1. Abdominal Pain
CHUA, Mary Francine P.
MD080022

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

3. Chief complaint
Abdominal pain

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Past medical history (-) Hypertension, diabetes, asthma
(+) allergies to shrimp and crabs
Unrecalled operation on the head secondary to mauling (1998), with blood transfusion

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

12. 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

13. 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 kg/m2
Weight 59 kilos
Height 175 cm

14. 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

15. 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

16. Cardiovascular Adynamic precordium PMI at 5th ICS, left MCL
Normal rate and regular rhythm, distinct S1/S2, no murmurs
No carotid bruits

17. Abdomen Flat, soft abdomen, no scars/ lesions Hypoactive bowel sounds
Tympanitic
(+) epigastric tenderness
Non-palpable liver edge
No palpable masses
(-) Murphy’s sign

18. Extremities (+) flushed skin, (+) jaundice No active dermatoses
Warm extremities
Good skin turgor
Full and equal pulses
No cyanosis, no clubbing
CRT < 2 seconds

19. Neurologic Awake, alert, well-groomed Oriented to 3 spheres GCS 15
No cranial nerve deficits
No dysmetria, dysdiadochokinesia
MMT: 5/5
DTRs: 2+

20. 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

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

22. Differential diagnoses
Gallstone pancreatitis

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

24. LGBP Ultrasound
Gallstone with cholecystitis
Dilated common bile duct

25. 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

26. 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

27. 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

28. 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

29. Management
Endoscopic retrograde cholangiopancrea- tography (ERCP)

30. Management
Laparoscopic cholecystectomy