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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


Er interesting case rounds

Pain..

RLQ = LLQ

7/10 at worst

No radiation

“crampy”

Worse with movement

Pain with BMs (diarrhea)


Er interesting case rounds

  • 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


Er interesting case rounds
LABS

  • Hgb = N

  • WBC = 13.5 (neuts = 11, monocytes 1.2)

  • Lytes = N

  • BG = N

  • Lipase = N


Er interesting case rounds

  • LEs…

  • ALP = N (104)

  • ALT = N (16)

  • GGT = 64 (8-35)

  • Bili T = 46 (0-20)

  • Bili D = 24 (0-7)


Er interesting case rounds

  • 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.”


Er interesting case rounds

  • 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


Er interesting case rounds

  • 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


Er interesting case rounds


Er interesting case rounds


Er interesting case rounds

  • Stool C + S = negative

  • Stool O + P = negative

  • Hep Serology = negative

  • C. diff = negative

  • Stool Fat Globules = negative


Er interesting case rounds

  • 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


Er interesting case rounds

  • Culture results:

  • Streptococcus milleri (heavy)

  • B fragiles (moderate)

  • E. Coli (scant)

  • NAAT:

  • Negative for both Chlamydea and Gonorrhea