Medical Transcription Services Company

September 18, 1999

J. John Trent, M.D.
5 Foothill Drive
Salt Lake City, Utah 84109-1494

Subject: Paul Frank

Dear Jack:

Thank you for your kind referral of Paul Frank. You are familiar with this very pleasant 55 year–oId gentleman's history of long-standing inflammatory bowel disease, total colectomy with ileoanal pull-through in July of 1998, a history of chronic and recurrent DVT, and a long–standing history of abnormal liver function test with a cholestatic pattern.

Recent abdominal ultrasound has revealed cholelithiasis and a diseased-appearing gallbladder with a suggestion of an abnormal distal common duct. A retrograde study performed today indeed showed an abnormal biliary tree. I was unable to inject contrast past the bifurcation on the right and left hepatic duct. The common duct was abnormal with a long stricture involving the majority of the duct and a suggestion of either sticture or a retained stone; I was unable to wire or brush his distal duct.

I plan to review his operative report from his colectomy to see if Dr. Pace performed a liver biopsy in July of 1998. This would be the reasonable next step. I am concerned about the likelihood of associated primary sclerosing cholangitis as the underlying etiology for this abnormal biliary tree. He has no complaints of pruritus. There was no evidence of varices by a limited inspection of his esophagus. However, he complains of chronic fatigue since his pull–through in July of 1998. Once I' ve had a chance to review his operative report and final radiographs, I will review these findings and then make my recommendations accordingly.

I greatly appreciate the chance to participate in his care with you.

Sincerely,

R. T Bellyakin, M.D.

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