (suggested by elevated bilirubin with leukocytosis) 1
• CT imaging can reveal complications requiring urgent surgical intervention including gas formation, intraluminal hemorrhage, and perforation 1
• Surgical planning is essential, as certain CT findings (absent gallbladder wall enhancement or infundibular stones) predict conversion from laparoscopic to open cholecystectomy 1

When to Involve GI

GI consultation should follow surgical evaluation for:

• ERCP consideration if choledocholithiasis is confirmed, particularly if the patient has high-risk features for CBD stones 1
• The combination of dilated CBD and elevated ALT/ALP are predictors of CBD stones, with 77% having raised ALP and 90% having elevated ALT when stones are present 1
• However, 42-58% of acute cholecystitis patients with elevated transaminases do NOT have CBD stones, so further risk stratification is needed 1

Risk Stratification for CBD Stones

Your patient likely has intermediate-to-high risk for choledocholithiasis based on:

• Dilated CBD on imaging (though CBD diameter alone is insufficient for diagnosis—a diameter >10mm has only 39% incidence of stones) 1
• Elevated transaminases (ALT/AST) and likely elevated alkaline phosphatase 1
• Elevated lipase suggesting possible biliary pancreatitis 1

Further diagnostic workup needed:

• If not already done, obtain MRCP or endoscopic ultrasound (EUS) to confirm CBD stones before ERCP, as these have sensitivities of 93% and 95% respectively 2
• MRCP is particularly valuable as it's non-invasive and provides excellent biliary visualization without radiation exposure 2
• The World Society of Emergency Surgery recommends performing LFTs (ALT, AST, bilirubin, ALP, GGT) and abdominal ultrasound in all acute cholecystitis patients to assess CBD stone risk 1

Clinical Algorithm

1. Immediate surgical consultation for acute cholecystitis management and operative planning 1
2. Concurrent risk stratification for CBD stones using clinical predictors and imaging 1
3. MRCP or EUS if intermediate probability of CBD stones (10-50%) to guide need for ERCP 2
4. GI consultation for ERCP if CBD stones confirmed or high clinical suspicion with cholangitis features 1
5. Coordinate timing: ERCP before or after cholecystectomy depends on stone burden, cholangitis presence, and surgical timing 1

Critical Pitfalls to Avoid

• Don't delay surgical consultation waiting for GI evaluation—acute cholecystitis is a surgical disease first 1
• Don't assume dilated CBD equals stones—only 39% with CBD >10mm actually have choledocholithiasis 1
• Don't perform ERCP without confirmation—15-50% of acute cholecystitis patients have elevated LFTs without CBD stones 1
• Watch for cholangitis (fever, jaundice, RUQ pain)—this requires urgent biliary decompression via ERCP before cholecystectomy 1, 3