1. Maria Margarita A. Mejia CCU Internal Medicine Rotation The Medical City December 1, 2010 1 ICU Case Presentation

2. Identifying Data 2 CFG, 58 y/o Filipino female Roman Catholic From Pasig Informants: Patient and sister (good reliability)

3. Chief Complaint 3 Abdominal pain

4. History of Present Illness 4 Experienced epigastric pain (6/10) after eating breakfast Pain was described as crushing and intermittent lasting for 30 minutes, with radiation to the back No associated fever, nausea, vomiting, and changes in bowel movement Morning PTA

5. History of Present Illness 5 Epigastric pain (6/10) persisted With associated chills and undocumented fever Persistence of symptoms prompted consult at TMC-ER and subsequent admission Afternoon PTA

6. Other History Pertinent ROS Past Medical History 6 No weight gain or weight loss, easy fatigability (+) generalized weakness No headache, seizures, blurring of vision, ear problems No dyspnea, cough, colds No Palpitations, chest pain No nausea, vomiting No dysuria, frequency (+) Hypertension – 20 years 2005 – open cholecystectomy with biliary stent insertion 2007 – biliary stent replacement Allergic to erythromycin – rashes

7. Other History Family History Personal-Social History 7 Hypertension Asthma Divorced Smoker Occasional alcohol beverage drinker Usual diet: prefers meat and fatty food, soda

8. Physical Exam 8 Anthropometrics: Height=152 cm, weight=68 kg, BMI=29.4 (overweight) Vitals: BP: 150/70 (at the ER), 125/65 (ICU); T: 39.5 o C (at ER), 36.4 o C (ICU), RR 21, HR 88 General: conscious, coherent, alert HEENT: Icteric sclerae, pink palpebral conjunctiva, neck veins non-distended, no cervicolymphadenopathies Chest: Symmetric chest expansion, no retractions, clear breath sounds

9. Physical Exam  Abdomen: Protuberant, 5 bowel sounds per minute (normoactive), tympanitic, no masses palpated, epigastric and right upper quadrant tenderness (at the ER)  Extremities: Full and equal pulses, jaundiced, good skin turgor  Digital rectal exam: not done

10. Salient Features 58 year old, female Abdominal pain (epigastric, RUQ areas) Accompanied by chills and fever Past medical history of cholecystectomy with biliary stent insertion and replacement (2005 and 2007) Acute onset Hypertensive, smoker Overweight (BMI=29.4) At the ER: febrile and hypertensive Icteric sclerae and jaundiced Epigastric and RUQ tenderness

11. Problem List CNS – Off midazolam; GCS 15 CVS – off levophed (11/30); noted atrial fibrillation (11/30); ECG (12/1): left atrial enlargement, leftward deviation Respiratory – weaning GI – NGT (supportan-1200kcal/day); jaundiced GU – Creatinine=1.68  GFR of 38.4 (CKD Stage 3) Hematology – anemia (Hb=108; Hct=0.32) Infectious – on ampicillin and ceftriaxone day 1

12. Assessment Septic shock secondary to ascending cholangitis s/p ERCP AKI vs. CKD

13. CASE DISCUSSION 13

14. Shocked!!! Shock – clinical syndrome of the following: Hypotension Acidemia Tissue hypoperfusion  impaired vital organ function Septic Shock – characterized by the following: Vasodilation Low central filling pressures, decreased intravascular volume, reduced peripheral vascular resistance Leaky capillaries  transudation of intravascular fluid

15. Ascending Cholangitis Infection of the biliary tract Common causes:  Choledocholithiasis*  Manipulations / interventions done on the biliary tract*  Stents*  Hepatobiliary malignancies

16. Ascending Cholangitis Potential for mortality and morbidity (13-88%) Asian (pyogenic) cholangitis – common in Southeast Asia Affects males and females equally; 50- 60 y/o

17. Differential Diagnosis 17 Cholecystitis and biliary colic Diverticular disease Hepatitis Mesenteric ischemia Pancreatitis Cirrhosis Liver failure Liver abscess Acute appendicitis Perforated peptic ulcer Pyelonephritis

18. Hepatitis

19. Pancreatitis

20. 20 Diagnostic Plan (1 of 2)

21. 21 Diagnostic Plan (2 of 2)

22. Principles of Management Septic ShockAscending Cholangitis 22 Close monitoring (vital signs, I/O) Hemodynamic support with IV fluids and vasopressors Identify underlying cause for sepsis ABC assessment IV Fluid resuscitation with crystalloids (e.g. plain NSS) Parenteral antibiotics Biliary decompression (severe cases) Extracorporeal shockwave lithotripsy (ESWL) for choleliths

23. Source: http://emedicine.medscape.com/article/774245-media

24. Looking Ahead – Ascending Cholangitis PrognosisComplications 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 Liver failure, hepatic abscess, microabscess Acute renal failure Bacteremia, sepsis (gram- negative)

25. Looking Ahead – Septic Shock PrognosisComplications Depends on the following: Severity of illness Co-morbidities Age Response to antibiotics Acute respiratory distress syndrome (ARDS) Renal dysfunction Disseminated intravascular coagulation (DIC) Mesenteric ischemia Myocardial ischemia and dysfunction

26. Other Aspects of the Case Psycho-socio-economic Impact Prevention and Public Health P100,000 per day with ICU admissions  current expense for the patient is around P400,000 On patient’s personal account Lifestyle and health- seeking behavior changes (e.g. low-fat diet, quit smoking, stent-removal) Patient education

27. Maria Margarita A. Mejia CCU Internal Medicine Rotation The Medical City December 1, 2010 27 ICU Case Presentation