Case No 2

76-year old woman with four-day history of low-grade fever and right upper quadrant pain

Medical History

Present Illness: Not feeling well for five days, chill, mild rising temperature, right upper quadrant pain. The pain persists mainly on empty stomach. Nausea, but did not vomit. Regular stool, now slightly soft. GP examined her, high CRP determined by a POCT.

FHx: Parents died at old age, younger brother is healthy
EHx: She has had no sick contacts. 4 days ago she had mayonnaise sandwich
WHx: Pensioner
PMHx: Arterial hypertension on therapy
PSHx: s/p surgery of left breast cyst
GHx: Postmenopause
Allergies: NKDA
Medications: Prestarium Neo 1-0-0 tabl, Detralex 2-0-0 tabl
Abuse: : Non-smoker, no alcohol drinking

Physical Examination

TT 36,5 °C, alert and oriented, cooperating, quiet breathing, eutrophic, no skin icterus. Head: NAD. Eyes: PERRL (Pupils Equal, Round, Reactive to Light), EOMI (Extra Ocular Muscles Intact), no scleral icterus. Ears, nose without any discharge. Throat clear with no erythema, tongue a little drier, with whitish coating. Neck supple with no LAD or masses. Breath sounds normal, RRR (Regular Rate and Rhythm), heart sounds normal, no m/g/r. Pulses 2+ equal on both sides. BP 110/60. Abdomen soft, non-distended. Liver not palpable, liver span approximately 10 cm, spleen not palpable. No masses. Murphy’s sign positive, no peritoneal signs. Normoactive bowel sounds. Rectal: Deferred. Extremities: Mild soft perimalleolar edemas, no tender to palpation, Homans and plantar sign negative. Meningeal signs negative.

Laboratory Tests

Hematologic examination:

Blood count: WBC: *12.4 10^9/l RBC: 4.58 10^12/l Hb: 128.0 g/l Hct: 0.378 1/1 MCV: 82.5 fl MCH: * 27.9 pg MCHC: 0.339 kg/l RDW: 14.5 % PLT: 389.0 10^9/l Pct: * 0.380 x10 ml/l MPV: 9.8 fl PDW2: 11.3 fl
Hemocoagulation: PT-time: 14.9 s PT-R: 1.17 1/1 INR: 1.22 1/1 PT-N: 12.7 s aptt-p: 38.6 s aptt-R: 1.16 1/1 aptt-n: 33.4 s

Biochemical lab tests:

Urine chem. and sed.: U-pH: 5.5 U-SG: * 1.025 kg/l U-Glu: 0 arb.unit U-Keto: *1 arb.unit U-Prot: *1 arb.unit U-Bil: *1 arb.unit U-Uro: * 1 arb.unit U-Krev: * 1 arb.unit U-Nit: 0 arb.unit U-Ery: * 52 /ul U-Leu: * 70 /ul U-VaHy: * 3 /ul U-EpDl: * 258 /ul U-Bakt: * 1 arb.unit U-Hlen: 4 arb.unit
Plasma or serum chemistry: Glucose: *7.0 mmol/l Na: 135 mmol/l K: *3.20 mmol/l Cl: 98 mmol/l Urea: 5.90 mmol/l Cr: 87 umol/l Bil: 18 umol/l AST: * 0.56 ukat/l ALT: 0.52 ukat/l ALP: 1.51 ukat/l GGT: * 1.02 ukat/l AMS: 0.46 ukat/l Lip: 0.15 ukat/l CRP: ! 251.1 mg/l
After 7 days: Gluc: *5.8 mmol/l Na: 139 mmol/l K: *3.70 mmol/l Cl: 103 mmol/l Urea: 3.90 mmol/l Cr: 61 umol/l Bil: *81 umol/l AST: * 4.44 ukat/l ALT: * 7.02 ukat/l ALP: * 10.15 ukat/l GGT: * 9.67 ukat/l AMS: 0.43 ukat/l Lip: 0.21 ukat/l CRP: * 141.3 mg/l
After 10 days: Gluc: *6.0 mmol/l Na: 136 mmol/l K: 4.20 mmol/l Cl: 101 mmol/l Urea: 4.20 mmol/l Cr: 53 umol/l Bil: *84 umol/l Bilconj: * 63 umol/l AST: * 2.23 ukat/l ALT: * 3.57 ukat/l ALP: * 11.42 ukat/l GGT: * 9.94 ukat/l AMS: ! 22.56 ukat/l Lip: ! 49.64 ukat/l CRP: * 184.3 mg/l

Microbiological examinations:

Blood culture: blood sample from venipuncture (ANA bottle BD BACTEC Lytic 10 Anaerobic /F / AE bottel BD BACTEC PLUS+Aerobic/F) in automated blood culture system BACTEC: aerobic culture: negative, anaerobic culture: negative
Urine culture: from the mid-stream urine sample: aerobic culture nonselective: primo-culture sterile, selected culture: for MRSA detection: negative

Imaging Studies

Chest and abdomen XR: Diaphragm segmentation on the right, slight dilatation of the heart shadow on the left, arteriosclerosis of the aortic arch, otherwise no apparent disorder (NAD) on the intrathoracic organs. No signs of neither ileus nor pneumoperitoneum
Abdominal ultrasonography (U/S): Right hepatic lobe in costal/upper rib margin, homogeneous hepatic parenchyma, size 39 mm in the left hepatic lobe. Gallbladder size approximatelly 9 × 7cm, anechoic and simple contents with thickened contents, with hyperechogenic wall. Pancreas not enlarged, homogeneous structures, diffusely higher echogenicity. Kidneys of usual size, shape and location, parenchymal layer preserved, without deposits, hollow system not dilated. Spleen non enlarged, homogeneous, without focal changes. Bowell loops of adequate width, preserved movements, wall not thickened. No free fluid in the abdominal cavity. Bladder of homogeneous anechogenic content, wall not thickened. Abdominal aorta slim, usual course. Conclusion: Gallbladder hydrops, pericholecystitis. Gallbladder concentrated anechoic content. Cyst of the left liver lobe.
CT scan of the abdomen and pelvis: Ionnic contrast administered i.v.: Iomeron 400 90 ml iv and oral without reaction: Lung bases without foci or infiltrations, pleural spaces basally without effusion. No hepatomegaly, liver parenchyma of natively slightly reduced density, around 33 HU. Gallbladder very large 100 × 65 × 69 mm with layered wall thickening of the fundus, hypodense content. The gallbladder is deeply immersed in the liver parenchyma. Fatty tissue of the gallbladder bed is mild infiltrated. Pancreas lipomatous, not enlarged, without focal changes in the parenchyma, major pancreatic duct not dilated. Adrenal glands not enlarged. Both kidneys of the usual placement, shape and size, without dilatation of the hollow system, small cortical cysts of the left kidney. Kidney surface smooth, flat. Spleen not enlarged, without focal changes. Stomach, duodenum and depicted loops of small and large intestine of approximately normal form and width. Diverticulosis of the splenic flexure. Appendix normal, localized subcecally. Rectosigma of roughly usual appearance, wall not thickened. Urinary bladder with hypodense homogeneous content, sharp, smooth contours, without clear wall thickening. Uterus of normal size and shape, smooth contours, adnexa not enlarged. Lymph nodes in the retroperitoneum, pelvis and groin not enlarged. Degenerative changes of the lumbar vertebrae and right of the hip joint, otherwise depicted skeleton without clear structural changes. Large vessels of the abdomen and the lesser pelvis of the usual appearance and course. No free fluid in the abdomen and the lesser pelvis.

Fig 1 Abdominal XR: Small bowel loops of adequate width, without dilatation, no air-fluid levels, air is only present in a small bowel loop in the left mesogastrium, no free intraperitoneal air. No evident calcification shadows in the presumed site of the urinary and biliary tract. No structural changes on the visualized skeleton, right-sided coxarthrosis, one phlebolith in the pelvis. Conclusion: No signs of neither ileus nor pneumoperitoneum.

Fig 2 Abdominal CT scan (transverse image): No hepatomegaly, liver parenchyma of natively slightly reduced density, around 33 HU. Gallbladder very large 100 × 65 × 69 mm with layered wall thickening of the fundus, hypodense content. The gallbladder is deeply immersed in the liver parenchyma. Fatty tissue of the gallbladder bed is mild infiltrated. Pancreas lipomatous, not enlarged, without focal changes in the parenchyma, major pancreatic duct not dilated.

Fig 3 CT scan of the abdomen and pelvis (reformatted coronal image): Liver not enlarged, cyst in the left lobe of the liver, size 40 × 23 mm, hepatic parenchyma of natively reduced density, about 33 HU. Intrahepatic bile ducts not dilated. Gallbladder very large 100 × 65 × 69 mm with a layered wall of the fundus, hypodense content, significantly immersed in the liver parenchyma. Fatty tissue of the gallbladder bed is mildly infiltrated. Pancreas lipomatous, not enlarged, without focal changes in the parenchyma, major pancreatic duct not dilated.

Other Paraclinical Examinations

Electrophysiologic examinations:

ECG: sinus rhythm 92/min., normal intervals (PR = 0.14, QRS = 0.08 QTc = 0.450) and normal axis. No ventricular hypertrophy or atrial enlargement. No signs of ischemia.

Endoscopic methods:

ERCP:
Indication: acute pancreatitis, probable biliar, prominent cholestasis
Premedication: Apaurin 6 mg iv, Buscopan 60 mg fractionated iv
Device: endoscope Olympus CF-H180AL
Examination: endoscope inserted freely into the D2, stomach without solid contents, clear pond. In D2 ampulla of Vater of the usual localization, balloon-arched, when trying to cannulate the choledochus, the Wirsungi is first cannulated, which we do not fill with contrast, we verify the position of the cannula with a wire. Subsequently, a deep cannulation of the choledochus, which is dilated to about 15 mm, IH bile ducts without significant dilatation, defects in the filling are not visible, but we assume lithiasis in the area of bulging duodenal papilla. A papillotomy of about 12 mm in length was performed, a dark concretion of about 5-7 mm in size is released by the incision, followed by abundant bile outflow with an admixture of sludge and pus. Choledochus revised repeatedly with a basket, extracted a few more small stones and small material from the dist. parts, the last revision of the basket without the capture of lithiasis and the bile tree is quickly emptied. Bleeding from papillotomy almost ceases spontaneously, however, still treated with about 5-6 ml of adrenaline solution diluted 1 : 10,000.
Conclusion: Dilatation of the ductus choledochus, a few small stones and sludge in the mouth of the papilla. Papillotomy and lithiasis extraction performed. Evacuation of bile ducts then satisfactory. The admixture/addition of pus in the bile indicates cholangitis. The procedure is complicated by a small soaking bleeding from papillotomy, which stops almost spontaneously. However, it is treated with an adrenaline solution with an effect.
Recommendation: Watch/inspection after returning to the inpatient department, today rest mode, limited fluids orally, parenteral hydration. Check of BC and AMS in the afternoon and morning, subsequent monitoring of cholestatic and inflammatory markers. Indometacin 100 mg supp. as prophylaxis of post-ERCP pancreatitis.

Diagnostic Conclusion

Make a diagnosis

Treatment

Determine for yourself

Course

76-year old woman with high blood pressure, admitted with acute cholecystitis with high inflammatory parameters, hypokalemia, CT showed pericholecystitis. Finding on CT scan confirmed it. Parenteral antibiotic therapy [what antibiotic was prescribed], rehydrated, potassium supplemented, symptomatic therapy administered. ATB therapy caused drop of inflammatory parameters, but after a week bilirubin and hepatic test values are rising, especially those of obstructive enzymes, and subsequently progress of acute pancreatitis. ERCP done, performed papillotomy, extracted concrement, several small stones were removed from common bile duct, bile drain enabled, the presence of pus in the bile indicates cholangitis. ATB therapy was escalated [---- what ATB ? ----], ERCP was performed. After intervention the patient's condition improves, abdominal pain subsides, she does not vomit, oral intake is well tolerated, jaundice regresses, is afebrile, KP is compensated. Inflammatory parameters decrease, liver test values and bilirubin, the activity of serum pancreatic enzymes is normalized. Released in good general condition home.

Task

Decide diagnoses and propose antibiotic therapy.