1. Asuncion * Dalman * Doromal * Dy Generoso * Mejia * Ong Internal Medicine Rotation- The Medical City December 22, 2010 1 G7 Grand Rounds

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

3. Chief Complaint 3 Epigastric pain

4. History of Present Illness 4 Post-prandial epigastric pain (6/10)  crampy, intermittent, 30 minute duration, with radiation to the back Took Itopride (Ganaton)  no relief (-) fever, nausea, vomiting, changes in bowel movement Morning PTA Afternoon PTA Epigastric pain with increased intensity; (+) chills and fever Consult at TMC-ER  admission

5. Review of Systems (+) generalized weakness No weight gain or weight loss, easy fatigability No headache, seizures, blurring of vision, ear problems No dyspnea, cough, colds No Palpitations, chest pain No nausea, vomiting No dysuria, frequency 5

6. Past Medical History (+) Hypertension – 20 years S/p laparoscopic cholecystectomy with subsequent development of stricture, s/p stent placement (2005) S/p biliary stent replacement (2007) Allergic to erythromycin – rashes

7. Past Medical History Hypertension – 20 years – On Losartan + Hydrochlorohiazide Asthma – No recent consults – Last attack unrecalled – No maintenance medications

8. Family History Hypertension Asthma

9. Personal and Social History Divorced Smoker Occasional alcohol beverage drinker Usual diet: prefers meat and fatty food, soda 9

10. Physical Exam 10 Anthropometrics: Height=152 cm, weight=68 kg, BMI=29.4 (overweight) Vitals: BP: 150/90, T: 39.5 o C, RR 21, HR 88 General: conscious, coherent, alert HEENT: anicteric sclerae, pink palpebral conjunctiva, neck veins non-distended, no cervicolymphadenopathies Chest: Symmetric chest expansion, no retractions, clear breath sounds

11. Physical Exam  Abdomen: Protuberant, normoactive, tympanitic, no masses palpated, scar on the left upper quadrant, epigastric and right upper quadrant direct tenderness  Extremities: Full and equal pulses, good skin color and turgor  Digital rectal exam:

12. Salient Features 58 year old, female Acute abdominal pain (epigastric, RUQ areas) Accompanied by chills and fever History of cholecystectomy with biliary stent insertion and replacement (2005 and 2007)

13. ASSESSMENT Ascending cholangitis

14. Differential Diagnosis 14 Cholecystitis and biliary colic Diverticular disease Hepatitis Mesenteric ischemia Pancreatitis Cirrhosis Liver failure Liver abscess Acute appendicitis Perforated peptic ulcer Pyelonephritis

15. Hepatitis

16. Pancreatitis

17. Peptic Ulcer Disease

18. 18 Diagnostic Plan (1 of 2)

19. 19 Diagnostic Plan (2 of 2)

20. COURSE IN THE WARDS

21. Hospital Day 1: Floors to ICU SubjectiveObjectiveAssessmentPlan Stable at the floors early in the AM Decreased responsiveness Restlessness BP: 160/60  90/60 HR: 100s RR: 40s O2 sat’n: 97%  88% + alar flaring + ronchi, rales Occasional wheezing Distended abdomen; soft, non-tender Normal rate, regular rhythm Distinct S1 No edema Full and equal pulses Flushed skin Severe septic shock secondary to ascending cholangitis secondary to biliary duct stricture s/p stent placement Hypertension Intubation Transfer to ICU Stat ERCP Antibiotics (Pip- Tazo  Linezolid and Imipenem)

22. Hospital Day 1 – Diagnostics CBC Hemoglobin = 132 g/dL Hematocrit = 0.37 Platelets = 224 WBC = 14.5 Neutrophils = 0.93 Lymphocytes = 0.06 Monocyte = 0.01 Urinalysis Color: Dark yellow Sp Gravity: 1.015 + erythrocytes, urobilinogen, bilirubin ABG pH = 7.382 pCO2 = 26.4 pO2 = 63.1 HCO3 = 15.7 BE = -7.1 O2 sat = 91.73 Liver Function Tests Hepatitis tests: non-reactive SGOT: 542.7 U/L ↑ SGPT: 636.8 U/L ↑ Alk Phos: 137.1 U/L ↑ Total Bilirubin: 6.17 mg/dL ↑ Direct Bilirubin: 4.02 mg/dL ↑ Indirect Bilirubin: 2.15 mg/dL ↑

23. Hospital Day 1 – Diagnostics ECG Normal sinus rhythm Leftward axis Left atrial enlargement Non-specific ST-T wave changes No significant changes from 11/27/2010 Chest X-ray Subsegmental atelectasis, right Cardiomegaly Atheromatous aorta Thoracic spondylosis and dextroscoliosis Cardiac Enzymes Troponin-T = 0.57 ng/mL* CK Total = 306.3 U/L ↑ CK MB = 23.44 U/L CK MM = 282.9 U/L ↑ Cultures Stent and blood: Klebsiella pneumoniae Bile: Heavy growth of Escherichia coli Stent: Proteus mirabilis All orgnisms sensitive to Ceftriaxone

24. Hospital Day 1 – Diagnostics Serum Electrolytes Sodium: 139 meq/L Potassium: 3.3 meq/L Others Amylase: 126 U/L ↑ Lipase: 96.56 U/L ↑ Lactate: 50.52 mg/dL ↑ Creatinine: 0.64 mg/dL NGAL: 225.2 ng/mL ↑

25. At the end of the 1 st hospital day... CNS: GCS 11, sedation with Midazolam CVS: – BP: 75/40 to 150/70, tachycardic  hypotensive episodes – On dopamine and/or norepinephrine drip – (+) Trop T, elevated CK enzymes, anterior wall ischemia on ECG – Given Enoxaparine (Clexane), 0.6 ml every 12 hours

26. At the end of the 1 st hospital day... Respiratory: – Oxygen saturation = 98% – (+) ronchi bilaterally – (+) rales on the right base IDS – Febrile – On linezolid and imipenem Unremarkable gastrointestinal, genitourinary and endocrine findings

27. Assessment at the end of the 1 st hospital day... Acute respiratory failure secondary to septic shock secondary to ascending cholangitis Asthma vs. COPD in acute exacerbation Hypertension, to consider non-ST elevation myocardial infarction

28. Plan at the end of the 1 st hospital day... Close monitoring Maintain hemodynamic stability Administration of antibiotics Mechanical ventilation

29. Hospital Day 4: in the ICU Subjective / ObjectiveAssessmentPlan CNS: GCS 11 (E4VtM6) with episodes of agitation; on Midazolam 5 ml/hr CVS: BP: 135/60, HR: 91, off norepinephrine Respiratory: no desturations, clear breath sounds; on mechanical ventilation with 60% FiO2 GI: NGT feeding; melena episode GU: adequate input and output; (+) hematuria; Crea=0.67; Na=150; K=3.4 IDS: afebrile, on Imipenem Day 3 Endo: CBG – 128 mg/dL Septic shock secondary to ascending cholangitis s/p ERCP Hypertension t/c non- ST elevation MI Acute kidney injury Anemia probably secondary to upper GI bleed Close monitoring For blood transfusion Ulcer prophylaxis Potassium correction For step-down antibiotics – Ceftriaxone and Ampicillin (culture- guided) Possible mechanical ventilation weaning (extubation on hospital day 6) CBC Hemoglobin = 83 g/dL Hematocrit = 0.25 Platelets = 119 WBC = 15.4 Bands = 0.02 Neutrophils = 0.85 Lymphocytes = 0.08 Monocyte = 0.04 Eosinophil = 0.01 Hypochromic

30. Course in the Hospital Day 6 – extubated; well-tolerated Day 7 – transfer to the floors Day 12 – discharged

31. Principles of Management Septic ShockAscending Cholangitis 31 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

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

33. 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)

34. 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

35. Other Aspects of the Case Psycho-socio-economic ImpactPrevention 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

36. Asuncion * Dalman * Doromal * Dy Generoso * Mejia * Ong Internal Medicine Rotation- The Medical City December 22, 2010 36 G7 Grand Rounds