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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)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Chief Complaint:Abdominal pain
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Chief Complaint:Abdominal pain
ER Consult
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Family History
• Hypertension
• Asthma
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
• Divorced
• Smoker (20 pack years)
• Occasional alcoholic drinks
• Usual diet: meat, fatty food, soda
• Occupation: Businesswoman/student
Personal-Social History
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Physical Examination
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Physical Examination
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Physical Examination
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Conscious
Coherent
Alert
Not in respiratory distress
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Physical Examination
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Icteric sclerae
Pink palpebral conjunctiva
Neck veins not distended
No CLAD
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Physical Examination
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Symmetric chest expansion
No retractions
Clear breath sounds
Adynamic precordium
Normal S1 and S2
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Physical Examination
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Protuberant
5 bowel sounds per minute (normoactive)
Tympanitic
No masses
Epigastric and right upper quadrant tenderness
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Physical Examination
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Full and equal pulses
Normal skin color
Good skin turgor
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Admitting Impression
Acid Peptic Disease
r/o failed biliary stent
r/o viral hepatitis
r/o beginning pancreatitis
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Differential Diagnoses
Cholecystitis and biliary colic
Diverticular disease
Hepatitis
Pancreatitis
Liver abscess
Acute appendicitis
Perforated peptic ulcer
Ascending cholangitis✓✓
✓
✓
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Acute onset + Acute onset
Icetric sclerae and not jaundiced - Jaundice
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
History of cholecystectomy with biliary stent insertion and replacement (2005 and 2007)
- Not significant
Acute onset - Recurrent unless perforation occus
Icetric sclerae and not jaundiced +/- Usually normal PE findings
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
History of cholecystectomy with biliary stent insertion and replacement (2005 and 2007)
+ Associated with biliary tract manipulation
Acute onset + Acute onset
Icetric sclerae and not jaundiced +/- Presents with jaunice
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Definition of termsSepticemia
• Presence of microbes or their toxins in blood
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Definition of termsAscending Colangitis
• Charcot’s Triad:
• Right upper quadrant pain, Fever, Jaundice
>38oC
33
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Duodenum Portal venous blood
Biliary Tree
Hepatic Ducts
bacteria bacteria
Acute Cholangitis
35
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Bacteria
LPSPeptidoglycan
Lipoteichoic acid
DNA fimbriae
Host binding protein
CD 14
Monocytes
macrophages
Neutrophils
TLR chemokinesCytokines
prostanoidsleukotriens
Septic Shock
36
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
chemokinesCytokines
prostanoidsleukotriens
Inc. Blood flow
Enhance vessel permeability
Recruit neutrophils
Elicit pain
IL-6
monocytesEndothelial
cells
Coagulation!
Septic Shock
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Septic Shock
• Control Mechanisms
•Prevent inflammation within organs distant from infection site
•Work of anti-inflammatory molecules
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Assessment
• Severe septic shock secondary to ascending cholangitis
• secondary to biliary duct stricture s/p stent replacement (2007)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Plan
• Intubation
• Transfer to ICU
• Stat ERCP
• Antibiotics (Pip-Tazo) → Linezolid and imipinem
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
ERCP
• Duodenoscope• Fiber-optic duodenoscope• Videoscope
“ERCP”. Jackson Siegelbaum. Gastroenterology.(http://gicare.com/Endoscopy-Center/ERCP.aspx)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
AntibioticsLinezolid and Imipenem
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Diagnostics
CBC Urinalysis
ABG Liver Function Tests
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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 ↑
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
ABG Interpretation• pH: Acidotic
• HCO3: below normal, metabolic acidosis
• pCO2: below normal, respiratory alkalosis
ABGpH = 7.352pCO2 = 26.4pO2 = 63.1HCO3 = 15.7BE = -7.1O2 sat. = 91.73
Acceptable ranges:
pH: 7.35-7.45pCO2: 35-45HCO3: 22-26BE: +2 to -2
Metabolic acidosis with concomitant respiratory alkalosis
Oxygenation: adequate
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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 ↑
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
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 ↑
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Diagnostics
ECG Chest X-ray
Cardiac Enzymes Cultures
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Diagnostics
Serum Electrolytes Other tests
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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 ↑
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Enzymes: Amylase, Lipase
• Slightly elevated amylase and lipase levels
• Not definitive for pancreatitis (requiring three-fold increase)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
DrugsEnoxaparin
• Anticoagulant
• Binds to anti-thrombin III and accelerates activity, inhibiting thrombin and Factor Xa (low molecular weight heparin)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Assessment
• Acute respiratory failure secondary to septic shock secondary to ascending cholangitis s/p ERCP
• Hypertension
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Plan
• Close monitoring
• Maintain hemodynamic stability
• Administration of Linezolid and Imipenem
• Mechanical ventilation
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
AntibioticsCeftriaxone and Ampicillin
• Culture guided antibiotics
• Mechanism of action...
• Coverage...
• For Mimi
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Acute Kidney Injury – Rifle Criteria
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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%)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Hospital course• Day 4: creatinine at 0.67
• Day 5: extubated, well-tolerated
• Day 6: transfer to the floors
• Day 11: discharged
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Principles of ManagementSeptic Shock
• Close monitoring (vital signs, I/O)
• Hemodynamic support with IV fluids and vasopressors
• Identify underlying cause for sepsis
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Ascending CholangitisComplications
• Liver failure, hepatic abscess, microabscess
• Acute renal failure
• Bactermia, sepsis (gram-negative)
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Septic ShockPrognosis
• Depends on the following:
•Severity of illness
•Co-morbidities
•Age
• Response to antibiotics
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Septic ShockComplications
• Acute respiratory distress syndrome (ARDS)
• Renal dysfunction
• Disseminated intravascular coagulation (DIC)
• Mesenteric ischemia
• Myocardial ischemia and dysfunction
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Preventable gallstones?
2004
5 million Filipinos with gallstones
2010
5.4 Filipinos estimated to have gallstones
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
Mejia, Ong
Risk Factors
Obesity
Diet
Smoking
Sedentary lifestyle
Medications
Weight cycling
Genetics
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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.
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Mejia, Ong
call-an-jee-tis
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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
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Mejia, Ong
Healthcare Availability
Php 488,000
12 days
Php 44,000 / day
x
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Mejia, Ong
How many Filipinos can afford the same
healthcare?
50%30%10%5%?Fewer than that!
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Mejia, Ong
Facts
Php 206,000Php 176,000
Earns:
Spends:
Php 30,000Savings:
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Mejia, Ong
Facts
16 years to pay
Grandrounds: Shockingly PainfulGroup 7: Asuncion, Dalman, Doromal, Dy, Generoso,
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)
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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