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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 l.jpg

WINNING THE BATTLE

BUT LOSING THE WAR

A Brief Case Presentation

Michael Caselnova, M.D.


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GOALS

  • Case presentation

  • Brief review of diagnoses encountered

  • Lessons learned

  • Recommendations to improve care


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The Case

  • Day 0

  • 67 y/o WM presented to another facility with:

    • Abdominal pain

    • Hypotension

    • Diaphoretic

    • “pale”


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ADDITIONAL FINDINGS

  • CT abdomen showed:

    • 7 cm AAA with large retroperitoneal hematoma

  • PMH significant for coronary stent


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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


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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


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Procedure

  • “EMERGENCY LIFE SAVING REPAIR OF ABDOMINAL AORTIC ANEURYSM”

  • 18 mm straight dacron tube graft


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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


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Received

  • 15 units PRBC

  • 10 units FFP

  • 20 units cryoprecipitate

  • Platelets

  • TPN post op


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Preliminary Dx

  • Ischemic colitis from profound hypotension

  • Needs CT w contrast but Azotemic

  • AFP requested (later came back normal)


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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


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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


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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


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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


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POD 18

  • Discharged to ECF in outlying city

  • Fluconazole for 30 days po

  • Pip/tazo for one more week

  • BATTLE WON!

  • BUT…..


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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


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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


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  • 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


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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


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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


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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


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POD 47

  • Pt expired

  • Final Dx on liver Bx was primary malignant liver neoplasm-report signed on POD 54

  • LOST THE WAR


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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


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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


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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


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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


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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


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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


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ISCHEMIC COLITISTX

  • Surgical intervention if clinical worsening

  • Surgical intervention for colonic infarction

  • Generally surgery performed without prep


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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


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Primary hepatocellular carcinoma

  • Most common metastase are to lung, intraabdominal lymph nodes, bone, adrenal gland


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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


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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


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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


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LESSONS LEARNED

  • TRY TO GET CONSULTING HOSPITALIST TO DO DISCHARGE SUMMARY AND DEATH CERTIFICATE

  • JUST KIDDING!


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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


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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


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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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