CHUA, Mary Francine P.MD080022
Abdominal Pain
Identifying informationR.C.25 years oldMaleFilipinoMarriedDealerIglesia ni Cristo
Chief complaintAbdominal pain
History of the present illness(+) RUQ pain
Sudden, intermittent, no radiations
(-) fever, nausea & vomiting, changes in bowel movement
Consult done UTZ revealed
gallbladder stones Advised surgery but
refusedSelf-medicated with
mixture of apple juice, vinegar & olive oil
Passage of ~70 stones Complete relief
1 ½ years PTA
History of the present illness(+) epigastric pain
Occurring ~10 minutes after meals
5/10, persistent, no radiations
(+) bloatedness(-) fever, nausea &
vomiting, changes in bowel movement
No consult doneSelf-medicated
with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief
4 days PTA
History of the present illness(+) epigastric pain(+) bloatedness(+) undocumented
fever, (-) chills(+) anorexia(+) tea-colored
urineNo consult doneSelf-medicated with
HNBB, AlOH3MgOH2 simethicone, omeprazole with relief
2 days PTA
History of the present illness(+) epigastric pain
8/10(+) bloatedness(+) undocumented
fever, (-) chills(+) anorexia(+) tea-colored
urine(+) acholic stoolsConsult done at ER Given paracetamol and
omeprazole with temporary relief
Discharged
1 day PTA
History of the present illness(+) epigastric pain
8/10(+) bloatedness(+) undocumented
fever, (-) chills(+) anorexia(+) tea-colored
urine(+) acholic stools(+) yellowing of
the eyesAdmission
Day of admission
Review of systems• General: (-) weight loss, fatigue, weakness• HEENT: (-) headache, dizziness, enlarged LN• Pulmonary: (+) dyspnea, (-) hemoptysis,
cough, wheezing• Cardiovascular: (-) palpitations, chest pains,
orthopnea• Genitourinary: (-) nocturia, dysuria, frequency,
hematuria• Musculoskeletal/Dermatologic: (+) back pain,
(-) back pain, arthralgia, rashes, pruritus• Endocrine: (-) excessive sweating, heat/cold
intolerance, polyuria, excessive thirst
Past medical history(-) Hypertension, diabetes, asthma(+) allergies to shrimp and crabsUnrecalled operation on the head
secondary to mauling (1998), with blood transfusion
Family history(+) Hypertension- father(-) Diabetes, asthma, TB, cancer
Personal & social historyMarried, no childrenDiet: rice, “mahilig sa baboy”Current smoker, 0.8 pack years (2
sticks/day, 8 years)Heavy alcoholic beverage drinker, ~8
bottles of beer, 3x/weekMarijuana use
High schoolLast use: February 2012
General surveyConscious, coherent, cooperative, in painVital signs
110/80 mmHg104 beats/min22 breaths/min39.3°CVAS 8/10
BMI 19.27 kg/m2
Weight 59 kilosHeight 175 cm
HEENT• Icteric sclerae, pink conjunctivae • No tragal swelling or tenderness• No nasal discharge• Pink lips, moist oral mucosa, no lesions or
sores, (+) multiple dental caries, no tonsillopharyngeal congestion
• No cervical lymphadenopathies, non-palpable thyroid gland
Pulmonary• (+) tattoo on the periareolar area, right• Symmetric chest expansion, no retractions• Equal tactile fremiti• No dullness on percussion• Good air entry, clear breath sounds
Cardiovascular• Adynamic precordium• PMI at 5th ICS, left MCL• Normal rate and regular rhythm, distinct
S1/S2, no murmurs• No carotid bruits
Abdomen• Flat, soft abdomen, no scars/ lesions• Hypoactive bowel sounds • Tympanitic• (+) epigastric tenderness• Non-palpable liver edge• No palpable masses• (-) Murphy’s sign
Extremities• (+) flushed skin, (+) jaundice• No active dermatoses• Warm extremities• Good skin turgor• Full and equal pulses• No cyanosis, no clubbing• CRT < 2 seconds
Neurologic• Awake, alert, well-groomed• Oriented to 3 spheres• GCS 15• No cranial nerve deficits• No dysmetria, dysdiadochokinesia• MMT: 5/5• DTRs: 2+
Salient featuresHistory
Epigastric painBloatednessAnorexiaFeverTea-colored urineAcholic stoolsGallstones on
ultrasoundHeavy alcoholic
beverage drinker
Physical examinationHigh grade fever,
39.3°CFlushed skin,
jaundiceIcteric scleraeEpigastric
tenderness, hypoactive bowel sounds
Initial impressionObstructive biliary disease, secondary
to calculous cholecystitis, to consider choledocholithiasis, ascending cholangitis
Differential diagnosesGallstone pancreatitis
Diagnostic evaluationCBCSGPT, SGOTALPBilirubin (direct, indirect, total)Prothrombin timeAPTTAmylaseLipaseUltrasoundSerum electrolytes (Na, K, Cl)Urinalysis
LGBP UltrasoundGallstone with cholecystitisDilated common bile duct
Acute cholangitisOne of the main
complications of choledochal stones
Ascending bacterial infection due to partial of complete obstruction of the bile ducts
Both bacterial contamination and biliary obstruction are requisites for its development
E. coli, Klebsiella pneumoniae, Streptococcus faecalis, Enterobacter, Bacteroides fragilis
Clinical presentationMild, intermittent and self-limited to fulminant,
potentially life-threatening septicemiaMost common: Charcot’s triad (2/3)
FeverEpigastric/ RUQ painJaundiceReynold’s pentad Septic shock Mental status changesOn abdominal examination, the findings are
indistinguishable from those of acute cholecystitis
Tokyo GuidelinesA. Clinical context/ manifestations
History of biliary diseaseFever ± chillsJaundiceAbdominal pain (RUQ/epigastric)
B. Laboratory dataEvidence of inflammation
WBC, CRPAbnormal LFTs
ALP, GGT, AST, ALTC. Imaging
Biliary dilatation or evidence of etiologyStricture, stone, stent
Suspected Dx: >2 in A
Definitive Dx:1.Charcot’s triad2.>2 in A + both B and C
Tokyo GuidelinesMild
(+) response to medical treatmentGeneral supportive care and antibiotics
ModerateNo response to medical treatmentNo onset of organ dysfunction SevereNo response to medical treatment(+) Onset of organ dysfunction
CVD: BP, need for vasopressorsNervous: consciousnessRespiratory: PaO2/FiO2 <300Kidney: Creatinine > 2 mg/dLLiver: PT-INR >1.5Hematologic: Platelets <100
ManagementEndoscopic
retrograde cholangiopancrea-tography (ERCP)
ManagementLaparoscopic
cholecystectomy