EM Clinical Case Presentation Arpan Patel

Triage 25 yo Male with abdominal pain Afebrile, VSS - nausea + vomiting and diarrhea

History 11 hours ago, sudden onset of sharp stabbing pain in the epigastric area (pt points there) Pain is non-radiating, not associated with meals or certain foods, and is not relieved by antacids. (He has been on Omeprazole for past 3 months) Explains he has had similar episodes for the past 4 years, last was 2 weeks ago, pain abates when he takes 12 Tylenols at once. Now denies nausea, vomiting, and diarrhea

More History Denies chest pain, SOB, UTI sx, GERD sx, constipation, blood in stool, cough, and fever. PMH: none PSH: none Meds: Omeprazole since 3/2012 Allergies: NKDA SH: Occasional smokes cigs, EtOH socially

Physical BP 143/74, P 64, R 17, T 97.0F, O2 Sat: 100% on RA General: Pt lying in bed, appears uncomfortable CV: RRR, S1S2, no mrg Resp: CTAB Abd: soft, non-distended, tender in epigastrium and RUQ, no guarding/rebound, +bs in all quadrants Back: No CVA tenderness

Differential Diagnosis RUQ: - Cholelithiasis - Biliary Colic - Acute Cholecystitis - Cholangitis - Acute Hepatitis - Perf. Duodenal Ulcer - RLL Pneumonia Epigastric: - Peptic Ulcer Disease - Pancreatitis - GERD - Myocardial Infarction Atypical Px’s of: - Appendicitis - R sided Kidney disease: Pyelonephritis or Nephrolithiasis

Let’s get some Labs BMP: 139/4.2 105/28.2 12/0.9 Glu 102 CBC: 13.4 > 14.3/45.5 < 292 UA completely negative Coags, LFTs, Lipase and Amylase all wnl

For you EM US Fellowship Chasers: Bedside US: Unable to visualize gallbladder, pt had not eaten in over 12 hours, but tells us he had an US done 4 years ago and was told he had many stones Official US: Gallbladder completely filled with calculi limiting evaluation of GB wall thickness Minimal pericholecystic fluid, no intra/extra hepatic bile duct dilation, CBD is 0.3 cm Positive sonographic Murphy’s sign R Kidney is 10.8 cm & nl, no hepatomegaly, some steatosis Likely cholelithiasis vs Acute chole, can confirm with HIDA

Final Diagnosis Acute Cholecystitis Started on Cefoxitin, Morphine for pain, and admitted to surgery. GB was removed 2 days later Why treat/remove? Even though AC may resolve in 7-10 days on its own, it has a high rate of progressing to gangrenous chole and perforating which increases morbidity and mortality

Diagnostic Criteria for Acute Chole Based on physical exam, labs, and imaging Physical: RUQ pain, Murphy’s sign, fever, tachy Labs: Leukocytosis (left shift), shouldn’t have elevated bili or Alk Phos in simple Acute Chole Imaging: On US - GB wall thickening (>4-5 mm), pericholecystic fluid, sono Murphy’s sign. On HIDA - the GB will not be visualized due to obstruction of the cystic duct by a stone or edema

What about the AC triad of RUQ pain, fever, and leukocytosis What about the AC triad of RUQ pain, fever, and leukocytosis? He was afebrile! Retrospective review of pts with AC dx’d with HIDA: fever defined as oral T>100 and rectal T>104, and leukocytosis as 11k or more Of these cases 52% were nongangrenous AC, 26% gangrenous AC, and 22% chronic chole In those with non-gangrenous AC, 71% were afebrile, 32% lacked leukocytosis, 28% lacked both In those with gangrenous AC, 59% afebrile, 27% no leukocytosis, 16% lacked both. Take home point: Do not rely on the presence of fever and leukocytosis to make a diagnosis of AC! Gruber PJ, Silverman RA, Gottesfeld S, Flaster E. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. 1996 Sep;28(3):273-7