1. Shockingly Painful A Case Presentation Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong December 22, 2010 Medicine Clerkship Rotation The Medical City

2. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong General Data CFG 58 years old Female Filipino Roman Catholic From Pasig City Informants: Patient and sister (good reliability)

3. Grandrounds: Shockingly Painful Group 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

4. Grandrounds: Shockingly Painful Group 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

5. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Chief Complaint: Abdominal pain ER Consult

6. Grandrounds: Shockingly Painful Group 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

7. Grandrounds: Shockingly Painful Group 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)

8. Grandrounds: Shockingly Painful Group 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)

9. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Family History Hypertension Asthma

10. Grandrounds: Shockingly Painful Group 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

11. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Vital Signs General HEENT Chest Abdominal Extremities

12. Grandrounds: Shockingly Painful Group 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 / 70 Temp: 39.5 o C HR: 88 RR: 21

13. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Vital Signs General HEENT Chest Abdominal Extremities Conscious Coherent Alert Not in respiratory distress

14. Grandrounds: Shockingly Painful Group 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

15. Grandrounds: Shockingly Painful Group 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

16. Grandrounds: Shockingly Painful Group 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

17. Grandrounds: Shockingly Painful Group 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

18. Grandrounds: Shockingly Painful Group 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)

19. Grandrounds: Shockingly Painful Group 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

20. Grandrounds: Shockingly Painful Group 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 ✓ ✓ ✓ ✓

21. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Hepatitis ✓ Salient Features+/-Hepatitis 58 year old, female+Mortality: 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+ Icetric sclerae and not jaundiced-Jaundice

22. Grandrounds: Shockingly Painful Group 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+ Icetric sclerae and not jaundiced-Jaundice

23. Grandrounds: Shockingly Painful Group 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

24. Grandrounds: Shockingly Painful Group 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 + Icetric sclerae and not jaundiced +/- Presents with jaunice

25. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostic Plan Laboratory testRationale 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 test Determine possible liver pathology (e.g. hepatitis) Prothrombin time/ activated partial thromboplastin time Coagulapthies (e.g. DIC, cirrhosis) LipaseUsually elevated in pancreatitis

26. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostic Plan Laboratory testRationale Urinalysis Baseline values; determine presence of infection, glucose, protein, etc. Culture and sensitivity for blood, bile, stent Determine foci of infection and resistance profiles Chest x-rayBaseline study UltrasoundVisualization of the biliary tree

27. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Hospital Day 1: Floors to ICU AM: Stable at the floors Decreased responsiveness Restlessness Febrile BP: 160/90→90/60 HR: 100s RR: 40s O 2 saturation: 97%→88% + Alar flaring, + Ronchi and rales Occasional wheezing Distended abdomen; soft, non-tender Normal rate, regular rhythm Distinct S1 No edema Full and equal pulses Flushed skin Signs of jaundice Subjective Objective

28. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Septicemia Presence of microbes or their toxins in blood

29. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms SIRS Systemic Inflammatory Response Syndrome 2 or more of the following: >38 o C < 36 o C > 24 breaths /min > 90 beats /min > 12000/L < 4000/L WBC

30. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Sepsis 2 or more of SIRS components with a proven or suspected microbial etiology >38 o C < 36 o C > 24 breaths /min > 90 beats /min > 12000/L < 4000/L WBC

31. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Septic shock SIRS + hypotension >38 o C < 36 o C > 24 breaths /min > 90 beats /min > 12000/L < 4000/L WBC BP: < 90 systolic < 40 mmHg less than patient’s normal

32. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Ascending Colangitis Charcot’s Triad: Right upper quadrant pain, Fever, Jaundice >38 o C

33. 33 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Biliary obstruction Host antibacterial defenses Immune dysfunction bacteria Acute Cholangitis

34. 34 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Duodenum Portal venous blood Biliary Tree Hepatic Ducts bacteria Acute Cholangitis

35. 35 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Bacteria LPS Peptidoglycan Lipoteichoic acid DNA fimbriae Host binding protein CD 14 Monocytes macrophages Neutrophils TLR chemokinesCytokines prostanoidsleukotriens Septic Shock

36. 36 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong chemokinesCytokines prostanoidsleukotriens Inc. Blood flow Enhance vessel permeability Recruit neutrophils Elicit pain IL-6 monocytes Endothelial cells Coagulation! Septic Shock

37. Grandrounds: Shockingly Painful Group 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

38. Grandrounds: Shockingly Painful Group 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. 39 Grandrounds: Shockingly Painful Group 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 cytokines Procoagulant molecules Nitric oxide PAF Inc. vascular resistance Microvascular thrombosis DIChypotension SHOCK!!! Septic Shock

40. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Hospital Day 1: Floors to ICU AM: Stable at the floors Decreased responsiveness Restlessness Febrile BP: 160/90→90/60 HR: 100s RR: 40s O 2 saturation: 97%→88% + Alar flaring, + Ronchi, rales Occasional wheezing Distended abdomen; soft, non-tender Normal rate, regular rhythm Distinct S1 No edema Full and equal pulses Flushed skin Signs of jaundice Subjective Objective

41. Grandrounds: Shockingly Painful Group 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)

42. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Plan Intubation Transfer to ICU Stat ERCP Antibiotics (Pip-Tazo) → Linezolid and imipinem

43. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ERCP Endoscopic Retrograde Cholangiopancreatography Diagnosis and treatment of benign malignant pancreaticobiliary diseases IndicationsBenefits 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

44. Grandrounds: Shockingly Painful Group 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)http://gicare.com/Endoscopy-Center/ERCP.aspx

45. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Antibiotics Linezolid and Imipenem

46. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics CBCUrinalysis ABGLiver Function Tests

47. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics CBC Hemoglobin = 132 g/dl Hematocrit = 0.37 Platelets = 224 WBC = 14.5 Neutrophils = 0.93 Lymphocyte - 0.06 Monocyte = 0.01 Urinalysis Color: Dark Yellow Sp. gravity: 1.015 + Erythrocytes, urobilinogen, bilirubin ABG pH = 7.352 pCO 2 = 26.4 pO 2 = 63.1 HCO 3 = 15.7 BE = -7.1 O 2 sat. = 91.73 Liver Function Tests Hepatitis tests: non-reactive SGOT: 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 ↑

48. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ABG Interpretation pH: Acidotic HCO 3 : below normal, metabolic acidosis pCO 2 : below normal, respiratory alkalosis ABG pH = 7.352 pCO 2 = 26.4 pO 2 = 63.1 HCO 3 = 15.7 BE = -7.1 O 2 sat. = 91.73 Acceptable ranges: pH: 7.35-7.45 pCO 2 : 35-45 HCO 3 : 22-26 BE: +2 to -2 Metabolic acidosis with concomitant respiratory alkalosis Oxygenation: adequate

49. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics CBC Hemoglobin = 132 g/dl Hematocrit = 0.37 Platelets = 224 WBC = 14.5 Neutrophils = 0.93 Lymphocyte - 0.06 Monocyte = 0.01 Urinalysis Color: Dark Yellow Sp. gravity: 1.015 + Erythrocytes, urobilinogen, bilirubin ABG pH = 7.352 pCO 2 = 26.4 pO 2 = 63.1 HCO 3 = 15.7 BE = -7.1 O 2 sat. = 91.73 Liver Function Tests Hepatitis tests: non-reactive SGOT: 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 ↑

50. Grandrounds: Shockingly Painful Group 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 Tests Hepatitis tests: non-reactive SGOT: 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 ↑

51. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics ECGChest X-ray Cardiac EnzymesCultures

52. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics ECG Normal sinus rhythm Leftward axis Left atrial enlargement Non-specific ST-T wave changes No significant changes from 11/27/2010 Chest X-ray Subsegmental atelectasis, right Cardiomegaly Atheromatous aorta Thoracic spondylosis and dextroscoliosis Cardiac Enzymes Troponin T = 0.57 ng/ml CK Total = 306.3 U/L ↑ CK MB = 23.44 U/L CK MM = 282.9 U/L ↑ Cultures Stent and blood Bile Stent

53. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics Serum ElectrolytesOther tests

54. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics Serum Electrolytes Sodium = 139 meq/L Potassium= 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 ↑

55. Grandrounds: Shockingly Painful Group 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)

56. Grandrounds: Shockingly Painful Group 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

57. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Hospital 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

58. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Drugs Enoxaparin Anticoagulant Binds to anti-thrombin III and accelerates activity, inhibiting thrombin and Factor Xa (low molecular weight heparin)

59. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Hospital 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

60. Grandrounds: Shockingly Painful Group 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 50mmHg (type 2)

61. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Assessment Acute respiratory failure secondary to septic shock secondary to ascending cholangitis s/p ERCP Hypertension

62. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Plan Close monitoring Maintain hemodynamic stability Administration of Linezolid and Imipenem Mechanical ventilation

63. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Hospital Day 3: ICU CNS: GCS 11 (E4VtM6) with episodes of agitation on Midazolam 5 ml/hr Hemoglobin = 83 g/dL Hematocrit = 0.25 Platelets = 119 WBC = 15.4 Serum Creatinine = 1.68 (↑ from 0.6) Objective Laboratory Bands = 0.02 Neutrophils = 0.85 Lymphoctes = 0.08 Monocytes = 0.04 Eosinophil = 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

64. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Antibiotics Ceftriaxone and Ampicillin Culture guided antibiotics Mechanism of action... Coverage... For Mimi

65. Grandrounds: Shockingly Painful Group 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

66. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Acute Kidney Injury – Rifle Criteria

67. Grandrounds: Shockingly Painful Group 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%)

68. Grandrounds: Shockingly Painful Group 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

69. Grandrounds: Shockingly Painful Group 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)

70. Grandrounds: Shockingly Painful Group 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

71. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Principles of Management Septic Shock Close monitoring (vital signs, I/O) Hemodynamic support with IV fluids and vasopressors Identify underlying cause for sepsis

72. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Principles of Management Ascending Cholangitis ABC assessment IV fluid resuscitation with crystalloids (e.g. plain NSS) Parenteral antibiotics Biliary decompression (severe cases) Extracorporeal shockwave lithotripsy (ESWL) for choleliths

73. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Acute Cholangitis Mild Severe ICUMonitor with reassessment ERCP Improvement No improvement Elective ERCP with definitive therapy (if not previously done) Percutaneous drainage Improvement Elective ERCP with definitive therapy of bile duct stones within 24-48 hrs No improvement Source: http://emedicine.medscape.com/article/774245-mediahttp://emedicine.medscape.com/article/774245-media

74. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Ascending Cholangitis Prognosis 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

75. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Ascending Cholangitis Complications Liver failure, hepatic abscess, microabscess Acute renal failure Bactermia, sepsis (gram-negative)

76. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Septic Shock Prognosis Depends on the following: Severity of illness Co-morbidities Age Response to antibiotics

77. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Septic Shock Complications Acute respiratory distress syndrome (ARDS) Renal dysfunction Disseminated intravascular coagulation (DIC) Mesenteric ischemia Myocardial ischemia and dysfunction

78. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Preventable gallstones? 2004 5 million Filipinos with gallstones 2010 5.4 Filipinos estimated to have gallstones

79. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Risk Factors Obesity Diet Smoking Sedentary lifestyle Medications Weight cycling Genetics

80. Grandrounds: Shockingly Painful Group 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 index Arch Intern Med. 2005 May 9;165(9):1011-5 Am J Clin Nutr. 2008 Mar;87(3):627-37 Increased risk Am J Epidemiol. 2009 Jan 15;169(2):153-60 Increased risk Ann Intern Med. 1998 Mar 15;128(6):417-25.

81. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong call-an-jee-tis

82. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Role of Practitioners Stop trans fat use Policy Surveillance of harmful dietary substances Education at the school level

83. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Healthcare Availability Php 488,000 12 days Php 44,000 / day x

84. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong How many Filipinos can afford the same healthcare? 50%30%10%5% ? Fewer than that!

85. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Facts Php 206,000 Php 176,000 Earns: Spends: Php 30,000 Savings:

86. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Facts 16 years to pay

87. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Average incomeNumber of families Average income per bracket Average expenditure per bracket P250,000 and above 3,264,000471,000361,000 P100,000 – P249,999 6,271,000157,000143,000 P60,000 – P99,999 4,122,00079,00077,000 P40,000 – P59,000 2,355,00050,00052,000 P40,000 and below 1,392,00030,00033,000 http://www.census.gov.ph/data/sectordata/2006/fies0608r.htm http://www.census.gov.ph/data/sectordata/2006/fies0602r.htm Total families: 17,403,000 (2006)

88. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong PhilHealth Php 488,000 to 454,400 Hospital discount: Php 33,600 Government/Public Tertiary hospital 1/3 of private costs: Php 162,000 The PhilHealth Member would pay only Php 128,400 Case B Private Tertiary Hospital

89. Shockingly Painful A Case Presentation Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong December 22, 2010 Medicine Clerkship Rotation The Medical City