Grand RoundsGrand RoundsCase PresentationCase Presentation

Michael S. Truitt, MDMichael S. Truitt, MDDepartment of SurgeryDepartment of Surgery

University of Colorado HSCUniversity of Colorado HSC

Presentation:Presentation:

82 year old female 82 year old female 24 hour history diffuse abdominal pain24 hour history diffuse abdominal painNausea and vomiting x 2Nausea and vomiting x 2AnorexicAnorexicDiarrhea (not grossly bloody)Diarrhea (not grossly bloody)

Past Medical History:Past Medical History:

HypertensionHypertensionAsthmaAsthmaHypothyroidismHypothyroidismHiatal Hernia Hiatal Hernia x 30 yearsx 30 years

Lasix 40mg PO BIDLasix 40mg PO BID

Ventolin & AtroventVentolin & Atrovent

Synthroid 0.075mg DailySynthroid 0.075mg Daily

No known drug allergiesNo known drug allergies

Meds:Meds:

Exam:Exam:

Temp: 98.6Temp: 98.6135/76 135/76 85 BPM85 BPM181890% RA 90% RA

Neuro: IntactNeuro: IntactPulm: Bialteral Pulm: Bialteral rhonchirhonchiCV: S1/S2, No CV: S1/S2, No MurmurMurmurGI: Soft, slight TTP in GI: Soft, slight TTP in the BUQ, ND, +BS, the BUQ, ND, +BS, No rebound or No rebound or guarding. Benignguarding. BenignExt: 1+ BLE EdemaExt: 1+ BLE Edema

35 135 96 3535 135 96 353.5 28 1.13.5 28 1.1

10 250 10 250 U/A: Normal U/A: Normal CV: EKG, Troponin were negative CV: EKG, Troponin were negative Amylase: normalAmylase: normalLFTLFT’’s: normals: normalXR: . .. .. .. .. . .XR: . .. .. .. .. . .

StudiesStudies

Studies:Studies:

ED Disposition:ED Disposition:

The ED diagnosed the patient with an adynamic ileus and felt that no further work-up was necessary. The patient was then reassured and instructed to follow up with her PCP in 7-10 days. Furthermore, she was instructed to return to the ER if her symptoms worsened ......

12 Hours Later...... 12 Hours Later......

Worsening BUQ painWorsening BUQ painRecalcitrant nausea, vomitingRecalcitrant nausea, vomitingSubjective fever and chillsSubjective fever and chillsAnorexiaAnorexiaShe denied CP, SOB, DOE, She denied CP, SOB, DOE, hematemesis, hematochezia, or hematemesis, hematochezia, or melenamelena

Secondary PresentationSecondary Presentation

Secondary Presentation:Secondary Presentation:

Vitals:Vitals:Temp 37.3Temp 37.3BP 105/60 BP 105/60 HR 105 HR 105 RR 20RR 20O2 95% RAO2 95% RA

Exam:Exam:–– Neuro: AAOx3Neuro: AAOx3–– Pulm: Bilateral rhonciPulm: Bilateral rhonci–– CV: S1/S2, No murmurCV: S1/S2, No murmur–– GI: Soft, Mild TTP in the GI: Soft, Mild TTP in the

BUQ (R>L), No rebound BUQ (R>L), No rebound or guardingor guarding

–– Ext: 1+ BLE edemaExt: 1+ BLE edema

Differential Diagnosis of Nausea & Differential Diagnosis of Nausea & Vomiting:Vomiting:

AcuteAcute–– Digitalis toxicityDigitalis toxicity–– KetoacidosisKetoacidosis–– Cancer Cancer

chemotherapeutic chemotherapeutic agentsagents–– Inferior myocardial Inferior myocardial

infarction infarction –– Drug withdrawalDrug withdrawal–– HepatitisHepatitis

Recurrent or chronicRecurrent or chronic–– Psychogenic vomitingPsychogenic vomiting–– Metabolic disturbances Metabolic disturbances

(uremia,adrenal (uremia,adrenal insufficiency)insufficiency)

–– Gastric retention Gastric retention (gastroparesis,outlet obst)(gastroparesis,outlet obst)

–– Bile refluxBile reflux

With Abdominal PainWith Abdominal PainViral gastroenteritisViral gastroenteritisAcute gastritisAcute gastritisFood poisoningFood poisoningPeptic ulcer diseasePeptic ulcer diseaseAcute pancreatitisAcute pancreatitisSmall bowel obstruction and Small bowel obstruction and pseudoobstructionpseudoobstruction

Acute appendicitisAcute appendicitisAcute cholecystitisAcute cholecystitisAcute cholangitisAcute cholangitisAcute pyelonephritisAcute pyelonephritisInferior myocardial infarctionInferior myocardial infarction

In Association with Neurologic SymptomsIn Association with Neurologic SymptomsIncreased intracranial pressureIncreased intracranial pressureMidline cerebellar hemorrhageMidline cerebellar hemorrhageVestibular disturbancesVestibular disturbancesMigraine headachesMigraine headachesAutonomic dysfunctionAutonomic dysfunction

Investigations:Investigations:

CBCCBCPT/PTTPT/PTTSMA 7 SMA 7 Troponin/EKGTroponin/EKGAmylaseAmylaseLFTLFT’’ssUAUAXRXR

38 137 96 3538 137 96 353.2 28 1.43.2 28 1.4

14.5 255 14.5 255 U/A: Normal U/A: Normal CV: EKG, Troponin were negative CV: EKG, Troponin were negative Amylase: normalAmylase: normalLFTLFT’’s: TB=2.2, AST/ALT=252/300, Alk s: TB=2.2, AST/ALT=252/300, Alk

Phos=278Phos=278XR: . .. .. .. .. . .XR: . .. .. .. .. . .

Secondary PresentationSecondary Presentation

Studies:Studies:

Secondary PresentationSecondary Presentation

Surgery consult was Surgery consult was obtained for obtained for cholecystitischolecystitisPatient taken to OR Patient taken to OR for Laparoscopic for Laparoscopic CholecystectomyCholecystectomyOn initial evaluation On initial evaluation of the abdomen..of the abdomen..

OR:OR:

Patient was Patient was converted to openconverted to openEnterolithotomy Enterolithotomy was performed, but was performed, but bowel was frankly bowel was frankly necrotic, so necrotic, so resection and resection and primary repair was primary repair was performedperformed

Gallstone IleusGallstone Ileus

More frequent in women and in patients More frequent in women and in patients older than 70 years oldolder than 70 years oldMechanical obstruction caused by a large Mechanical obstruction caused by a large gallstonegallstoneMainly small bowel at the terminal ileumMainly small bowel at the terminal ileumCan cause gastric outlet obstruction: Can cause gastric outlet obstruction: BouveretBouveret’’s Syndromes SyndromeDiagnosis has a 20% mortality rate mainly Diagnosis has a 20% mortality rate mainly due to age/comorbidities of patientsdue to age/comorbidities of patients

Etiology:Etiology:

Develops as a complication Develops as a complication of chronic cholecystitisof chronic cholecystitisInflamed gallbladder Inflamed gallbladder becomes adherent to becomes adherent to adjacent intestine adjacent intestine A stone may ulcerate A stone may ulcerate through the wall to form a through the wall to form a cholecystenteric fistulacholecystenteric fistulaStones pass through fistula Stones pass through fistula and air from the bowel into and air from the bowel into the biliary tree the biliary tree (pneumobilia)(pneumobilia)Stones usually solitary and Stones usually solitary and greater than 2.5cm greater than 2.5cm diameterdiameter

Diagnosis:Diagnosis:

High index of suspicionHigh index of suspicionElderly patientElderly patientPneumobilia (40% of Pneumobilia (40% of cases)cases)Small bowel Small bowel obstructionobstructionAbdominal XAbdominal X--ray may ray may detect these featuresdetect these featuresUltrasoundUltrasoundCTCT

Treatment:Treatment:

Board Answer:Board Answer:–– EnterolithotomyEnterolithotomy

Debate:Debate:–– Enterolithotomy Enterolithotomy

plus plus cholecystectomy cholecystectomy and fistula closureand fistula closure

No difference in No difference in morbidity or morbidity or mortalitymortality