CHUA, Mary Francine P.MD080022

Abdominal Pain

Identifying informationR.C.25 years oldMaleFilipinoMarriedDealerIglesia ni Cristo

Chief complaintAbdominal pain

History of the present illness(+) RUQ pain

Sudden, intermittent, no radiations

(-) fever, nausea & vomiting, changes in bowel movement

Consult done UTZ revealed

gallbladder stones Advised surgery but

refusedSelf-medicated with

mixture of apple juice, vinegar & olive oil

Passage of ~70 stones Complete relief

1 ½ years PTA

History of the present illness(+) epigastric pain

Occurring ~10 minutes after meals

5/10, persistent, no radiations

(+) bloatedness(-) fever, nausea &

vomiting, changes in bowel movement

No consult doneSelf-medicated

with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief

4 days PTA

History of the present illness(+) epigastric pain(+) bloatedness(+) undocumented

fever, (-) chills(+) anorexia(+) tea-colored

urineNo consult doneSelf-medicated with

HNBB, AlOH3MgOH2 simethicone, omeprazole with relief

2 days PTA

History of the present illness(+) epigastric pain

8/10(+) bloatedness(+) undocumented

fever, (-) chills(+) anorexia(+) tea-colored

urine(+) acholic stoolsConsult done at ER Given paracetamol and

omeprazole with temporary relief

Discharged

1 day PTA

History of the present illness(+) epigastric pain

8/10(+) bloatedness(+) undocumented

fever, (-) chills(+) anorexia(+) tea-colored

urine(+) acholic stools(+) yellowing of

the eyesAdmission

Day of admission

Review of systems• General: (-) weight loss, fatigue, weakness• HEENT: (-) headache, dizziness, enlarged LN• Pulmonary: (+) dyspnea, (-) hemoptysis,

cough, wheezing• Cardiovascular: (-) palpitations, chest pains,

orthopnea• Genitourinary: (-) nocturia, dysuria, frequency,

hematuria• Musculoskeletal/Dermatologic: (+) back pain,

(-) back pain, arthralgia, rashes, pruritus• Endocrine: (-) excessive sweating, heat/cold

intolerance, polyuria, excessive thirst

Past medical history(-) Hypertension, diabetes, asthma(+) allergies to shrimp and crabsUnrecalled operation on the head

secondary to mauling (1998), with blood transfusion

Family history(+) Hypertension- father(-) Diabetes, asthma, TB, cancer

Personal & social historyMarried, no childrenDiet: rice, “mahilig sa baboy”Current smoker, 0.8 pack years (2

sticks/day, 8 years)Heavy alcoholic beverage drinker, ~8

bottles of beer, 3x/weekMarijuana use

High schoolLast use: February 2012

General surveyConscious, coherent, cooperative, in painVital signs

110/80 mmHg104 beats/min22 breaths/min39.3°CVAS 8/10

BMI 19.27 kg/m2

Weight 59 kilosHeight 175 cm

HEENT• Icteric sclerae, pink conjunctivae • No tragal swelling or tenderness• No nasal discharge• Pink lips, moist oral mucosa, no lesions or

sores, (+) multiple dental caries, no tonsillopharyngeal congestion

• No cervical lymphadenopathies, non-palpable thyroid gland

Pulmonary• (+) tattoo on the periareolar area, right• Symmetric chest expansion, no retractions• Equal tactile fremiti• No dullness on percussion• Good air entry, clear breath sounds

Cardiovascular• Adynamic precordium• PMI at 5th ICS, left MCL• Normal rate and regular rhythm, distinct

S1/S2, no murmurs• No carotid bruits

Abdomen• Flat, soft abdomen, no scars/ lesions• Hypoactive bowel sounds • Tympanitic• (+) epigastric tenderness• Non-palpable liver edge• No palpable masses• (-) Murphy’s sign

Extremities• (+) flushed skin, (+) jaundice• No active dermatoses• Warm extremities• Good skin turgor• Full and equal pulses• No cyanosis, no clubbing• CRT < 2 seconds

Neurologic• Awake, alert, well-groomed• Oriented to 3 spheres• GCS 15• No cranial nerve deficits• No dysmetria, dysdiadochokinesia• MMT: 5/5• DTRs: 2+

Salient featuresHistory

Epigastric painBloatednessAnorexiaFeverTea-colored urineAcholic stoolsGallstones on

ultrasoundHeavy alcoholic

beverage drinker

Physical examinationHigh grade fever,

39.3°CFlushed skin,

jaundiceIcteric scleraeEpigastric

tenderness, hypoactive bowel sounds

Initial impressionObstructive biliary disease, secondary

to calculous cholecystitis, to consider choledocholithiasis, ascending cholangitis

Differential diagnosesGallstone pancreatitis

Diagnostic evaluationCBCSGPT, SGOTALPBilirubin (direct, indirect, total)Prothrombin timeAPTTAmylaseLipaseUltrasoundSerum electrolytes (Na, K, Cl)Urinalysis

LGBP UltrasoundGallstone with cholecystitisDilated common bile duct

Acute cholangitisOne of the main

complications of choledochal stones

Ascending bacterial infection due to partial of complete obstruction of the bile ducts

Both bacterial contamination and biliary obstruction are requisites for its development

E. coli, Klebsiella pneumoniae, Streptococcus faecalis, Enterobacter, Bacteroides fragilis

Clinical presentationMild, intermittent and self-limited to fulminant,

potentially life-threatening septicemiaMost common: Charcot’s triad (2/3)

FeverEpigastric/ RUQ painJaundiceReynold’s pentad Septic shock Mental status changesOn abdominal examination, the findings are

indistinguishable from those of acute cholecystitis

Tokyo GuidelinesA. Clinical context/ manifestations

History of biliary diseaseFever ± chillsJaundiceAbdominal pain (RUQ/epigastric)

B. Laboratory dataEvidence of inflammation

WBC, CRPAbnormal LFTs

ALP, GGT, AST, ALTC. Imaging

Biliary dilatation or evidence of etiologyStricture, stone, stent

Suspected Dx: >2 in A

Definitive Dx:1.Charcot’s triad2.>2 in A + both B and C

Tokyo GuidelinesMild

(+) response to medical treatmentGeneral supportive care and antibiotics

ModerateNo response to medical treatmentNo onset of organ dysfunction SevereNo response to medical treatment(+) Onset of organ dysfunction

CVD: BP, need for vasopressorsNervous: consciousnessRespiratory: PaO2/FiO2 <300Kidney: Creatinine > 2 mg/dLLiver: PT-INR >1.5Hematologic: Platelets <100

ManagementEndoscopic

retrograde cholangiopancrea-tography (ERCP)

ManagementLaparoscopic

cholecystectomy