ER Interesting Case Rounds

1. ER Interesting Case Rounds

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

3. Pain.. RLQ = LLQ 7/10 at worst No radiation “crampy” Worse with movement Pain with BMs (diarrhea)

4. Diarrhea… • Non-bloody • 3-4x/day • “mucousy” • No PV symptoms • No urinary symptoms

5. Physical Exam • Vitals = normal • Chest = clear • CV = normal • Abdo = • Tender to direct palpation. RLQ = LLQ • No rebound/guarding etc. • No mass

6. LABS • Hgb = N • WBC = 13.5 (neuts = 11, monocytes 1.2) • Lytes = N • BG = N • Lipase = N

7. LEs… • ALP = N (104) • ALT = N (16) • GGT = 64 (8-35) • Bili T = 46 (0-20) • Bili D = 24 (0-7)

8. 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”

9. 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.”

10. Repeat labs • Bili 29 (down from 46) • GGT 56 (down from 64) • WBCs 12.2 (down from 13.5) • K = 3.4 • Dx: “gastroenteritis”

11. Visit #3 • Returns 5 days later… • Persistent diarrhea • Malaise • ABDO PAIN!! • 9 lb wt loss in 10 days

12. OTHER HX? • No travel • No well water exposure • No recent ABX • No sick contacts • No exposure to uncooked meats

13. 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

14. VS: HR 100, Temp 38 • ABDO= • Tender lower quadrants • Rebound • Involuntary guarding • +RUQ pain

15. WBC: 19.9 (neuts 13, bands 4.2) • GGT 109 • ALP 175 • Bili T = 23

16. Stool C + S = negative • Stool O + P = negative • Hep Serology = negative • C. diff = negative • Stool Fat Globules = negative

17. 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

18. DIAGNOSIS???

19. 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.

20. 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

21. 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

22. Diagnosis • RULING IN pelvic inflammatory disease • RULING OUT other causes of RUQ pain +/or elevated liver enzymes

23. Pathogenesis Multiple Theories: • Direct Infection of Liver? • Hematogenous Spread? • Lymphatic Spread? • Exaggerated Immune Response?

24. How Common? • Studies show broad ranges • 4%-27% of patients with PID • RISK FACTORS: • IUDs, pelvic surgery, multiple partners, lack of barrier protection etc.

25. 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)

26. Atypical Presentations • Ileus/obstruction • Peri-splenitis • Peri-appendicitis • Fitz-Hugh-Curtis in a male • Chilaiditi syndrome • Ovarian Ca • Perforated Ulcer • Pleural effusion

27. 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

28. 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

29. 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

30. 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.)

31. 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

32. 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

33. Complications • Those of PID: • Infertility • Adhesions • Chronic pain • Ectopic pregnancy • Reiter’s syndrome

34. Culture results: • Streptococcus milleri (heavy) • B fragiles (moderate) • E. Coli (scant) • NAAT: • Negative for both Chlamydea and Gonorrhea