Spasm of sphincter of Oddi

K83.4

Clinical Vignette:

Patient Profile:

* Age: 45 years old

* Sex: Female

* Name: Isabella

History of Present Illness:

Isabella, a 45-year-old professor of philosophy with a penchant for critically analyzing metaphysical concepts, presented to the clinic with recurring abdominal pain over the past six months. The pain was described as episodic, typically intensifying post-meals, particularly those rich in fats. It was located in the right upper quadrant of her abdomen and radiated towards her back.

Additionally, Isabella reported episodes of nausea and occasional vomiting. Recently, she had noticed a subtle yellowing of her skin and eyes. She had no significant medical history, apart from a gallbladder removal surgery performed two years ago due to gallstones.

Physical Examination:

Upon examination, Isabella showed mild signs of jaundice. Abdominal palpation revealed no tenderness or organomegaly, although a surgical scar was present in the right upper quadrant, a testament to her prior cholecystectomy.

Investigations and Diagnosis:

The combination of Isabella's postprandial pain, jaundice, and history of cholecystectomy led the clinical team to suspect post-cholecystectomy syndrome, potentially due to sphincter of Oddi dysfunction. To confirm, an endoscopic retrograde cholangiopancreatography (ERCP) was carried out. The results showed a dilated common bile duct with delayed contrast drainage, solidifying the diagnosis of Spasm of the Sphincter of Oddi.

Isabella's symptomatology, coupled with the results from the ERCP, enabled the final diagnosis.

Diagnosis and ICD-10-CM Code:

Spasm of sphincter of Oddi (K83.4)