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ER Interesting Case Rounds. Visit #1. 18 yo female…. 4 day history of.. “Fevers” Nausea/Emesis Diarrhea Lower abdominal pain. Pain.. RLQ = LLQ 7/10 at worst No radiation “crampy” Worse with movement Pain with BMs (diarrhea). Diarrhea… Non-bloody 3-4x/day “mucousy” No PV symptoms

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visit 1
Visit #1
  • 18 yo female…. 4 day history of..
  • “Fevers”
  • Nausea/Emesis
  • Diarrhea
  • Lower abdominal pain
slide3
Pain..

RLQ = LLQ

7/10 at worst

No radiation

“crampy”

Worse with movement

Pain with BMs (diarrhea)

slide4
Diarrhea…
  • Non-bloody
  • 3-4x/day
  • “mucousy”
  • No PV symptoms
  • No urinary symptoms
physical exam
Physical Exam
  • Vitals = normal
  • Chest = clear
  • CV = normal
  • Abdo =
  • Tender to direct palpation. RLQ = LLQ
  • No rebound/guarding etc.
  • No mass
slide6
LABS
  • Hgb = N
  • WBC = 13.5 (neuts = 11, monocytes 1.2)
  • Lytes = N
  • BG = N
  • Lipase = N
slide7
LEs…
  • ALP = N (104)
  • ALT = N (16)
  • GGT = 64 (8-35)
  • Bili T = 46 (0-20)
  • Bili D = 24 (0-7)
slide8
Urine dip
  • Beta = negative
  • 3+ ketones
  • 2+ bilirubin
  • Tx—fluids, anti-emetic, booked for abdo u/s in am. Dx “abdo pain NYD/mild LFT abnormality”
visit 2
VISIT #2
  • Returned next day post u/s:
  • “Well seen and NORMAL liver, GB, ducts, pancreas, kidneys, spleen, aorta, para-aorta areas, bowel, uterus, overies, adnexa. No free fluid.”
slide10
Repeat labs
  • Bili 29 (down from 46)
  • GGT 56 (down from 64)
  • WBCs 12.2 (down from 13.5)
  • K = 3.4
  • Dx: “gastroenteritis”
visit 3
Visit #3
  • Returns 5 days later…
  • Persistent diarrhea
  • Malaise
  • ABDO PAIN!!
  • 9 lb wt loss in 10 days
other hx
OTHER HX?
  • No travel
  • No well water exposure
  • No recent ABX
  • No sick contacts
  • No exposure to uncooked meats
slide13
Phx = healthy, no surgeries, PAP 6 months prior was normal
  • No meds (was on OCP in past)
  • Social = infrequent EtOH, no IVDU,
  • No risky sexual behaviour
  • 1 partner. Using condoms.
  • Tattoo at end of June
  • Fam Hx: No IBD
slide14
VS: HR 100, Temp 38
  • ABDO=
  • Tender lower quadrants
  • Rebound
  • Involuntary guarding
  • +RUQ pain
slide15
WBC: 19.9 (neuts 13, bands 4.2)
  • GGT 109
  • ALP 175
  • Bili T = 23
slide16
Stool C + S = negative
  • Stool O + P = negative
  • Hep Serology = negative
  • C. diff = negative
  • Stool Fat Globules = negative
slide17
Speculum Exam:
  • thick yellow d/c from cervical os
  • Bimanual Exam:
  • + cervical motion tenderness
  • CT Abdo/Pelvis: complex fluid collection in pouch of Douglas, compressing rectum, consistent with large tubo-ovarian abscess
fitz hugh curtis
Fitz-Hugh-Curtis
  • Perihepatitis in association with pelvic inflammatory disease
  • Originally described by Carlos Stajano (1919) in Uroguay.
  • 1930’s… re-described by Thomas Fitz-Hugh and Arthur Curtis.
etiology
Etiology
  • Originally felt only to be secondary to N. gonorrhea (Fitz-Hugh discovered gram negative diplococci on smears taken from the liver capsule)
  • 1970s, Chlamydia trachomatis implicated and remains the most common pathogen
  • Case reports... strept milleri, tuberculosis
organisms associated with pid
Organisms Associated with PID
  • Aerobes:
  • N. gonorrhea
  • C. trachomatis
  • U. urealyticum
  • Mycoplasma sp. (genitalium, hominus)
  • Gardnerella vaginalis
  • Strept Pyogenes
  • Coag – staph
  • E. Coli
  • H. influenzae
  • S. pneumoniae
  • Mycobacterium tuberculosis
  • Anaerobes:
  • B. fragilis
  • Peptostreptococcus
  • Clostridium bifermentans
  • Fusobacterium sp.
  • Viruses:
  • HSV
  • Echovirus
  • Cocksackie
diagnosis
Diagnosis
  • RULING IN pelvic inflammatory disease
  • RULING OUT other causes of RUQ pain +/or elevated liver enzymes
pathogenesis
Pathogenesis

Multiple Theories:

  • Direct Infection of Liver?
  • Hematogenous Spread?
  • Lymphatic Spread?
  • Exaggerated Immune Response?
how common
How Common?
  • Studies show broad ranges
  • 4%-27% of patients with PID
  • RISK FACTORS:
  • IUDs, pelvic surgery, multiple partners, lack of barrier protection etc.
symptoms
Symptoms
  • Symptoms of PID (fever, abdominal pain, vaginal discharge, vaginal bleeding)
  • Right Upper Quadrant Pain—usually pleuritic.
  • Possible for patient to present with RUQ pain only (subacute/chronic PID)
atypical presentations
Atypical Presentations
  • Ileus/obstruction
  • Peri-splenitis
  • Peri-appendicitis
  • Fitz-Hugh-Curtis in a male
  • Chilaiditi syndrome
  • Ovarian Ca
  • Perforated Ulcer
  • Pleural effusion
physical exam1
Physical Exam
  • Cervical motion tenderness
  • Adnexal/uterine tenderness
  • Lower Abdominal tenderness
  • RUQ tenderness (may occur on its own)
  • +/- friction rub over right anterior costal margin
radiographic studies
Radiographic Studies
  • Ultrasound:
  • Excludes cholelithiasis, cholecystitis etc.
  • Insensitive for FHC
  • May demonstrate “violin-string” adhesions, loculated fluid in the hepatorenal space.
  • “Violin String” also in Familial Mediterranean Fever, Diaphragmatic Endometriosis
radiographic studies1
Radiographic Studies
  • CT Scan:
  • Helpful IF can demonstrate contrast enhancement of the liver capsule
  • Sensitivity of only 28%! (Joo et al. 2007)
  • Depends if biphasic CT vs. portal phase only
lab tests
LAB TESTS
  • Liver Enzymes: often normal but can be elevated
  • Litt and Cohen (JAMA, 1978) found ALT most likely, but ‘cholestatic’ enzyme elevations also reported
  • +/- ESR
  • +/- Leukocytosis
  • Cultures: N gonorrhea, C Trachomatis from cervix. Cultures from pelvic aspirates tend not to correlate. (mixed anaerobes, aerobes etc.)
treatment
Treatment
  • Similar to that of PID
  • Generally focused on N gonorrhea and C trachomatis, gram negative rods, anaerobes
  • Direct therapy according to cultures
  • Drain abscesses
pid tx
PID tx
  • Tx regimens:
  • Ceftriaxone 250 mg IM/Doxy 100 bid x 14 days
  • Levo od/Flagyl bid x 14 days
  • Cefoxitin 2g IV q6/Doxy 100 bid
  • IV for 48 hours afebrile, then PO
  • Poor response to ABX = laparoscopy
complications
Complications
  • Those of PID:
  • Infertility
  • Adhesions
  • Chronic pain
  • Ectopic pregnancy
  • Reiter’s syndrome
slide34
Culture results:
  • Streptococcus milleri (heavy)
  • B fragiles (moderate)
  • E. Coli (scant)
  • NAAT:
  • Negative for both Chlamydea and Gonorrhea
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