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ER Interesting Case Rounds

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Presentation on theme: "ER Interesting Case Rounds"— Presentation transcript:

1 ER Interesting Case Rounds

2 Visit #1 18 yo female…. 4 day history of.. “Fevers” Nausea/Emesis
Diarrhea Lower abdominal pain

3 Pain.. RLQ = LLQ 7/10 at worst No radiation “crampy” Worse with movement Pain with BMs (diarrhea)

4 Diarrhea… Non-bloody 3-4x/day “mucousy” No PV symptoms No urinary symptoms

5 Physical Exam Vitals = normal Chest = clear CV = normal Abdo =
Tender to direct palpation. RLQ = LLQ No rebound/guarding etc. No mass

6 LABS Hgb = N WBC = 13.5 (neuts = 11, monocytes 1.2) Lytes = N BG = N
Lipase = N

7 LEs… ALP = N (104) ALT = N (16) GGT = 64 (8-35) Bili T = 46 (0-20) Bili D = 24 (0-7)

8 Urine dip Beta = negative 3+ ketones 2+ bilirubin Tx—fluids, anti-emetic, booked for abdo u/s in am. Dx “abdo pain NYD/mild LFT abnormality”

9 VISIT #2 Returned next day post u/s:
“Well seen and NORMAL liver, GB, ducts, pancreas, kidneys, spleen, aorta, para-aorta areas, bowel, uterus, overies, adnexa. No free fluid.”

10 Repeat labs Bili 29 (down from 46) GGT 56 (down from 64) WBCs 12.2 (down from 13.5) K = 3.4 Dx: “gastroenteritis”

11 Visit #3 Returns 5 days later… Persistent diarrhea Malaise ABDO PAIN!!
9 lb wt loss in 10 days

12 OTHER HX? No travel No well water exposure No recent ABX
No sick contacts No exposure to uncooked meats

13 Phx = healthy, no surgeries, PAP 6 months prior was normal
No meds (was on OCP in past) Social = infrequent EtOH, no IVDU, No risky sexual behaviour 1 partner. Using condoms. Tattoo at end of June Fam Hx: No IBD

14 VS: HR 100, Temp 38 ABDO= Tender lower quadrants Rebound Involuntary guarding +RUQ pain

15 WBC: 19.9 (neuts 13, bands 4.2) GGT 109 ALP 175 Bili T = 23

16 Stool C + S = negative Stool O + P = negative Hep Serology = negative C. diff = negative Stool Fat Globules = negative

17 Speculum Exam: thick yellow d/c from cervical os Bimanual Exam: + cervical motion tenderness CT Abdo/Pelvis: complex fluid collection in pouch of Douglas, compressing rectum, consistent with large tubo-ovarian abscess

18 DIAGNOSIS???

19 Fitz-Hugh-Curtis Perihepatitis in association with pelvic inflammatory disease Originally described by Carlos Stajano (1919) in Uroguay. 1930’s… re-described by Thomas Fitz-Hugh and Arthur Curtis.

20 Etiology Originally felt only to be secondary to N. gonorrhea (Fitz-Hugh discovered gram negative diplococci on smears taken from the liver capsule) 1970s, Chlamydia trachomatis implicated and remains the most common pathogen Case reports... strept milleri, tuberculosis

21 Organisms Associated with PID
Aerobes: N. gonorrhea C. trachomatis U. urealyticum Mycoplasma sp. (genitalium, hominus) Gardnerella vaginalis Strept Pyogenes Coag – staph E. Coli H. influenzae S. pneumoniae Mycobacterium tuberculosis Anaerobes: B. fragilis Peptostreptococcus Clostridium bifermentans Fusobacterium sp. Viruses: HSV Echovirus Cocksackie

22 Diagnosis RULING IN pelvic inflammatory disease
RULING OUT other causes of RUQ pain +/or elevated liver enzymes

23 Pathogenesis Multiple Theories: Direct Infection of Liver?
Hematogenous Spread? Lymphatic Spread? Exaggerated Immune Response?

24 How Common? Studies show broad ranges 4%-27% of patients with PID
RISK FACTORS: IUDs, pelvic surgery, multiple partners, lack of barrier protection etc.

25 Symptoms Symptoms of PID (fever, abdominal pain, vaginal discharge, vaginal bleeding) Right Upper Quadrant Pain—usually pleuritic. Possible for patient to present with RUQ pain only (subacute/chronic PID)

26 Atypical Presentations
Ileus/obstruction Peri-splenitis Peri-appendicitis Fitz-Hugh-Curtis in a male Chilaiditi syndrome Ovarian Ca Perforated Ulcer Pleural effusion

27 Physical Exam Cervical motion tenderness Adnexal/uterine tenderness
Lower Abdominal tenderness RUQ tenderness (may occur on its own) +/- friction rub over right anterior costal margin

28 Radiographic Studies Ultrasound:
Excludes cholelithiasis, cholecystitis etc. Insensitive for FHC May demonstrate “violin-string” adhesions, loculated fluid in the hepatorenal space. “Violin String” also in Familial Mediterranean Fever, Diaphragmatic Endometriosis

29 Radiographic Studies CT Scan:
Helpful IF can demonstrate contrast enhancement of the liver capsule Sensitivity of only 28%! (Joo et al. 2007) Depends if biphasic CT vs. portal phase only

30 LAB TESTS Liver Enzymes: often normal but can be elevated
Litt and Cohen (JAMA, 1978) found ALT most likely, but ‘cholestatic’ enzyme elevations also reported +/- ESR +/- Leukocytosis Cultures: N gonorrhea, C Trachomatis from cervix. Cultures from pelvic aspirates tend not to correlate. (mixed anaerobes, aerobes etc.)

31 Treatment Similar to that of PID
Generally focused on N gonorrhea and C trachomatis, gram negative rods, anaerobes Direct therapy according to cultures Drain abscesses

32 PID tx Tx regimens: Ceftriaxone 250 mg IM/Doxy 100 bid x 14 days
Levo od/Flagyl bid x 14 days Cefoxitin 2g IV q6/Doxy 100 bid IV for 48 hours afebrile, then PO Poor response to ABX = laparoscopy

33 Complications Those of PID: Infertility Adhesions Chronic pain
Ectopic pregnancy Reiter’s syndrome

34 Culture results: Streptococcus milleri (heavy) B fragiles (moderate) E. Coli (scant) NAAT: Negative for both Chlamydea and Gonorrhea


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