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WINNING THE BATTLE. BUT LOSING THE WAR A Brief Case Presentation Michael Caselnova, M.D. GOALS. Case presentation Brief review of diagnoses encountered Lessons learned Recommendations to improve care. The Case . Day 0 67 y/o WM presented to another facility with: Abdominal pain

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winning the battle

WINNING THE BATTLE

BUT LOSING THE WAR

A Brief Case Presentation

Michael Caselnova, M.D.

goals
GOALS
  • Case presentation
  • Brief review of diagnoses encountered
  • Lessons learned
  • Recommendations to improve care
the case
The Case
  • Day 0
  • 67 y/o WM presented to another facility with:
    • Abdominal pain
    • Hypotension
    • Diaphoretic
    • “pale”
additional findings
ADDITIONAL FINDINGS
  • CT abdomen showed:
    • 7 cm AAA with large retroperitoneal hematoma
  • PMH significant for coronary stent
the problem
The Problem?
  • NO Cardiothoracic surgeon available at the outlying facility
  • Decision made to transfer pt by air to our facility
  • Transfused during transport
  • Met by CT surgeon and anesthesiology on helipad and taken directly to OR
findings on arrival
FINDINGS ON ARRIVAL
  • SBP in 60-80 range
  • Cyanosis of abdomen and legs
  • No peripheral pulses
  • As he was being placed on table:
    • pH 6.8
    • SBP unobtainable
procedure
Procedure
  • “EMERGENCY LIFE SAVING REPAIR OF ABDOMINAL AORTIC ANEURYSM”
  • 18 mm straight dacron tube graft
findings at time of surgery
Findings at time of surgery
  • Large retroperitoneal hematoma, R>L
  • Compression of vena cava
  • Free intra abdominal blood
  • Coagulopathy
  • Hypothermia 33.8 degrees
  • ? Hepatic tumor on palpation
  • TEE showed good LV function
  • BP 120/70 post op
received
Received
  • 15 units PRBC
  • 10 units FFP
  • 20 units cryoprecipitate
  • Platelets
  • TPN post op
slide10
POD 1 Small mucoid bloody stools x 7
  • POD 2 2 more bloody stools and abd pain
  • GI consult
  • CT read as 3.5-4 cm exophytic liver mass
  • Alk phos normal
  • Bili normal
  • AST 165
preliminary dx
Preliminary Dx
  • Ischemic colitis from profound hypotension
  • Needs CT w contrast but Azotemic
  • AFP requested (later came back normal)
pod 4
POD 4
  • Neurology consult for weakness and numbness of lower extremities
  • Initial impression:
    • Either direct compression of lumbar plexus by retroperitoneal hematoma or
    • Cord ischemia due to hypotension
  • Prognosis good for recovery of function
pod 5
POD 5
  • Colonoscopy: ischemic colitis in section of rectum and sigmoid and descending colon
    • No areas of circumferential ischemic colitis
    • No areas that looked like they wouldn’t heal
  • Rec: FEED
pod 9
POD 9
  • Fever to 102.6
  • Pulmonary consult
  • Atelectasis on CXR
  • WBC on POD 8 was 19.5
  • Had been started on Moxi and Vanc
  • Blood Cult growing GNR
  • Moxi stopped and pip/tazo added
pod 12
POD 12
  • BC growing Pseudomonas and Klebsiella pneumoniae
  • Urine C&S 2 GNR
  • Few candida from central line
  • ID consult- candida felt likely colonization BUT concern for graft so fluconazole rec for 2-4 wks
  • One culture pos for staph epi sens to all
  • Vanco stopped
pod 18
POD 18
  • Discharged to ECF in outlying city
  • Fluconazole for 30 days po
  • Pip/tazo for one more week
  • BATTLE WON!
  • BUT…..
pod 37
POD 37
  • Brought to ER with fever, nausea, vomiting abd pain
  • No dysuria
  • Few days of diarrhea but no hematochezia
  • CT: air and fluid in aortic lumen, surrounding the graft, and anterior to aorta at level of prox graft anastomosis consistent w infection/abscess formation
  • Abnormal area of low attenuation in liver- possible infarct/infection/can’t exclude mass
transfer to our facility
Transfer to our facility
  • CT surgeon accepted pt- felt the air and fluid were expected findings post op
  • Hospitalist Consult requested
  • Afebrile on arrival
  • Pt was on oral cipro and augmentin
  • WBC 11K, Hgb 12.2, plt 127K, alb 1.9, alk phos 409, CXR w hazy opacity R either atelectasis or infiltrate, but improved from previous
slide19
Cultured again
  • Pip/tazo and vanco
  • C dif neg
  • Gram pos cocci in 1of 2 BC from referring facility
  • RUQ tenderness
  • NO mention of hepatic mass in the DC summary
slide20
RUQ sono-thickened GB wall and sludge
  • Amylase and lipase normal
  • Gen Surg consult
  • HIDA neg for acute cholecystitis and EF was 42%; decreased uptake R side of liver
pod 44
POD 44
  • Renal function worsening BUN 49, Cr 2.9
  • Plt 76K, WBC 15.8, INR 2.87
  • Nephrology Consult-? Vanco, ? ATN, ? obstruction
  • Renal sono normal
  • Start CRRT dialysis
  • CT directed liver Bx done POD 41-results pending
pod 45
POD 45
  • ID consult- ? Sepsis
  • Vanco continued but imipenem added
  • Transaminases increasing, ? Hepatorenal syndrome
  • Heme/onc consult for liver mass (path still pending)
  • Can’t treat malignancy due to overall condition
pod 46
POD 46
  • CTA chest/abd/pelvis
  • Increasing R pleural effusion
  • Increasing ascites
  • Perigraft fluid w air, ? Infectious process
  • Decision made w family to change status to DNR
pod 47
POD 47
  • Pt expired
  • Final Dx on liver Bx was primary malignant liver neoplasm-report signed on POD 54
  • LOST THE WAR
abdominal aortic aneurysm
Abdominal Aortic Aneurysm
  • Diameter > 3.0 cm at level of renal arteries
  • Risk factors include age1,2, smoking3, male sex4, HTN5, family Hx1, atherosclerosis
  • Most are asymptomatic until rupture, but if symptoms are present (abd or back pain or tenderness on palpation) the risk for rupture is higher
  • Ruptured AAA typically presents with abd or back pain, hypotension, pulsatile abd mass
slide26
AAA
  • Overall survival rate for ruptured AAA is 25%; 50% survive to reach hospital but 50% reaching hospital don’t survive6
  • If BP is stable, the aneurysm rupture is temporarily contained
ischemic colitis
ISCHEMIC COLITIS
  • Caused by reduction in intestinal blood flow, by occlusion, vasospasm, or hypoperfusion of mesenteric vessels
  • More common in elderly
  • Majority develop non-gangrenous ischemia and resolve w/o sequelae, but can develop stricture7
  • 15% develop gangrene7
  • Splenic flexure and rectosigmoid junction most vulnerable sites
  • Occurs in 1-7% of aortoiliac surgery8,9
ischemic colitis28
ISCHEMIC COLITIS
  • Findings include:
    • Abdominal pain and tenderness which is usually mild
    • Rectal bleeding or bloody diarrhea within 24 hrs of onset of pain
  • May develop ileus or proceed to severe gangrene with shock
ischemic colitis dx
ISCHEMIC COLITISDX
  • CLINICAL SETTING
  • PHYSICAL EXAM
  • RADIOLOGIC
  • ENDOSCOPIC
  • NO SPECIFIC LAB FINDINGS
  • PLAIN FILMS USUALLY NON SPECIFIC
  • MRI/MRA NOT USEFUL
  • CT W CONTRAST OFTEN NONSPECIFIC
  • COLONOSCOPY WITHOUT PREP, MINIMAL AIR INSUFFLATION
ischemic colitis tx
ISCHEMIC COLITIS TX
  • In absence of perforation or gangrene
    • Supportive care, bowel rest, IVF to maintain perfusion
    • Empiric broad spectrum Abx
    • NGT if ileus present
    • ? TPN
ischemic colitis tx31
ISCHEMIC COLITISTX
  • Surgical intervention if clinical worsening
  • Surgical intervention for colonic infarction
  • Generally surgery performed without prep
primary hepatocellular carcinoma
PRIMARY HEPATOCELLULAR CARCINOMA
  • Usually develops in setting of chronic liver Disease
  • Often untreatable at time of Dx
  • Usually asymptomatic until late in course
  • Fever may develop with central tumor necrosis
  • Lab findings usually nonspecific
    • AFP not elevated in all cases- 40% are normal12
  • Extrahepatic spread in 10-20% at time of Dx10, 11
primary hepatocellular carcinoma33
Primary hepatocellular carcinoma
  • Most common metastase are to lung, intraabdominal lymph nodes, bone, adrenal gland
primary hepatocellular carcinoma dx
PRIMARY HEPATOCELLULAR CARCINOMA DX
  • Usually have underlying liver disease
  • Rising alpha fetoprotein (but not all tumors secrete AFP)
  • CT or MRI- dominant solid nodule, hypervascular, venous invasion with elevated AFP
  • Percutaneous Bx
aaa post op
AAA POST OP
  • Hematoma present in all patients-usually resolves in 7-65 days in 82% of patients
  • Perigraft fluid resolves over 3 mos
  • Perigraft gas usually resolves in one week
lessons learned
LESSONS LEARNED
  • INCLUDE IN DISCHARGE SUMMARY ANYTHING SIGNIFICANT WHICH NEEDS FOLLOW UP-SUBSEQUENT PROVIDERS WILL BE RELYING ON IT
  • REVIEW OTHER MEDICAL RECORDS WHEN RE ADMITTING PATIENT- PRIOR H&P, CONSULTS, RADIOLOGY, ETC
lessons learned37
LESSONS LEARNED
  • TRY TO GET CONSULTING HOSPITALIST TO DO DISCHARGE SUMMARY AND DEATH CERTIFICATE
  • JUST KIDDING!
references
REFERENCES
  • 1. Hirsch, AT, Haskal, ZJ, Hertzer, NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease Circulation 2006; 113:e463
  • 2. Singh, K, Bonaa, KH, Jacobsen, BK, et al. Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study : The Tromso Study. Am J epidemiol 2001; 154:236
  • 3. Powell, JT, Greenhalgh, RM. Clinical Practice. Small abdominal aortic aneurysms. N Engl J Med 2003; 348: 1895
  • 4. Singh, K, Bonaa, KH, Jacobsen, BK, et al. Prevalence of and Risk Factors for abdominal aortic aneurysms in a population-based study. Am J Epidemiol 2001; 154: 236
  • 5. Lederle, FA, Johnson, GR, Wilson, SE, et al. Prevalence and associations of abdominal aortic aneurysm through screening. Aneurysm Detection and Management Veterans Affairs Cooperatice Sdtudy Group. Ann Intern Med 1997; 126: 441
references39
REFERENCES
  • 6. Thomas, PR, Stewart, RD. Abdominal aortic aneurysm. Br J Surg 1988; 75: 733
  • 7. Greenwald, DA, Brandt, LJ. Colonic ischemia. J Clin Gastroenterol 1998; 27: 122
  • 8. Hagihara, PF, Ernst, CB, Griffen WO, Jr. Incidence of ischemic colitis following abdominal aortic reconstruction. Surg Gynecol Obstret 1979; 149: 571
  • 9. Brewster, DC, Franklin, DP, Cambria, RP, et al. Intestinal ischemia complicating abdominal aortic surgery. Surgery, 1991; 109:447
  • 10. Kew, MC, Dos Santos, HA, Sherlock, S. Diagnosis of primary cancer of the liver. Br Med J 1971; 4: 408
  • 11. Yoon,KT, Kim, JK, Kin do, Y, et al. Role of 18F-fluorodeoxyglucose positron emission tomography in detecting extrahepatic metastasis in pretreatment staging of hepatocellular carcinoma. Oncology 2007; 72 Suppl 1:104
references40
References
  • 12. Chen, DS, Sung, JL, Sheu, JC, et al. Serum alpha-fetoprotein in the early stage of human hepatocellular carcinoma. Gastroenterology 1984; 86: 1404
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