DUTY REPORTEMERGENCY ROOM29TH MAY 2015ACUTE ABDOMEN WITH OBSTRUCTIVE JAUNDICE CAUSED BY SUSPECTED CHOLEDOCHOLITHIASISUNCONTROLLED GRADE II ESSENTIAL HYPERTENSION

GP on duty: dr. Karen Pandhika & dr. Husnah

Co-ass on duty: Raymond Pranata & Grace Fonda

Supervisor : dr Soroy Lardo SpPD FINASIM

PPDS FKUI

Department Of Internal Medicine

Indonesia Army Central Hospital Gatot Soebroto

RECAPITULATION

1. Mr. Y GERD

2. Mrs. S Abdominal pain in jaundice e.c. cholecystitis

3. Mr. Y dyspnea e.c. suspect COPD

4. Mr. B polycythemia vera

5. Mrs. S dyspepsia + herpes zoster infection

6. Mr. S dyspnea e.c. acute asthma exacerbation

7. Mr. G dyspnea e.c. acute asthma exacerbation +

neurodermatitis + Hepatitis C

8. Mrs. M acute psychosis

9. Ms. G acute gastroenteritis e.c. viral infection

10. Ms. S acute gastroenteritis e.c. suspect food intoxication

PATIENT’S IDENTITY

Name : Mrs. S Age : 61 y.o Occupation : housewife Medical record No : 09-51-xx Address :

ANAMNESIS

Alloanamnesis with patient’s daughter

Chief complaint:

Abdominal pain since 1 week before admission

Additional complaint:

Jaundice

Pale color stool

Dark color urine

1 week before admission

• Sudden onset abd. pain, radiating to epigastrium, back and shoulder

• Dark urine color + acholic stool

• Not relieved with antacid

3 days before admission

• Abd. pain persists

• Sclera looked icteric on both eyes

• 2d before admission whole body jaundice

Days of admission

• Abd. pain persists

• Blood test 1d before admission increase liver function test and bilirubin

HISTORY OF PRESENT ILLNESS

Abdominal pain since 1 week before admission

Site: Right upper quadrant

Onset: sudden at midnight (1 week before admission)

Characteristic: sharp, stabbing

Radiation: to epigastrium, back, and shoulder

Not improve with antacid or food, not relieved by defecation

Continuous throughout the day and interfere with daily

activities

Getting worse with activity and deep inspiration

Weight loss (-)

Associated symptoms:

Jaundice

Sclera 3 days

before admission

Whole body 2 days before admission

Pruritus (-)

Dark urine color (‘tea’ color)

Onset: 1 week

before admission

Frequency: no

changes

No blood, painless

Pale color

stool

Onset: 1 week

before admission

Consistency: no

changes

Blood (-), mucus

(-), steatorrhea (-)

Tenesmus (-), foul

smell (-)

History of other systemic illnesses:

Uncontrolled hypercholesterolemia

Uncontrolled hypertension with BetaBlock™

High uric acid controlled without drug

Habits:

Frequent consumption of fried and oily food

Alcohol bingeing (-)

Smoking (-)

NSAID use (-)

History of past illnesses (including surgery)

Appendectomy at year 2009

Cataract surgeries on both eyes

Patient had once been admitted to hospital because of

abnormally high blood cholesterol and cardiomegaly

History of family illnesses

DM (-)

Hypertension (+) in both parents

Cardiovascular disease (+) in father at age 50

Cerebrovascular disease (-)

Kidney disease (-)

Hypercholesterolemia (-)

Allergy (-), Asthma (-)

PHYSICAL EXAMINATION

General Examination

General condition: moderately ill

State of consciousness: compos mentis

Vital signs:

Blood Pressure : 150/80 mmHg

Heart rate : 98 bpm

Respiratory : 22x/minute

Temperature : 36,7oC

Body weight : 82 kg

Body height : 165 cm

Body mass index :

Head : normocephal

Eye : sclera icteric +/+, pale conjunctiva -/-

ENT : nasal flare (-), discharge (-), blood (-),

hyperemic pharynx (-)

Mouth : moist lip, papillary atrophy (-)

Neck : JVP 5+1cmH2O

Skin : generalized jaundice

Thorax

Pulmonary examination

Inspection: normochest, symmetrical lung movement, scar (-)

Palpation: symmetrical chest expansion and vocal fremitus,

mass (-), tenderness (-)

Percussion: sonor at both lung field

Auscultation: VBS +/+, no additional breath sound

Cardiac examination

Inspection: ictus cordis not visible

Palpation: ictus cordis not palpable

Percussion: right cardiac border at ICS IV right parasternal line,

left cardiac border at ICS V left mid-clavicular line, upper border

at ICS III left parasternal line

Auscultation: normal S1/S2 regular, no murmur, no gallop

Abdomen

Inspection: flat, jaundice, no venous engorgement

Auscultation: bowel sound (+) 8 times per minute

Percussion: tympanic on four abdominal quadrant,

shifting dullness (-)

Palpation: supple, tenderness (+) on epigastrium and

RUQ, (+) rebound tenderness in RUQ, Murphy sign (+),

splenomegaly (-), liver palpation was not done due to

tenderness, fluid wave (-)

Extremities: CRT <2 seconds, warm distal extremities, no

edema, no deformities, jaundice

LABORATORY EXAMINATION

ExaminationResult

Reference Range28/5/2015 29/5/2015

Hemoglobin 12.5 12.7 12 – 16 g/dL

Hematocrit 38.3 37 37 – 47%

Leukocyte 14,500 13,190 4,800 – 10,800/uL

Thrombocyte 312,000 262,000 150,000 – 400,000/uL

Bleeding Time 1 1 – 3 minutes

Clotting time 9 7 – 15 minutes

Random Blood Glucose

96 102 70 – 18 mg/dL

Kidney function

Ureum 17.5 17 <48 mg/dL

Creatinine 0.8 0.5 0.45 – 0.75 mg/dL

ExaminationResult

Reference Range28/5/2015 29/5/2015

Liver Function

Total bilirubin 10.94 10.5 0.1 – 1.0 mg/dL

Direct Bilirubin 8.49 0 – 0.2 mg/dL

Indirect bilirubin 2.46 0.1 – 0.7 mg/dL

Alkaline Phosphatase 337 30 – 120 U/L

AST (SGOT) 148 153 <35 U/L

ALT (SGPT) 195 131 <35 U/L

Gamma GT 774 0 – 30 U/L

Electrolyte

Sodium 141.5 142 135 – 147 mmol/L

Potassium 3.99 4.3 3.5 – 5.0 mmol/L

Chloride 101.5 107 95 – 105 mmol/L

Abdominal ultrasonography (23/05/2015 at

Ananda Hospital, Bekasi)

Thickening of gallbladder wall (thickness: 6,5mm)

Sludge (+)

Suggestive of cholecystitis

RESUME

Patient, 61 y.o female came with chief complaint of RUQ

abdominal pain radiating to epigastrium, back, and shoulder

since 1 week before admission. No fever. Nausea (+), vomit (-).

Dark color urine (+), acholic stool (+). Jaundice (+) since 3 days

before admission. History of hypercholesterolemia, uncontrolled

hypertension, high uric acid.

PE: high BP, generalized jaundice (+), (+) tenderness on

abdominal palpation, rebound tenderness on RUQ, Murphy

sign (+), ascites (-)

Lab: leukocytosis, direct hyperbilirubinemia, increased

ALT/AST/ALP/GGT

Abd. Ultrasound suggestive of cholecystitis

LIST OF PROBLEMS

Acute abdomen

Jaundice with direct hyperbilirubinemia and

elevated liver function test

Uncontrolled grade II hypertension

Suspected hypercholesterolemia (?)

Suspected hyperuricemia (?)

WORKING DIAGNOSIS

1. Acute abdomen with obstructive jaundice caused

by suspected choledocholithiasis

2. Uncontrolled grade II essential hypertension

Differential diagnosis:

3. Acute abdomen with obstructive jaundice caused

by suspected cholecystitis dd/ ascending

cholangitis

Findings Cholecystitis Choledocholithiasis

RUQ pain radiates to the back

+ +

Fever + +

Nausea and vomiting

+ +

Jaundice - +

Dark color urine - +

Acholic stool - +

Elevated liver enzyme

- to + +

Elevated bilirubin + ++

Elevated lipase - +

RECOMMENDATION

Further examination:

ERCP + US of biliary tree to see the presence of

common bile duct stone

Serum lipase

Funduscopy: to exclude hypertensive retinopathy

Chest x-ray

ECG LVH (?), arryhthmia (?)

Urinalysis bilirubin, protein (nephropathy?)

Lipid profile dyslipidemia (?)

Serum uric acid hyperuricemia(?)

TREATMENT

Cholecystitis

IVFD NaCl 0.9% 20 drips per minute

Ketorolac 1x30 mg IV

Ondansetron 1x8 mg IV

Ceftriaxone 1x2 gram IV

Urdafalk 3x1 cap PO

Consult gastroentero-hepatologist, digestive surgeon

Hypertension

Captopril 1x25 mg per day PO

Continue beta-blocker medication

Monitor daily blood pressure

Suspected hypercholesterolemia (?)

Atorvastatin 1x20 mg per day PO

Suspected hyperuricemia (?)

Serum uric acid level (?)

Source: Lange Symptoms to Diagnosis, 2nd ed. 2009

Source: Tintinalli Emergency Manual

PITFALLS

1. Dilated CBD or CBD stone is seen in only 25%

of patients via trans-abdominal ultrasound

2. ERCP, MRCP and EUS are highly accurate in

detecting CBD stones (sensitivity 90-100%,

specificity 90-100%)

3. Jaundice and marked elevation of liver enzymes

are seen only if the stone migrates into the

CBD and causes obstruction

Source: Lange Symptoms to diagnosis, 2nd ed. 2009

No clinical finding is sufficiently sensitive to rule out

cholecystitis.

1. Fever: present in 35% of patients

2. Murphy sign

Sensitivity, 65%; specificity, 87%

LR+ = 5.0, LR− = 0.4

Laboratory findings:

3. Leukocytosis (> 10,000/mcL) 63% of patients.

4. Cholecystitis does not typically cause significant

increases in lipase complications of pancreatitis and

choledocholithiasis.

Ultrasound

1. Acute cholecystitis gallstones with gallbladder wall

thickening, pericholecystic fluid, sonographic Murphy sign,

or gallbladder enlargement >5 cm

2. Sensitivity, 88%; specificity, 80%

3. Cholescintigraphy (HIDA) scans

Nonvisualization of the gallbladder cystic duct obstruction and

is highly specific for acute cholecystitis (97% sensitive, 90% specific).

Nonvisualization can also be seen in prolonged fasting,

hepatitis, and alcohol abuse.

Useful when the pretest probability is high and the

ultrasound is nondiagnostic

Visualization of the gallbladder excludes acute cholecystitis.

Source: UpToDate, Treatment of Acute Cholecystitis

Decompression of the biliary system (preferably

via ERCP):

Emergently done in patient w/ persistent pain,

hypotension, altered mental status, persistent high

fever, WBC <20,000/uL, bilirubin >10 mg/dL

Electively in more stable patient

Source:Kaplan’s Clinical Hypertension (2010)

Source:

Kaplan’s Clinical Hypertension (2010)

PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad sanationam : dubia ad bonam

Quo ad functionam : dubia ad bonam

THANK YOU