Presentation on theme: "Tim Ridgway MD FACP Associate Professor of Medicine University of South Dakota Sanford School of Medicine."— Presentation transcript:
Tim Ridgway MD FACP Associate Professor of Medicine University of South Dakota Sanford School of Medicine
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.
Hypertension Anxiety Osteoarthritis with predominant knee involvement No surgeries
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
Abdomen: Nondistended and soft. Bowel sounds present but decreased. No focal tenderness to palpation Neurologic: Disoriented and minimally responsive. No focal neurologic deficit noted
Gradual clinical improvement leading to weaning of pressors and extubation Streptococcus Intermedius bacteremia Liver abscess developed in area adjacent to pnumobilia-percutaneous drainage performed
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
Fistulous connection between duodenal bulb and left lateral segment of liver (hepatoduodenal fistula) Liver abscess adjacent to gallbladder Left lateral segment abscess/mass
Drainage of liver abscess Cholecystectomy Repair of duodenal ulcer/fistula with a Graham patch Open hepatic segmentectomy (segment 3)
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
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
Completed course of Vancomycin Eventual bilateral Total Knee Arthroplasty Full recovery!
< 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
NSAIDS highest risk for perforation and penetration Few cases resolve without surgical management Complications include GI bleeding and hepatic abscess
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