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ER Interesting Case Rounds
Visit #1
• 18 yo female…. 4 day history of..
• “Fevers”
• Nausea/Emesis
• Diarrhea
• Lower abdominal pain
Pain..
RLQ = LLQ
7/10 at worst
No radiation
“crampy”
Worse with movement
Pain with BMs (diarrhea)
• Diarrhea…
• Non-bloody
• 3-4x/day
• “mucousy”
• No PV symptoms
• No urinary symptoms
Physical Exam
• Vitals = normal
• Chest = clear
• CV = normal
• Abdo =
• Tender to direct palpation. RLQ = LLQ
• No rebound/guarding etc.
• No mass
LABS
• Hgb = N
• WBC = 13.5 (neuts = 11, monocytes 1.2)
• Lytes = N
• BG = N
• Lipase = N
• LEs…
• ALP = N (104)
• ALT = N (16)
• GGT = 64 (8-35)
• Bili T = 46 (0-20)
• Bili D = 24 (0-7)
• Urine dip
• Beta = negative
• 3+ ketones
• 2+ bilirubin
• Tx—fluids, anti-emetic, booked for abdo u/s in am. Dx “abdo pain NYD/mild LFT abnormality”
VISIT #2
• Returned next day post u/s:
• “Well seen and NORMAL liver, GB, ducts, pancreas, kidneys, spleen, aorta, para-aorta areas, bowel, uterus, overies, adnexa. No free fluid.”
• Repeat labs
• Bili 29 (down from 46)
• GGT 56 (down from 64)
• WBCs 12.2 (down from 13.5)
• K = 3.4
• Dx: “gastroenteritis”
Visit #3
• Returns 5 days later…
• Persistent diarrhea
• Malaise
• ABDO PAIN!!
• 9 lb wt loss in 10 days
OTHER HX?
• No travel
• No well water exposure
• No recent ABX
• No sick contacts
• No exposure to uncooked meats
• Phx = healthy, no surgeries, PAP 6 months prior was normal
• No meds (was on OCP in past)• Social = infrequent EtOH, no IVDU,• No risky sexual behaviour• 1 partner. Using condoms.• Tattoo at end of June• Fam Hx: No IBD
• VS: HR 100, Temp 38
• ABDO=
• Tender lower quadrants
• Rebound
• Involuntary guarding
• +RUQ pain
• WBC: 19.9 (neuts 13, bands 4.2)
• GGT 109
• ALP 175
• Bili T = 23
• Stool C + S = negative
• Stool O + P = negative
• Hep Serology = negative
• C. diff = negative
• Stool Fat Globules = negative
• Speculum Exam:
• thick yellow d/c from cervical os
• Bimanual Exam:
• + cervical motion tenderness
• CT Abdo/Pelvis: complex fluid collection in pouch of Douglas, compressing rectum, consistent with large tubo-ovarian abscess
• DIAGNOSIS???
Fitz-Hugh-Curtis
• Perihepatitis in association with pelvic inflammatory disease
• Originally described by Carlos Stajano (1919) in Uroguay.
• 1930’s… re-described by Thomas Fitz-Hugh and Arthur Curtis.
Etiology
• Originally felt only to be secondary to N. gonorrhea (Fitz-Hugh discovered gram negative diplococci on smears taken from the liver capsule)
• 1970s, Chlamydia trachomatis implicated and remains the most common pathogen
• Case reports... strept milleri, tuberculosis
Organisms Associated with PID• Aerobes:• N. gonorrhea• C. trachomatis• U. urealyticum• Mycoplasma sp. (genitalium, hominus)• Gardnerella vaginalis• Strept Pyogenes• Coag – staph• E. Coli• H. influenzae• S. pneumoniae• Mycobacterium tuberculosis• Anaerobes:• B. fragilis• Peptostreptococcus• Clostridium bifermentans• Fusobacterium sp.• Viruses:• HSV• Echovirus• Cocksackie
Diagnosis
• RULING IN pelvic inflammatory disease
• RULING OUT other causes of RUQ pain +/or elevated liver enzymes
Pathogenesis
Multiple Theories:
• Direct Infection of Liver?
• Hematogenous Spread?
• Lymphatic Spread?
• Exaggerated Immune Response?
How Common?
• Studies show broad ranges
• 4%-27% of patients with PID
• RISK FACTORS:
• IUDs, pelvic surgery, multiple partners, lack of barrier protection etc.
Symptoms
• Symptoms of PID (fever, abdominal pain, vaginal discharge, vaginal bleeding)
• Right Upper Quadrant Pain—usually pleuritic.
• Possible for patient to present with RUQ pain only (subacute/chronic PID)
Atypical Presentations
• Ileus/obstruction• Peri-splenitis• Peri-appendicitis• Fitz-Hugh-Curtis in a male• Chilaiditi syndrome• Ovarian Ca• Perforated Ulcer• Pleural effusion
Physical Exam
• Cervical motion tenderness
• Adnexal/uterine tenderness
• Lower Abdominal tenderness
• RUQ tenderness (may occur on its own)
• +/- friction rub over right anterior costal margin
Radiographic Studies
• Ultrasound:
• Excludes cholelithiasis, cholecystitis etc.
• Insensitive for FHC
• May demonstrate “violin-string” adhesions, loculated fluid in the hepatorenal space.
• “Violin String” also in Familial Mediterranean Fever, Diaphragmatic Endometriosis
Radiographic Studies
• CT Scan:
• Helpful IF can demonstrate contrast enhancement of the liver capsule
• Sensitivity of only 28%! (Joo et al. 2007)
• Depends if biphasic CT vs. portal phase only
LAB TESTS
• Liver Enzymes: often normal but can be elevated
• Litt and Cohen (JAMA, 1978) found ALT most likely, but ‘cholestatic’ enzyme elevations also reported
• +/- ESR• +/- Leukocytosis• Cultures: N gonorrhea, C Trachomatis from
cervix. Cultures from pelvic aspirates tend not to correlate. (mixed anaerobes, aerobes etc.)
Treatment
• Similar to that of PID
• Generally focused on N gonorrhea and C trachomatis, gram negative rods, anaerobes
• Direct therapy according to cultures
• Drain abscesses
PID tx
• Tx regimens:
• Ceftriaxone 250 mg IM/Doxy 100 bid x 14 days• Levo od/Flagyl bid x 14 days• Cefoxitin 2g IV q6/Doxy 100 bid
• IV for 48 hours afebrile, then PO• Poor response to ABX = laparoscopy
Complications
• Those of PID:
• Infertility
• Adhesions
• Chronic pain
• Ectopic pregnancy
• Reiter’s syndrome
• Culture results:• Streptococcus milleri (heavy)• B fragiles (moderate)• E. Coli (scant)
• NAAT:• Negative for both Chlamydea and
Gonorrhea
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