Differential Diagnosis for Chronic LUQ Pain with Sludge on CT and MRCP
Single Most Likely Diagnosis
- Chronic Pancreatitis: The presence of sludge on CT and MRCP, along with mid CBD dilation and distal CBD stricture, is highly suggestive of chronic pancreatitis. The normal LFTs do not rule out this diagnosis, as liver function can be preserved despite significant pancreatic disease.
Other Likely Diagnoses
- Choledocholithiasis: The presence of sludge and CBD dilation suggests the possibility of choledocholithiasis, which can cause chronic LUQ pain. However, the absence of elevated LFTs and the presence of a distal CBD stricture make this diagnosis less likely.
- Primary Sclerosing Cholangitis (PSC): PSC can cause CBD strictures and dilation, and can present with normal LFTs. However, it is less common than chronic pancreatitis and often associated with inflammatory bowel disease.
- CBD Stricture due to Trauma or Instrumentation: A stricture in the distal CBD can be caused by trauma or instrumentation, such as ERCP. This diagnosis is possible, but less likely given the presence of sludge and mid CBD dilation.
Do Not Miss Diagnoses
- Pancreatic Cancer: Although less likely given the normal LFTs and presence of sludge, pancreatic cancer can cause CBD obstruction and stricture. It is essential to rule out this diagnosis due to its high mortality rate.
- Cholangiocarcinoma: Similar to pancreatic cancer, cholangiocarcinoma can cause CBD obstruction and stricture. Although rare, it is a diagnosis that should not be missed due to its poor prognosis.
Rare Diagnoses
- Congenital Anomalies of the Pancreaticobiliary Tree: Anomalies such as pancreas divisum or choledochal cysts can cause chronic LUQ pain and CBD dilation. However, these conditions are rare and often diagnosed at a younger age.
- Parasitic Infections: Parasites such as Ascaris lumbricoides or Clonorchis sinensis can cause biliary obstruction and CBD dilation. However, these infections are rare in developed countries and typically associated with travel or exposure history.