Shockingly Painful A Case Presentation Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong December 22, 2010 Medicine Clerkship Rotation The Medical

Shockingly PainfulA Case Presentation

Group 7:Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

December 22, 2010Medicine Clerkship Rotation

The Medical City

Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,

Mejia, Ong

General Data

CFG58 years oldFemaleFilipinoRoman CatholicFrom Pasig CityInformants: Patient and sister (good reliability)


Mejia, Ong

Chief Complaint:Abdominal pain

Morning PTA Abdominal pain Post-prandial Epigastric 30 minute duration Crampy, 6/10 pain scale No relief with Itopride (Ganaton) No aggravating factors Radiates to the back Intermittent

No associated:Fever, Nausea, Vomiting, Bowel movement changes

Persistent

Afternoon PTA


Mejia, Ong


Morning PTA Abdominal pain

Persistent

Afternoon PTA Abdominal pain Increased intensity Epigastric 30 minute duration Crampy, 6/10 pain scale No relief with Itopride (Ganaton) No aggravating factors Radiates to the back Intermittent

Associated chills and undocumented fever


Mejia, Ong


ER Consult


Mejia, Ong

•No weight gain or weight loss. Easy fatiguability

•No headache, seizures, blurring of vision, ear problems

•No dyspnea, cough, colds

•No palpitations, chest pain

•No nausea, vomiting

•No dysuria, frequency

Pertinent Review of Systems

• (+) Generalized weakness


Mejia, Ong

Past Medical History

Hypertension Stage II

20 years

On Losartan + Hydrochlorothiazide

Asthma

No recent consults

Unrecalled last exacerbation

No maintenance medications

Erythromycin allergy (rashes)


Mejia, Ong

Past Medical History

s/p Laparoscopic cholecystectomy with subsequent development of stricture, s/p biliary stent placement (2005)

s/p Biliary stent replacement (2007)


Mejia, Ong

Family History

• Hypertension

• Asthma


Mejia, Ong

• Divorced

• Smoker (20 pack years)

• Occasional alcoholic drinks

• Usual diet: meat, fatty food, soda

• Occupation: Businesswoman/student

Personal-Social History


Mejia, Ong

Physical Examination

Vital Signs

General

HEENT

Chest

Abdominal

Extremities


Mejia, Ong


Vital Signs

General

HEENT

Chest

Abdominal

Extremities

Ht: 152 cm, Weight 68 kg, BMI: 29.4 (overweight)

BP: 150 / 70Temp: 39.5oC

HR: 88RR: 21


Mejia, Ong


Vital Signs

General

HEENT

Chest

Abdominal

Extremities

Conscious

Coherent

Alert

Not in respiratory distress


Mejia, Ong


Vital Signs

General

HEENT

Chest

Abdominal

Extremities

Icteric sclerae

Pink palpebral conjunctiva

Neck veins not distended

No CLAD


Mejia, Ong


Vital Signs

General

HEENT

Chest

Abdominal

Extremities

Symmetric chest expansion

No retractions

Clear breath sounds

Adynamic precordium

Normal S1 and S2


Mejia, Ong


Vital Signs

General

HEENT

Chest

Abdominal

Extremities

Protuberant

5 bowel sounds per minute (normoactive)

Tympanitic

No masses

Epigastric and right upper quadrant tenderness


Mejia, Ong


Vital Signs

General

HEENT

Chest

Abdominal

Extremities

Full and equal pulses

Normal skin color

Good skin turgor


Mejia, Ong

Salient Features

58 year old female

Acute abdominal pain (epigastric)

Accompanied by chills and fever

History of cholecystectomy with biliary stent placement and replacement (2005 and 2007)


Mejia, Ong

Admitting Impression

Acid Peptic Disease

r/o failed biliary stent

r/o viral hepatitis

r/o beginning pancreatitis


Mejia, Ong

Differential Diagnoses

Cholecystitis and biliary colic

Diverticular disease

Hepatitis

Pancreatitis

Liver abscess

Acute appendicitis

Perforated peptic ulcer

Ascending cholangitis✓✓

✓

✓


Mejia, Ong

Hepatitis✓Salient Features +/- Hepatitis

58 year old, female + Mortality: < 5 y/o and > 50 y/o

Abdominal pain and tenderness (epigastric) radiating to the back

+Epigastric or RUQ pain with

radiation to back

Accompanied by chills and fever + Accompanied by fever

Acute onset + Acute onset

Icetric sclerae and not jaundiced - Jaundice


Mejia, Ong

Pancreatitis✓Salient Features +/- Pancreatitis

58 year old, female + African-American; 35-64 y/o

Abdominal pain and tenderness (epigastric) radiating to the back

+Epigastric or RUQ pain with

radiation to back

Accompanied by chills and fever + Accompanied by fever

History of cholecystectomy with biliary stent insertion and replacement (2005 and 2007)

-History of recent surgery or

invasive procedure


Icetric sclerae and not jaundiced - Jaundice


Mejia, Ong

Peptic Ulcer Disease✓Salient Features +/- Peptic Ulcer Disease

58 year old, female + Tends to occur later in life

Abdominal pain and tenderness (epigastric) radiating to the back + Epigastric pain

Accompanied by chills and fever +/- Not usually associated with chills and fever


- Not significant

Acute onset - Recurrent unless perforation occus

Icetric sclerae and not jaundiced +/- Usually normal PE findings


Mejia, Ong

Ascending cholangitis✓Salient Features +/- Ascending cholangitis

58 year old, female + No age or sex prediliction

Abdominal pain and tenderness (epigastric) radiating to the back + Presents as abdominal pain

Accompanied by chills and fever + Patient was febrile


+ Associated with biliary tract manipulation


Icetric sclerae and not jaundiced +/- Presents with jaunice


Mejia, Ong

Diagnostic PlanLaboratory test Rationale

CBC with differential count

Baseline values; determine presence of infection , anemia, etc.

Electrolyte panel with renal function

Assess metabolic state and kidney function

Liver function testDetermine possible liver pathology(e.g. hepatitis)

Prothrombin time/ activated partial thromboplastin time

Coagulapthies (e.g. DIC, cirrhosis)

Lipase Usually elevated in pancreatitis


Mejia, Ong

Diagnostic Plan

Laboratory test Rationale

UrinalysisBaseline values; determine presence of infection , glucose, protein, etc.

Culture and sensitivity for blood, bile, stent

Determine foci of infection and resistance profiles

Chest x-ray Baseline study

Ultrasound Visualization of the biliary tree


Mejia, Ong

Hospital Day 1: Floors to ICU

AM: Stable at the floorsDecreased responsivenessRestlessness

FebrileBP: 160/90→90/60HR: 100sRR: 40sO2 saturation: 97%→88%

+ Alar flaring, + Ronchi and ralesOccasional wheezingDistended abdomen; soft, non-tenderNormal rate, regular rhythmDistinct S1No edemaFull and equal pulsesFlushed skinSigns of jaundice

Su

bje

cti

ve

Ob

jecti

ve


Mejia, Ong

Definition of termsSepticemia

• Presence of microbes or their toxins in blood


Mejia, Ong

Definition of termsSIRS

• Systemic Inflammatory Response Syndrome

•2 or more of the following:

>38oC

< 36oC > 24 breaths/min

> 90 beats/min

> 12000/L< 4000/L

WBC


Mejia, Ong

Definition of termsSepsis

• 2 or more of SIRS components with a proven or suspected microbial etiology

>38oC

< 36oC

> 24 breaths/min

> 90 beats/min > 12000/L

< 4000/LWBC


Mejia, Ong

Definition of termsSeptic shock

• SIRS + hypotension

>38oC

< 36oC

> 24 breaths/min

> 90 beats/min

> 12000/L

< 4000/LWBC

BP: < 90 systolic< 40 mmHg less

than patient’s normal


Mejia, Ong

Definition of termsAscending Colangitis

• Charcot’s Triad:

• Right upper quadrant pain, Fever, Jaundice

>38oC

33


Mejia, Ong

Biliary obstruction Host antibacterial defenses

Immune dysfunction

bacteria

bacteria

bacteria

bacteria bacteria

bacteria

bacteria

bacteria

bacteria

bacteriabacteria

bacteria

bacteria bacteriabacteria

bacteria

Acute Cholangitis

34


Mejia, Ong

Duodenum Portal venous blood

Biliary Tree

Hepatic Ducts

bacteria bacteria

Acute Cholangitis

35


Mejia, Ong

Bacteria

LPSPeptidoglycan

Lipoteichoic acid

DNA fimbriae

Host binding protein

CD 14

Monocytes

macrophages

Neutrophils

TLR chemokinesCytokines

prostanoidsleukotriens

Septic Shock

36


Mejia, Ong

chemokinesCytokines

prostanoidsleukotriens

Inc. Blood flow

Enhance vessel permeability

Recruit neutrophils

Elicit pain

IL-6

monocytesEndothelial

cells

Coagulation!

Septic Shock


Mejia, Ong

Septic Shock

• Control Mechanisms

•Prevent inflammation within organs distant from infection site

•Work of anti-inflammatory molecules


Mejia, Ong

Septic Shock

• Organ dysfunction and shock

• Prevalence of anti-inflammatory molecules

• Blood leukocytes often HYPOresponsive to agonists such as LPS

• - Increases risk of mortality

39


Mejia, Ong

• Vascular injury

• Endothelial injury

Leukokcyte-derived mediators

Platelet-leukocyte-fibrin thrombi

Vascular injury

TNFa Vascular endothelial cells cytokinesProcoagulant

moleculesNitric oxidePAF

SHOCK!!!

Septic Shock


Mejia, Ong

Hospital Day 1: Floors to ICU

AM: Stable at the floorsDecreased responsivenessRestlessness

FebrileBP: 160/90→90/60HR: 100sRR: 40sO2 saturation: 97%→88%

+ Alar flaring, + Ronchi, ralesOccasional wheezingDistended abdomen; soft, non-tenderNormal rate, regular rhythmDistinct S1No edemaFull and equal pulsesFlushed skinSigns of jaundice

Su

bje

cti

ve

Ob

jecti

ve


Mejia, Ong

Assessment

• Severe septic shock secondary to ascending cholangitis

• secondary to biliary duct stricture s/p stent replacement (2007)


Mejia, Ong

Plan

• Intubation

• Transfer to ICU

• Stat ERCP

• Antibiotics (Pip-Tazo) → Linezolid and imipinem


Mejia, Ong

ERCP• Endoscopic Retrograde

Cholangiopancreatography

• Diagnosis and treatment of benign malignant pancreaticobiliary diseases

Indications Benefits

• Gallstones trapped in main bile duct• Blockage of bile duct• Jaundice• Undiagnosed persistent, recurrent upper

abdominal pain• Unexplained loss of appetite and weight

loss• Cancer of the bile ducts or pancreas• Pancreatitis

• Diagnostic and therapeutic technique (e.g. gallstones, blockage)

• Shorter hospital stay


Mejia, Ong

ERCP

• Duodenoscope• Fiber-optic duodenoscope• Videoscope

“ERCP”. Jackson Siegelbaum. Gastroenterology.(http://gicare.com/Endoscopy-Center/ERCP.aspx)

http://gicare.com/Endoscopy-Center/ERCP.aspx


Mejia, Ong

AntibioticsLinezolid and Imipenem


Mejia, Ong

Diagnostics

CBC Urinalysis

ABG Liver Function Tests


Mejia, Ong

Diagnostics

CBCHemoglobin = 132 g/dlHematocrit = 0.37Platelets = 224WBC = 14.5Neutrophils = 0.93Lymphocyte - 0.06Monocyte = 0.01

UrinalysisColor: Dark YellowSp. gravity: 1.015+ Erythrocytes, urobilinogen, bilirubin

ABGpH = 7.352pCO2 = 26.4pO2 = 63.1HCO3 = 15.7BE = -7.1O2 sat. = 91.73

Liver Function TestsHepatitis tests: non-reactiveSGOT: 542.7 U/L ↑SGPT: 636.8 U/L ↑Alk. Phos: 137.1 U/L ↑Total Bilirubin: 6.17 mg/dL ↑Direct Bilirubin: 4.02 mg/dL ↑Indirect Bilirubin: 2.15 mg/dL ↑


Mejia, Ong

ABG Interpretation• pH: Acidotic

• HCO3: below normal, metabolic acidosis

• pCO2: below normal, respiratory alkalosis


Acceptable ranges:

pH: 7.35-7.45pCO2: 35-45HCO3: 22-26BE: +2 to -2

Metabolic acidosis with concomitant respiratory alkalosis

Oxygenation: adequate


Mejia, Ong

Diagnostics

CBCHemoglobin = 132 g/dlHematocrit = 0.37Platelets = 224WBC = 14.5Neutrophils = 0.93Lymphocyte - 0.06Monocyte = 0.01

UrinalysisColor: Dark YellowSp. gravity: 1.015+ Erythrocytes, urobilinogen, bilirubin




Mejia, Ong

Liver Function Interpretation

• Inflammation or damage to hepatocytes

• Usually due to biliary obstruction in the occurrence of abdominal pain

• Elevated alkaline phosphatase cholestasis



Mejia, Ong

Diagnostics

ECG Chest X-ray

Cardiac Enzymes Cultures


Mejia, Ong

Diagnostics

ECG

Normal sinus rhythmLeftward axisLeft atrial enlargementNon-specific ST-T wave changesNo significant changes from 11/27/2010

Chest X-ray

Subsegmental atelectasis, rightCardiomegalyAtheromatous aortaThoracic spondylosis and dextroscoliosis

Cardiac Enzymes

Troponin T = 0.57 ng/mlCK Total = 306.3 U/L ↑CK MB = 23.44 U/L CK MM = 282.9 U/L ↑

Cultures

Stent and bloodBileStent


Mejia, Ong

Diagnostics

Serum Electrolytes Other tests


Mejia, Ong

Diagnostics

Serum Electrolytes

Sodium = 139 meq/LPotassium= 3.3 meq/L

Others

Amylase = 126 U/L ↑Lipase = 96.56 U/L ↑Lactate = 50.52 mg/dL ↑Creatinine = 0.64 mg/dL ↑NGAL = 225.2 ng/mL ↑


Mejia, Ong

Enzymes: Amylase, Lipase

• Slightly elevated amylase and lipase levels

• Not definitive for pancreatitis (requiring three-fold increase)


Mejia, Ong

Neutrophil Gelatinase-associated Lipocalin (NGAL)

• Biomarker for acute ischemic renal injury

• Expressed by neutrophils and other epithelia (e.g. renal proximal tubules)

• Measured in urine or serum


Mejia, Ong

Physical ExaminationHospital Day 1

• CNS: GCS 11, sedation with Midazolam

• CVS:

•BP: 75/40 to 150/70, tachycardic → hypotensive episodes

•On dopamine and/or norepinephrine drip

•(+) Trop T, elevated CK enzymes, anterior wall ischemia on ECG

•Given Enoxaparin (Clexane), 0.6 ml every 12 hours


Mejia, Ong

DrugsEnoxaparin

• Anticoagulant

• Binds to anti-thrombin III and accelerates activity, inhibiting thrombin and Factor Xa (low molecular weight heparin)


Mejia, Ong

Physical ExaminationHospital Day 1

• Respiratory:

•Oxygen saturation = 98%

•+ Ronchi bilaterally

•+ Rales on the right base

• IDS

•Febrile

•On Linezolid and Imipenem

• Unremarkable GI, GU and Endocrine findings


Mejia, Ong

Acute Respiratory Failure

• Syndrome of failure in one or both gas exchange functions (oxygenation and/or carbon dioxide elimination)

• PaO2 < 60mmHg (type 1) or PaCO2 > 50mmHg (type 2)


Mejia, Ong

Assessment

• Acute respiratory failure secondary to septic shock secondary to ascending cholangitis s/p ERCP

• Hypertension


Mejia, Ong

Plan

• Close monitoring

• Maintain hemodynamic stability

• Administration of Linezolid and Imipenem

• Mechanical ventilation


Mejia, Ong

Hospital Day 3: ICU

CNS: GCS 11 (E4VtM6) with episodes of agitationon Midazolam 5 ml/hr

Hemoglobin = 83 g/dLHematocrit = 0.25Platelets = 119WBC = 15.4

•Serum Creatinine = 1.68 (↑ from 0.6)

Ob

jecti

ve

Lab

ora

tory

Bands = 0.02Neutrophils = 0.85Lymphoctes = 0.08Monocytes = 0.04Eosinophil = 0.01 Hypochromic

Cultures:

Stent and blood: Klebsiella pneumoniae

Bile: Heavy growth of Escherichia coli

Stent: Proteus mirabilis

*All organisms sensitive to Ceftriaxone and ampicillin


Mejia, Ong

AntibioticsCeftriaxone and Ampicillin

• Culture guided antibiotics

• Mechanism of action...

• Coverage...

• For Mimi


Mejia, Ong

Acute Kidney Injury

• Broad spectrum of sublethal injury to tubular and other renal cells

• Occurs in 1% to 25% of ICU patients

• Cause ICU of mortality (Hoise et al.)

RIFLE F 26.3% mortality

RIFLE I 11.4% mortality

RIFLE R 8.8% mortality


Mejia, Ong

Acute Kidney Injury – Rifle Criteria


Mejia, Ong

Anemia

• Deficiency in red blood cells, hemoglobin, or in total volume

• Gastrointestinal bleeds: manifest as melena, hematochezia, hematemesis

• Most common etiologies: ulcers (31-59%), varices (7-20%), Mallory-Weiss tears (4-8%)


Mejia, Ong

Assessment

• Acute Respiratory Failure secondary to Septic shock secondary to ascending cholangitis s/p ERCP

• Acute kidney injury

• Anemia probably secondary to upper GI bleed


Mejia, Ong

Plan

• Close monitoring

• For blood transfusion

• Ulcer prophylaxis

• Potassium correction

• For step-down antibiotics - Ceftriaxone and ampicillin (culture guided)

• Possible mechanical ventilation weaning (extubation on hospital day 6)


Mejia, Ong

Hospital course• Day 4: creatinine at 0.67

• Day 5: extubated, well-tolerated

• Day 6: transfer to the floors

• Day 11: discharged


Mejia, Ong

Principles of ManagementSeptic Shock

• Close monitoring (vital signs, I/O)

• Hemodynamic support with IV fluids and vasopressors

• Identify underlying cause for sepsis


Mejia, Ong

Principles of ManagementAscending Cholangitis

• ABC assessment

• IV fluid resuscitation with crystalloids (e.g. plain NSS)

• Parenteral antibiotics

• Biliary decompression (severe cases)

• Extracorporeal shockwave lithotripsy (ESWL) for choleliths


Mejia, Ong

Acute Cholangitis

Mild Severe

ICUMonitor with reassessment

ERCP

Improvement No improvement

Elective ERCPwith definitive therapy (if not previously done)

Percutaneous drainage

Improvement

Elective ERCPwith definitive therapy

of bile duct stoneswithin 24-48 hrs

No improvement

Source: http://emedicine.medscape.com/article/774245-media

http://emedicine.medscape.com/article/774245-media


Mejia, Ong

Ascending CholangitisPrognosis

• Depends on the following:

•Early recognition and treatment of cholangitis

•Response to therapy

•Underlying medical conditions of the patient

• Mortality rate: 5-10% (higher in patients who require emergency decompression or surgery)

• Good response to antibiotics = good prognosis


Mejia, Ong

Ascending CholangitisComplications

• Liver failure, hepatic abscess, microabscess

• Acute renal failure

• Bactermia, sepsis (gram-negative)


Mejia, Ong

Septic ShockPrognosis

• Depends on the following:

•Severity of illness

•Co-morbidities

•Age

• Response to antibiotics


Mejia, Ong

Septic ShockComplications

• Acute respiratory distress syndrome (ARDS)

• Renal dysfunction

• Disseminated intravascular coagulation (DIC)

• Mesenteric ischemia

• Myocardial ischemia and dysfunction


Mejia, Ong

Preventable gallstones?

2004

5 million Filipinos with gallstones

2010

5.4 Filipinos estimated to have gallstones


Mejia, Ong

Risk Factors

Obesity

Diet

Smoking

Sedentary lifestyle

Medications

Weight cycling

Genetics


Mejia, Ong

Risk Factors

More trans fat

> 36 inches

15/1000 smokers

Sedentary lifestyle

2x risk for cholecystectomy

Increased risk

Gut. 2006 May; 55(5): 708-14

High glycemic indexArch Intern Med. 2005 May 9;165(9):1011-5

Am J Clin Nutr. 2008 Mar;87(3):627-37

Increased riskAm J Epidemiol. 2009 Jan 15;169(2):153-60

Increased riskAnn Intern Med. 1998 Mar 15;128(6):417-25.


Mejia, Ong

call-an-jee-tis


Mejia, Ong

Role of Practitioners

Stop trans fat useStop trans fat use

PolicyPolicy

Surveillance of harmful dietary substances

Surveillance of harmful dietary substances

Education at the school levelEducation at the school level


Mejia, Ong

Healthcare Availability

Php 488,000

12 days

Php 44,000 / day

x


Mejia, Ong

How many Filipinos can afford the same

healthcare?

50%30%10%5%?Fewer than that!


Mejia, Ong

Facts

Php 206,000Php 176,000

Earns:

Spends:

Php 30,000Savings:


Mejia, Ong

Facts

16 years to pay


Mejia, Ong

Average income

Number of families

Average income per

bracket

Average expenditure per bracket

P250,000 and above 3,264,000 471,000 361,000

P100,000 – P249,999 6,271,000 157,000 143,000P60,000 – P99,999 4,122,000 79,000 77,000P40,000 – P59,000 2,355,000 50,000 52,000P40,000 and below 1,392,000 30,000 33,000

http://www.census.gov.ph/data/sectordata/2006/fies0608r.htmhttp://www.census.gov.ph/data/sectordata/2006/fies0602r.htm

Total families: 17,403,000 (2006)

http://www.census.gov.ph/data/sectordata/2006/fies0608r.htm


Mejia, Ong

PhilHealth

Php 488,000 to 454,400 Php 488,000 to 454,400

Hospital discount: Php 33,600Hospital discount: Php 33,600

Government/Public Tertiary hospitalGovernment/Public Tertiary hospital

1/3 of private costs: Php 162,000 1/3 of private costs: Php 162,000

The PhilHealth Member would pay only Php 128,400The PhilHealth Member would pay only Php 128,400

Case B

Private Tertiary HospitalPrivate Tertiary Hospital

Shockingly PainfulA Case Presentation

Group 7:Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

December 22, 2010Medicine Clerkship Rotation

The Medical City

Documents

Shockingly Painful A Case Presentation Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong December 22, 2010 Medicine Clerkship Rotation The Medical