1. Tim Ridgway MD FACP Associate Professor of Medicine University of South Dakota Sanford School of Medicine

2. A 63 year old female presents with increasing lethargy and altered mental status over the previous 2 days. She also complained of nonspecific colicky abdominal pain over the past 3 weeks. On the evening prior to admission, she noted shaking chills. The following day she developed increasing shortness of breath, prompting evaluation locally and transfer to our facility.

3.  Hypertension  Anxiety  Osteoarthritis with predominant knee involvement  No surgeries

4.  Amlodipine 2.5mg daily  Omeprazole 20mg daily (recently started)  Temazepam 30mg nightly  Diclofenac 75mg bid  Paroxetine 40mg daily  Quetiapine 100mg nightly  Losarten-hydrochlorothiazide 100-25mg daily

5. Admitted to the Intensive Care Unit appearing acutely ill Temp 97.6 RR25 BP 87/63 Pulse 101 Oxygen saturation 70% on room air Lungs: Tachypneic with decreased breath sounds bilaterally without wheezes Cardiac: Hyperdynamic precordium without murmurs. No JVD

6. Abdomen: Nondistended and soft. Bowel sounds present but decreased. No focal tenderness to palpation Neurologic: Disoriented and minimally responsive. No focal neurologic deficit noted

7. WBC 15.7 (90% neutrophils and 24% bands) Hemoglobin 9.8 g/dl Hematocrit 29% AST 67 U/L, ALT 49 U/L Alk Phos 522 U/L, Total bili 3.8 mg/dl ABG: pH 7.3, pCO2 48mm Hg, pO2 65mm Hg Bicarbonate 20 meq/L, Lactate 1.7mmol/L Electrolytes unremarkable Creatinine 1.8 g/dl

8.  Progressive respiratory failure requiring endotracheal intubation  Progressive neurologic deterioration leading to unresponsiveness  Marked hypotension requiring pressor support  Broad spectrum antibiotics started after appropriate cultures

9.  Abdominal Ultrasound: Contracted gallbladder with wall thickening and pericholecystic inflammatory changes suggestive of cholecystitis. No gallstones or CBD stones seen. CBD 4.2mm diameter  CT Chest: Mild pleural effusions bilaterally and bilateral lower lung infiltrates suggestive of bilateral pneumonia  CT Head: No focal abnormality noted

17.  Gradual clinical improvement leading to weaning of pressors and extubation  Streptococcus Intermedius bacteremia  Liver abscess developed in area adjacent to pnumobilia-percutaneous drainage performed

18.  F/U EGD on 11 th hospital day: Severely deformed gastric antrum and deep necrotic ulcer along anterior wall of duodenal bulb  Biopsies negative for H. Pylori  Biliary stent removed  Operative intervention-15 th hospital day

19.  Fistulous connection between duodenal bulb and left lateral segment of liver (hepatoduodenal fistula)  Liver abscess adjacent to gallbladder  Left lateral segment abscess/mass

20.  Drainage of liver abscess  Cholecystectomy  Repair of duodenal ulcer/fistula with a Graham patch  Open hepatic segmentectomy (segment 3)

21.  Liver segment: Liver parenchyma with abscess/fistula tract (containing fecal/vegetable material  Left lateral segment mass: Necrotic tissue with acute and chronic inflammation  Gallbladder: Mild chronic cholecystitis with adjacent focal abscess formation

22.  Bilateral septic emboli to lungs-resolved  Respiratory failure-resolved  Acute Kidney Injury-resolving  Central Nervous System dysfunction-resolved  Liver abscesses-resolved  Discharge on hospital day 30  IV Vancomycin additional 2 weeks

23.  Completed course of Vancomycin  Eventual bilateral Total Knee Arthroplasty  Full recovery!

24.  < 20 cases reported in the medical literature  GI bleeding most common presentation  Most are diagnosed by histologic exam of endoscopic biopsies or at surgery  This is the only known case which presented as sepsis

25.  NSAIDS highest risk for perforation and penetration  Few cases resolve without surgical management  Complications include GI bleeding and hepatic abscess

26.  A thick gallbladder wall seen on imaging is a nonspecific finding  Chronic NSAID use-BEWARE!  Pneumobilia without previous intervention- SERIOUS!  Sepsis presentation-you have a narrow window of opportunity