Morning Report !! Friday the 13 th …. AAAaaah !!!. Speaks English !! . CASE.
Friday the 13th …. AAAaaah !!!
65 Years old Chinese woman presented to the ED for severe Abdominal pain !! Abdominal pain : Colicky intermittent severe, estimated 8/10 started progressively over 4 hours PTA diffuse Nausea Vomiting Fever Diarrhea Chest pain
Ask me questions !
65 Years old Chinese woman presented to the ED for severe Abdominal pain !!PMH: Medications: HTN Aspirin DM Lisinopril PVD MetforminSH:Somking 2 PPD “since I was born” ETOH Occasionally (which turned out to be every other day !!!)Sexual Activity Active, no protection, multiple partners (“Why are you asking ? “)
Ironically, she watches her diet and exercise !!!
65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Physical Exam: Vitals BP: 164/85 HR: 89 RR: Cooper 20 PO2: 96% Abdominal exam:Bowel sounds present and symmetric Soft Abdomen Mildly tender to palpation Mildly Distended No Guarding No Rebound Tenderness Negative Murphy / Negative McBurney’s
Ask me details… if needed !
65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Labs: CBC LFTs Normal WBC 14.000 Amylase Normal Hb 15.1 Lipase Normal Platelets 365.000 INR Normal Chem7 Na 138 Cl 98 BUN 16 K 5.4 Co2 20 Creat 1.2 Glucose 89
Reflex Cooper ED Lactate: 0.9
65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Imagery: Abdominal CT Dilated and Thickened loops of small bowel Mild AscitesSubobstructionECG T wave Inversions in Lateral leads
What do you wana do next ?
65 Years old Chinese woman presented to the ED for severe Abdominal pain !!In ED: GI consult Surgery Consult => No surgical issues Cardiology Consult => No cardiac issues(Enzymes were pending) Patient was transferred to the DUMPING ZONE => Medicine !
Fortunately for the patient…
Differential Diagnosis ?
65 Years old Chinese woman presented to the ED for severe Abdominal pain !!On Medicine floor: The following day… Pain is improved No more nausea/vomiting VS , Physical exam and Labs unchangedBUT… New Lower lips edema… huge… not present on admission… Associated tongue edema… No Urticaria or rash No Itching
What the… diagnosis… is going on ?
65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Final Diagnosis: ANGIOEDEMA secondary to Ace Inh !!C4 level and C1 inhibitor were normalLisinopril was stopped… switched to Diovan.Patient clinically improved and was d/c
GAME OVER !
2 types of Angioedema: 1. Mast cell-mediated Allergic Reactions (IgE-mediated) Direct mast cell release (Opiates, Contrast…) Aspirin and NSAIDs Chronic Urticaria 2. Bradykinin-mediated Ace Inhibitors (ACE degrades Bradykinin…) ARB ( small chance…) Hereditary and acquired angioedema (Young age…) Estrogen (Weird ! )
ARB ? … The patient will be back soon !!
Anatomic Sites: Larynx Skin and Mucous membranes Bowel wallDiagnosis: Clinically (HISTORY +++)Physical Exam: Look for signs of AllergiesLabs: CBC , Chem7 , LFTs , C4 , C3
Labs are normal in majority of cases !
Differential Diagnosis of CutaneousAngioedema: Contact Dermatitis Cellulitis and Erysipelas Facial Lymphedema Autoimmune conditions Eyelid Edema Parasitic Infections Hypothyroidism Hyperthyroidism SVC syndromeCheilitisgranulomatosa and Mekersson-Rosenthal syndrome Idiopathic edema
What’s Mekersson-Rosenthal syndrome ?
TREATMENTAngioedema in or near the airway Airway managementAngioedema in anaphylaxis IM epi O2 IVF Acute allergic Angioedema H1 & H2 blockers, Steroids C1-Inh Deficiency (Hereditary Angio) Purified C1 inh Concentrate FFP, Bradykinin B2recep inh Ace inh & ARB induced Angioedema Discontinuation of drug
Antihistamines and glucocorticoids will likely be ineffective if the angioedema is bradykinin-mediated !!