Asuncion * Dalman * Doromal * DyGeneroso * Mejia * Ong

Internal Medicine Rotation- The Medical CityDecember 22, 2010

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G7 Grand Rounds

Identifying Data

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• CFG, 58 y/o • Filipino female• Roman Catholic• From Pasig• Informants: Patient and sister (good

reliability)

Chief Complaint

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• Epigastric pain

History of Present Illness

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• Post-prandial epigastric pain (6/10) crampy, intermittent, 30 minute duration, with radiation to the back

• Took Itopride (Ganaton) no relief• (-) fever, nausea, vomiting, changes in bowel

movement

Morning PTA

Afternoon PTA• Epigastric pain with increased intensity; (+) chills and

fever• Consult at TMC-ER admission

Review of Systems

• (+) generalized weakness• No weight gain or weight loss, easy fatigability• No headache, seizures, blurring of vision, ear

problems• No dyspnea, cough, colds• No Palpitations, chest pain• No nausea, vomiting• No dysuria, frequency

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Past Medical History

• (+) Hypertension – 20 years• S/p laparoscopic cholecystectomy with

subsequent development of stricture, s/p stent placement (2005)

• S/p biliary stent replacement (2007)• Allergic to erythromycin – rashes

Past Medical History

• Hypertension– 20 years– On Losartan + Hydrochlorohiazide

• Asthma– No recent consults– Last attack unrecalled– No maintenance medications

Family History

• Hypertension• Asthma

Personal and Social History

• Divorced• Smoker• Occasional alcohol beverage drinker• Usual diet: prefers meat and fatty food, soda

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Physical Exam

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• Anthropometrics: Height=152 cm, weight=68 kg, BMI=29.4 (overweight)• Vitals: BP: 150/90, T: 39.5oC, RR 21, HR 88• General: conscious, coherent, alert• HEENT: anicteric sclerae, pink palpebral conjunctiva,

neck veins non-distended, no cervicolymphadenopathies• Chest: Symmetric chest expansion, no retractions ,

clear breath sounds

Physical Exam

Abdomen: Protuberant, normoactive, tympanitic, no masses palpated, scar on the left upper quadrant, epigastric and right upper quadrant direct tenderness

Extremities: Full and equal pulses, good skin color and turgor

Digital rectal exam:

Salient Features

• 58 year old, female• Acute abdominal pain (epigastric, RUQ areas)• Accompanied by chills and fever• History of cholecystectomy with biliary stent

insertion and replacement (2005 and 2007)

ASSESSMENTAscending cholangitis

Differential Diagnosis

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• Cholecystitis and biliary colic

• Diverticular disease• Hepatitis• Mesenteric ischemia• Pancreatitis

• Cirrhosis• Liver failure• Liver abscess• Acute appendicitis• Perforated peptic ulcer• Pyelonephritis

Hepatitis

Pancreatitis

Peptic Ulcer Disease

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Diagnostic Plan (1 of 2)

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Diagnostic Plan (2 of 2)

COURSE IN THE WARDS

Hospital Day 1: Floors to ICUSubjective Objective Assessment Plan

• Stable at the floors early in the AM • Decreased responsiveness• Restlessness

BP: 160/60 90/60HR: 100sRR: 40sO2 sat’n: 97% 88%+ alar flaring+ ronchi, ralesOccasional wheezingDistended abdomen; soft, non-tenderNormal rate, regular rhythmDistinct S1No edemaFull and equal pulsesFlushed skin

Severe septic shock secondary to ascending cholangitis secondary to biliary duct stricture s/p stent placement

Hypertension

• Intubation• Transfer to ICU• Stat ERCP• Antibiotics (Pip-Tazo Linezolid and Imipenem)

Hospital Day 1 – DiagnosticsCBC

Hemoglobin = 132 g/dLHematocrit = 0.37Platelets = 224WBC = 14.5Neutrophils = 0.93Lymphocytes = 0.06Monocyte = 0.01

Urinalysis

Color: Dark yellowSp Gravity: 1.015+ erythrocytes, urobilinogen, bilirubin

ABGpH = 7.382pCO2 = 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 ↑

Hospital Day 1 – DiagnosticsECG

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/mL*CK Total = 306.3 U/L ↑CK MB = 23.44 U/LCK MM = 282.9 U/L ↑

Cultures

Stent and blood: Klebsiella pneumoniaeBile: Heavy growth of Escherichia coliStent: Proteus mirabilis•All orgnisms sensitive to Ceftriaxone

Hospital Day 1 – DiagnosticsSerum Electrolytes

Sodium: 139 meq/LPotassium: 3.3 meq/L

OthersAmylase: 126 U/L ↑Lipase: 96.56 U/L ↑Lactate: 50.52 mg/dL ↑Creatinine: 0.64 mg/dLNGAL: 225.2 ng/mL ↑

At the end of the 1st hospital day...

• 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 Enoxaparine (Clexane), 0.6 ml every 12

hours

At the end of the 1st hospital day...

• Respiratory:– Oxygen saturation = 98%– (+) ronchi bilaterally– (+) rales on the right base

• IDS– Febrile– On linezolid and imipenem

• Unremarkable gastrointestinal, genitourinary and endocrine findings

Assessment at the end of the 1st hospital day...

• Acute respiratory failure secondary to septic shock secondary to ascending cholangitis

• Asthma vs. COPD in acute exacerbation• Hypertension, to consider non-ST elevation

myocardial infarction

Plan at the end of the 1st hospital day...

• Close monitoring

• Maintain hemodynamic stability

• Administration of antibiotics

• Mechanical ventilation

Hospital Day 4: in the ICUSubjective / Objective Assessment Plan

• CNS: GCS 11 (E4VtM6) with episodes of agitation; on Midazolam 5 ml/hr• CVS: BP: 135/60, HR: 91, off norepinephrine• Respiratory: no desturations, clear breath sounds; on mechanical ventilation with 60% FiO2• GI: NGT feeding; melena episode• GU: adequate input and output; (+) hematuria; Crea=0.67; Na=150; K=3.4• IDS: afebrile, on Imipenem Day 3• Endo: CBG – 128 mg/dL

Septic shock secondary to ascending cholangitis s/p ERCP

Hypertension t/c non-ST elevation MI

Acute kidney injury

Anemia probably secondary to upper GI bleed

• 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)

CBCHemoglobin = 83 g/dL

Hematocrit = 0.25Platelets = 119

WBC = 15.4Bands = 0.02

Neutrophils = 0.85Lymphocytes = 0.08

Monocyte = 0.04Eosinophil = 0.01

Hypochromic

Course in the Hospital

• Day 6 – extubated; well-tolerated

• Day 7 – transfer to the floors

• Day 12 – discharged

Principles of Management

Septic Shock Ascending Cholangitis

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• Close monitoring (vital signs, I/O)

• Hemodynamic support with IV fluids and vasopressors

• Identify underlying cause for sepsis

• ABC assessment• IV Fluid resuscitation with

crystalloids (e.g. plain NSS)• Parenteral antibiotics• Biliary decompression

(severe cases)• Extracorporeal shockwave

lithotripsy (ESWL) for choleliths

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

Looking Ahead – Ascending Cholangitis

Prognosis Complications• 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

• Liver failure, hepatic abscess, microabscess

• Acute renal failure• Bacteremia, sepsis (gram-

negative)

Looking Ahead – Septic Shock

Prognosis Complications• Depends on the following:

– Severity of illness– Co-morbidities– Age

• Response to antibiotics

• Acute respiratory distress syndrome (ARDS)

• Renal dysfunction• Disseminated intravascular

coagulation (DIC)• Mesenteric ischemia• Myocardial ischemia and

dysfunction

Other Aspects of the Case

Psycho-socio-economic Impact Prevention and Public Health• P100,000 per day with ICU

admissions current expense for the patient is around P400,000

• On patient’s personal account

• Lifestyle and health-seeking behavior changes (e.g. low-fat diet, quit smoking, stent-removal)

• Patient education

Asuncion * Dalman * Doromal * DyGeneroso * Mejia * Ong

Internal Medicine Rotation- The Medical CityDecember 22, 2010

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G7 Grand Rounds