1. Abdominal Pain CHUA, Mary Francine P. MD080022

2. Identifying information • R.C. • 25 years old • Male • Filipino • Married • Dealer • Iglesia ni Cristo

3. Chief complaint • Abdominal pain

4. 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 refused • Self-medicated with mixture of apple juice, vinegar & olive oil • Passage of ~70 stones • Complete relief 1 ½ years PTA

5. 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 done • Self-medicated with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief 4 days PTA

6. History of the present illness • (+) epigastric pain • (+) bloatedness • (+) undocumented fever, (-) chills • (+) anorexia • (+) tea-colored urine • No consult done • Self-medicated with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief 2 days PTA

7. History of the present illness • (+) epigastric pain • 8/10 • (+) bloatedness • (+) undocumented fever, (-) chills • (+) anorexia • (+) tea-colored urine • (+) acholic stools • Consult done at ER • Given paracetamol and omeprazole with temporary relief • Discharged 1 day PTA

8. History of the present illness Day of admission • (+) epigastric pain • 8/10 • (+) bloatedness • (+) undocumented fever, (-) chills • (+) anorexia • (+) tea-colored urine • (+) acholic stools • (+) yellowing of the eyes • Admission

9. 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

10. Past medical history • (-) Hypertension, diabetes, asthma • (+) allergies to shrimp and crabs • Unrecalled operation on the head secondary to mauling (1998), with blood transfusion

11. Family history • (+) Hypertension- father • (-) Diabetes, asthma, TB, cancer

12. Personal & social history • Married, no children • Diet: rice, “mahilig sa baboy” • Current smoker, 0.8 pack years (2 sticks/day, 8 years) • Heavy alcoholic beverage drinker, ~8 bottles of beer, 3x/week • Marijuana use • High school • Last use: February 2012

13. General survey • Conscious, coherent, cooperative, in pain • Vital signs • 110/80 mmHg • 104 beats/min • 22 breaths/min • 39.3°C • VAS 8/10 • BMI 19.27 kg/m2 • Weight 59 kilos • Height 175 cm

14. 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

15. 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

16. Cardiovascular • Adynamic precordium • PMI at 5th ICS, left MCL • Normal rate and regular rhythm, distinct S1/S2, no murmurs • No carotid bruits

17. Abdomen • Flat, soft abdomen, no scars/ lesions • Hypoactive bowel sounds • Tympanitic • (+) epigastric tenderness • Non-palpable liver edge • No palpable masses • (-) Murphy’s sign

18. Extremities • (+) flushed skin, (+) jaundice • No active dermatoses • Warm extremities • Good skin turgor • Full and equal pulses • No cyanosis, no clubbing • CRT < 2 seconds

19. Neurologic • Awake, alert, well-groomed • Oriented to 3 spheres • GCS 15 • No cranial nerve deficits • No dysmetria, dysdiadochokinesia • MMT: 5/5 • DTRs: 2+

20. Salient features • History • Epigastric pain • Bloatedness • Anorexia • Fever • Tea-colored urine • Acholic stools • Gallstones on ultrasound • Heavy alcoholic beverage drinker • Physical examination • High grade fever, 39.3°C • Flushed skin, jaundice • Icteric sclerae • Epigastric tenderness, hypoactive bowel sounds

21. Initial impression • Obstructive biliary disease, secondary to calculous cholecystitis, to consider choledocholithiasis, ascending cholangitis

22. Differential diagnoses • Gallstone pancreatitis

23. Diagnostic evaluation • CBC • SGPT, SGOT • ALP • Bilirubin (direct, indirect, total) • Prothrombin time • APTT • Amylase • Lipase • Ultrasound • Serum electrolytes (Na, K, Cl) • Urinalysis

24. LGBP Ultrasound • Gallstone with cholecystitis • Dilated common bile duct

25. Acute cholangitis • One 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

26. Clinical presentation • Mild, intermittent and self-limited to fulminant, potentially life-threatening septicemia • Most common: Charcot’s triad (2/3) • Fever • Epigastric/ RUQ pain • Jaundice • Reynold’s pentad • Septic shock • Mental status changes • On abdominal examination, the findings are indistinguishable from those of acute cholecystitis

27. Tokyo Guidelines • A. Clinical context/ manifestations • History of biliary disease • Fever ± chills • Jaundice • Abdominal pain (RUQ/epigastric) • B. Laboratory data • Evidence of inflammation • WBC, CRP • Abnormal LFTs • ALP, GGT, AST, ALT • C. Imaging • Biliary dilatation or evidence of etiology • Stricture, stone, stent • Suspected Dx: • >2 in A • Definitive Dx: • Charcot’s triad • >2 in A + both B and C

28. Tokyo Guidelines • Mild • (+) response to medical treatment • General supportive care and antibiotics • Moderate • No response to medical treatment • No onset of organ dysfunction • Severe • No response to medical treatment • (+) Onset of organ dysfunction • CVD: BP, need for vasopressors • Nervous: consciousness • Respiratory: PaO2/FiO2 <300 • Kidney: Creatinine > 2 mg/dL • Liver: PT-INR >1.5 • Hematologic: Platelets <100

29. Management • Endoscopic retrograde cholangiopancrea-tography (ERCP)

30. Management • Laparoscopic cholecystectomy