Abdominal Pain CHUA, Mary Francine P. MD080022

Identifying information R.C. 25 years old Male Filipino Married Dealer Iglesia ni Cristo

Chief complaint Abdominal pain

History of the present illness 1 ½ years PTA (+) RUQ pain Sudden, intermittent, no radiations (-) fever, nausea & vomiting, changes in bowel movement Consult done UTZ revealed gallbladder stones Advised surgery but refused Self-medicated with mixture of apple juice, vinegar & olive oil Passage of ~70 stones Complete relief

History of the present illness 4 days PTA (+) epigastric pain Occurring ~10 minutes after meals 5/10, persistent, no radiations (+) bloatedness (-) fever, nausea & vomiting, changes in bowel movement No consult done Self-medicated with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief

History of the present illness 2 days PTA (+) epigastric pain (+) bloatedness (+) undocumented fever, (-) chills (+) anorexia (+) tea-colored urine No consult done Self-medicated with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief

History of the present illness 1 day PTA (+) epigastric pain 8/10 (+) bloatedness (+) undocumented fever, (-) chills (+) anorexia (+) tea-colored urine (+) acholic stools Consult done at ER Given paracetamol and omeprazole with temporary relief Discharged

History of the present illness Day of admission (+) epigastric pain 8/10 (+) bloatedness (+) undocumented fever, (-) chills (+) anorexia (+) tea-colored urine (+) acholic stools (+) yellowing of the eyes 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 crabs Unrecalled operation on the head secondary to mauling (1998), with blood transfusion

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

Personal & social history Married, no children Diet: rice, “mahilig sa baboy” Current smoker, 0.8 pack years (2 sticks/day, 8 years) Heavy alcoholic beverage drinker, ~8 bottles of beer, 3x/week Marijuana use High school Last use: February 2012

General survey Conscious, coherent, cooperative, in pain Vital signs 110/80 mmHg 104 beats/min 22 breaths/min 39.3°C VAS 8/10 BMI 19.27 kg/m2 Weight 59 kilos Height 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 features History Physical examination Epigastric pain Bloatedness Anorexia Fever Tea-colored urine Acholic stools Gallstones on ultrasound Heavy alcoholic beverage drinker Physical examination High grade fever, 39.3°C Flushed skin, jaundice Icteric sclerae Epigastric tenderness, hypoactive bowel sounds

Initial impression Obstructive biliary disease, secondary to calculous cholecystitis, to consider choledocholithiasis, ascending cholangitis

Differential diagnoses Gallstone pancreatitis

Diagnostic evaluation CBC SGPT, SGOT ALP Bilirubin (direct, indirect, total) Prothrombin time APTT Amylase Lipase Ultrasound Serum electrolytes (Na, K, Cl) Urinalysis

LGBP Ultrasound Gallstone with cholecystitis Dilated common bile duct

Acute cholangitis One 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 presentation Mild, intermittent and self-limited to fulminant, potentially life-threatening septicemia Most common: Charcot’s triad (2/3) Fever Epigastric/ RUQ pain Jaundice Reynold’s pentad Septic shock Mental status changes On abdominal examination, the findings are indistinguishable from those of acute cholecystitis

Tokyo Guidelines A. Clinical context/ manifestations History of biliary disease Fever ± chills Jaundice Abdominal pain (RUQ/epigastric) B. Laboratory data Evidence of inflammation WBC, CRP Abnormal LFTs ALP, GGT, AST, ALT C. Imaging Biliary dilatation or evidence of etiology Stricture, stone, stent Suspected Dx: >2 in A Definitive Dx: Charcot’s triad >2 in A + both B and C

Tokyo Guidelines Mild Moderate Severe (+) response to medical treatment General supportive care and antibiotics Moderate No response to medical treatment No onset of organ dysfunction Severe (+) Onset of organ dysfunction CVD: BP, need for vasopressors Nervous: consciousness Respiratory: PaO2/FiO2 <300 Kidney: Creatinine > 2 mg/dL Liver: PT-INR >1.5 Hematologic: Platelets <100

Management Endoscopic retrograde cholangiopancrea- tography (ERCP)

Management Laparoscopic cholecystectomy