Grand RoundsGrand RoundsCase PresentationCase Presentation
Michael S. Truitt, MDMichael S. Truitt, MDDepartment of SurgeryDepartment of Surgery
University of Colorado HSCUniversity of Colorado HSC
Presentation:Presentation:
82 year old female 82 year old female 24 hour history diffuse abdominal pain24 hour history diffuse abdominal painNausea and vomiting x 2Nausea and vomiting x 2AnorexicAnorexicDiarrhea (not grossly bloody)Diarrhea (not grossly bloody)
Past Medical History:Past Medical History:
HypertensionHypertensionAsthmaAsthmaHypothyroidismHypothyroidismHiatal Hernia Hiatal Hernia x 30 yearsx 30 years
Lasix 40mg PO BIDLasix 40mg PO BID
Ventolin & AtroventVentolin & Atrovent
Synthroid 0.075mg DailySynthroid 0.075mg Daily
No known drug allergiesNo known drug allergies
Meds:Meds:
Exam:Exam:
Temp: 98.6Temp: 98.6135/76 135/76 85 BPM85 BPM181890% RA 90% RA
Neuro: IntactNeuro: IntactPulm: Bialteral Pulm: Bialteral rhonchirhonchiCV: S1/S2, No CV: S1/S2, No MurmurMurmurGI: Soft, slight TTP in GI: Soft, slight TTP in the BUQ, ND, +BS, the BUQ, ND, +BS, No rebound or No rebound or guarding. Benignguarding. BenignExt: 1+ BLE EdemaExt: 1+ BLE Edema
35 135 96 3535 135 96 353.5 28 1.13.5 28 1.1
10 250 10 250 U/A: Normal U/A: Normal CV: EKG, Troponin were negative CV: EKG, Troponin were negative Amylase: normalAmylase: normalLFTLFT’’s: normals: normalXR: . .. .. .. .. . .XR: . .. .. .. .. . .
StudiesStudies
Studies:Studies:
ED Disposition:ED Disposition:
The ED diagnosed the patient with an adynamic ileus and felt that no further work-up was necessary. The patient was then reassured and instructed to follow up with her PCP in 7-10 days. Furthermore, she was instructed to return to the ER if her symptoms worsened ......
12 Hours Later...... 12 Hours Later......
Worsening BUQ painWorsening BUQ painRecalcitrant nausea, vomitingRecalcitrant nausea, vomitingSubjective fever and chillsSubjective fever and chillsAnorexiaAnorexiaShe denied CP, SOB, DOE, She denied CP, SOB, DOE, hematemesis, hematochezia, or hematemesis, hematochezia, or melenamelena
Secondary PresentationSecondary Presentation
Secondary Presentation:Secondary Presentation:
Vitals:Vitals:Temp 37.3Temp 37.3BP 105/60 BP 105/60 HR 105 HR 105 RR 20RR 20O2 95% RAO2 95% RA
Exam:Exam:–– Neuro: AAOx3Neuro: AAOx3–– Pulm: Bilateral rhonciPulm: Bilateral rhonci–– CV: S1/S2, No murmurCV: S1/S2, No murmur–– GI: Soft, Mild TTP in the GI: Soft, Mild TTP in the
BUQ (R>L), No rebound BUQ (R>L), No rebound or guardingor guarding
–– Ext: 1+ BLE edemaExt: 1+ BLE edema
Differential Diagnosis of Nausea & Differential Diagnosis of Nausea & Vomiting:Vomiting:
AcuteAcute–– Digitalis toxicityDigitalis toxicity–– KetoacidosisKetoacidosis–– Cancer Cancer
chemotherapeutic chemotherapeutic agentsagents–– Inferior myocardial Inferior myocardial
infarction infarction –– Drug withdrawalDrug withdrawal–– HepatitisHepatitis
Recurrent or chronicRecurrent or chronic–– Psychogenic vomitingPsychogenic vomiting–– Metabolic disturbances Metabolic disturbances
(uremia,adrenal (uremia,adrenal insufficiency)insufficiency)
–– Gastric retention Gastric retention (gastroparesis,outlet obst)(gastroparesis,outlet obst)
–– Bile refluxBile reflux
With Abdominal PainWith Abdominal PainViral gastroenteritisViral gastroenteritisAcute gastritisAcute gastritisFood poisoningFood poisoningPeptic ulcer diseasePeptic ulcer diseaseAcute pancreatitisAcute pancreatitisSmall bowel obstruction and Small bowel obstruction and pseudoobstructionpseudoobstruction
Acute appendicitisAcute appendicitisAcute cholecystitisAcute cholecystitisAcute cholangitisAcute cholangitisAcute pyelonephritisAcute pyelonephritisInferior myocardial infarctionInferior myocardial infarction
In Association with Neurologic SymptomsIn Association with Neurologic SymptomsIncreased intracranial pressureIncreased intracranial pressureMidline cerebellar hemorrhageMidline cerebellar hemorrhageVestibular disturbancesVestibular disturbancesMigraine headachesMigraine headachesAutonomic dysfunctionAutonomic dysfunction
Investigations:Investigations:
CBCCBCPT/PTTPT/PTTSMA 7 SMA 7 Troponin/EKGTroponin/EKGAmylaseAmylaseLFTLFT’’ssUAUAXRXR
38 137 96 3538 137 96 353.2 28 1.43.2 28 1.4
14.5 255 14.5 255 U/A: Normal U/A: Normal CV: EKG, Troponin were negative CV: EKG, Troponin were negative Amylase: normalAmylase: normalLFTLFT’’s: TB=2.2, AST/ALT=252/300, Alk s: TB=2.2, AST/ALT=252/300, Alk
Phos=278Phos=278XR: . .. .. .. .. . .XR: . .. .. .. .. . .
Secondary PresentationSecondary Presentation
Studies:Studies:
Secondary PresentationSecondary Presentation
Surgery consult was Surgery consult was obtained for obtained for cholecystitischolecystitisPatient taken to OR Patient taken to OR for Laparoscopic for Laparoscopic CholecystectomyCholecystectomyOn initial evaluation On initial evaluation of the abdomen..of the abdomen..
OR:OR:
Patient was Patient was converted to openconverted to openEnterolithotomy Enterolithotomy was performed, but was performed, but bowel was frankly bowel was frankly necrotic, so necrotic, so resection and resection and primary repair was primary repair was performedperformed
Gallstone IleusGallstone Ileus
More frequent in women and in patients More frequent in women and in patients older than 70 years oldolder than 70 years oldMechanical obstruction caused by a large Mechanical obstruction caused by a large gallstonegallstoneMainly small bowel at the terminal ileumMainly small bowel at the terminal ileumCan cause gastric outlet obstruction: Can cause gastric outlet obstruction: BouveretBouveret’’s Syndromes SyndromeDiagnosis has a 20% mortality rate mainly Diagnosis has a 20% mortality rate mainly due to age/comorbidities of patientsdue to age/comorbidities of patients
Etiology:Etiology:
Develops as a complication Develops as a complication of chronic cholecystitisof chronic cholecystitisInflamed gallbladder Inflamed gallbladder becomes adherent to becomes adherent to adjacent intestine adjacent intestine A stone may ulcerate A stone may ulcerate through the wall to form a through the wall to form a cholecystenteric fistulacholecystenteric fistulaStones pass through fistula Stones pass through fistula and air from the bowel into and air from the bowel into the biliary tree the biliary tree (pneumobilia)(pneumobilia)Stones usually solitary and Stones usually solitary and greater than 2.5cm greater than 2.5cm diameterdiameter
Diagnosis:Diagnosis:
High index of suspicionHigh index of suspicionElderly patientElderly patientPneumobilia (40% of Pneumobilia (40% of cases)cases)Small bowel Small bowel obstructionobstructionAbdominal XAbdominal X--ray may ray may detect these featuresdetect these featuresUltrasoundUltrasoundCTCT
Treatment:Treatment:
Board Answer:Board Answer:–– EnterolithotomyEnterolithotomy
Debate:Debate:–– Enterolithotomy Enterolithotomy
plus plus cholecystectomy cholecystectomy and fistula closureand fistula closure
No difference in No difference in morbidity or morbidity or mortalitymortality