HB Morning Report


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HB Morning Report

  1. 1. Title: The Oxbow (View from Mount Holyoke, Northampton, Massachussetts, after a Thunderstorm)<br />Artist: Thomas Cole<br />Date: 1836<br />Source/ Museum: The Metropolitan Museum of Art, New York<br />Medium: oil on canvas<br />Size: 51 1/2 x 76" (1.31 x 1.94 m)<br />
  2. 2. HC Morning Report<br />Cathy Larrain, MD, PGY2<br />Cooper University Hospital<br />November 4, 2009<br />
  3. 3. 75 y.o. M with a history of DM, HTN, HPL, BPH presents with 5 days of painless jaundice, nausea, epigastric fullness, and tactile fever/chills.<br />ROS:<br />(+)tactile fever/chills<br />unspecified weight loss over the past 4-5 mos.<br />mild dyspnea<br />shoulder pain<br />epigastric fullness and sensation of tightness<br />admits to using acetaminophen for URI and HA<br />
  4. 4. Denies tobacco or illicit drug use, (+)social alcohol use<br />Works at a post office<br />No known drug allergies<br />Home medications: antihypertensives, Metformin, medication for cholesterol<br />Family history: Mother died @75 y.o. from lung cancer. Otherwise noncontributory<br />
  5. 5. Differential Diagnoses<br />
  6. 6. Infectious Disorders (Specific Agent)<br />Viral hepatitis<br />Leptospirosis<br />Yellow fever<br />Cirrhosis, syphilitic (Heparlobatum)<br />NeoplasticDisorders<br />Adenocarcinoma, ampulla of Vater<br />Metastatic liver disease<br />Adenocarcinoma, pancreatic<br />Carcinoma, gallbladder<br />Carcinoma, biliarytree<br />Allergic, AutoImmuneDisorders<br />Autoimmune hepatitis (Plasma cell)<br />Cirrhosis, Primary Biliary<br />Hereditary Disorders<br />Cirrhosis/childhood Indian type<br />Reference to Organ System<br />Cirrhosis<br />Cirrhosis, cryptogenic<br />Drug Induced<br />Toxic hepatitis<br />
  7. 7. Physical Examination<br />T 98.6, HR 67, BP 88/58, RR 12, SaO2 96% on RA<br />NAD, AAOx3 with diffuse jaundice and scleralicterus, PERRLA, NC/AT<br />No palpable LAD, supple neck, depressed JVP<br />CTAB bilaterally no r/r/w, RRR no m/r/g<br />Abd soft (+)BS (-)Murphy’s (+)hepatomegaly, ND, NT<br />No c/c/e, no asterixis<br />
  8. 8. Laboratory and Imaging<br />Albumin 3.2 {3.5-5.3}<br />AlkPhos495 {39-117}<br />Totalprot 6 {5.9-8.3}<br />SGPT (ALT) 118 {0-40}<br />SGOT (AST) 122 {0-37}<br />Totalbili27.4 {0-1}<br />Directbili20.3 {0-0.3}<br />Indirectbili7.1<br />Influenza A&B (-)<br />AG 16.8<br />Amylase 60 {15-120}<br />Lipase 30<br />Ammonia 75 {28.2-80.4}<br />GGT 199 {8-69}<br />CK 180 {40-172}<br />TnI 0.24 {0.01-0.4}<br />Ca 8.2<br />12.7<br />127<br />92<br />37<br />38.2<br />17.8<br />18.2<br />322<br />125<br />2.8<br />21<br />1.32<br />1.5<br />36.2<br />
  9. 9. 10/28 Blood culture E.coli<br />10/29 Blood culture E.coli<br />10/29 Urine culture <10,000 cfu/ml mixed gram positive organisms, probable contamination<br />UA negative<br />UDS negative<br />
  10. 10. Electrocardiogram: NSR 80 bpm, left axis deviation<br />CT abdomen and pelvis: severe heterogeneity of liver consistency with hepatocellular disease vs infiltrating malignancy. Intrahepatic & extrahepaticbiliary duct dilation with possible calculus in distal CBD. Limited evaluation of gallbladder with possible pericholecystic fluid. Enlarged prostate.<br />
  11. 11. Underaeration<br />Patchy parenchymal opacities may represent atelectasis. Infectious vs inflammatory process cannot be excluded<br />
  12. 12. Sludge and tiny stones presumably filling GB lumen and extending into normal caliber CBD. Top size normal liver with mildly heterogeneous echogenicity. Trace perinephric fluid on left. Bilateral pleural effusions.<br />
  13. 13. CBD 5-6 mm distal CHD 8 mm<br />6 mm impacted calculus within the distal duct<br />Biliarysphincterotomy was performed with stone removal<br />10-Fr 7 cm biliaryendoprosthesis was placed for complete drainage of contrast <br />Normal pancreatic duct<br />
  14. 14. Acute Cholangitis<br />
  15. 15. Charcot’s triad: RUQ pain, fever with chills, jaundice<br />Usually in the setting of biliary obstruction<br />Bacteremia and shock are common<br />Medical emergency with high morbidity and mortality<br />ERCP is an established mode of treatment<br />The cause of biliary obstruction may influence the outcome, with malignant biliary obstruction having a worse prognosis<br />Malnutrition, weakened immunity, effects of chemotherapy and the malignancy itself<br />
  16. 16. Primary SclerosingCholangitis<br />Cholestatic liver disorder characterized by inflammation, fibrosis, eventual obliteration of the extrahepatic and intrahepatic bile ducts<br />Middle aged men<br />Presentation of jaundice, hepatomegaly, pruritis, weight loss, and fatigue<br />Associated with IBD (70% with UC) and cholangiocarcinoma (6-20% patients)<br />May progress to cirrhosis and ESLD<br />Should be considered in individuals with IBD and increased AP<br />Confirmation by ERCP or MRCP +/- liver biopsy<br />
  17. 17. Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6.<br />Acute cholangitis associated with bile duct stones carries a considerable morbidity and mortality.<br />Conservative treatment with antibiotics is effective in only 80% of cases. <br />20% of patients who developed suppurativecholangitis do poorly without drainage.<br />This is because complete bile duct obstruction affects the excretion and penetration of antibiotics into bile.<br />Retrospective analysis, as well as prospective randomized controlled trials, have shown that urgent endoscopic drainage is an effective treatment for suppurativecholangitis and is superior to surgical drainage with a better clinical outcome<br />
  18. 18. Siegel JH, Rodriguez R, Cohen SA, Kasmin FE, Cooperman AM. Endoscopic Management of Cholangitis: Critical Review of an Alternative Technique and Report of a Large Series. American J Gastroenterology. 2008; 89 (8): 1142-46.<br />Objective: To assess the outcome of endoscopic techniques as the solitary treatment modality for the complete management of ascending, bacterial cholangitis, compared with results of radiological and surgical methods as historical controls.<br />Methods: Endoscopic techniques were used to decompress bile ducts obstructed by stones (898 patients) or stenosis (49 patients). <br />Endoscopic sphincterotomy (ES) was performed in 839 patientswith either 7-Fr stents or nasobiliary tubes.<br />Of these latter patients, 68 subsequently underwent ES and stone removal, 17 had ES, litho-tripsy, and stone removal, 18 were left with stents in place, and 5 were lost to follow-up. Follow-up was conducted by direct patient contact, by telephone, or through the referring physicians. <br />Results: All patients were managed by endoscopic techniques. There were four deaths (0.42%) in the first 30 days (none before 2 wk); no deaths were related to the procedures but were attributed to intercurrent medical problems. Two patients underwent surgery: one pancreatitis, one perforation. Complications were infrequent, occurring in 6% of patients. Bleeding occurred in 3%, pancreatitis in 2.8%, and perforation 0.2%.<br />Conclusions: Endoscopic management of cholangitis is as effective as surgical or radiological methods for managing bacterial cholangitis, a potentially fatal syndrome, but ERCP and ES have been shown to be safer. Endoscopy is the preferred index technique both for establishing a definitive diagnosis and providing therapy.<br />
  19. 19. Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest. Endosc. 1991; 37: 383-91.<br />Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliarysphincterotomynot without risk.<br />Complications occur in about 10% of patients<br />2 to 3% have a prolonged hospital stay, with a risk of mortality<br />Emphasis on the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues<br />
  20. 20. Mirizzi syndrome is a rare complication of cholelithiasis, characterized by the narrowing of the common hepatic duct as a result of mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct <br />
  21. 21. Polson J, Wians FH Jr., Orsulak P, et al. False positive acetaminophen concentrations in patients with liver injury. Clinica ChimicaActa. 2008; 391 (1-2): 24-30.<br />False positive acetaminophen tests may result when enzymatic-colorimetric assays are used, most commonly with bilirubin concentrations > 10 mg/dl, leading to potential clinical errors in this setting.<br />
  22. 22.
  23. 23. References<br />Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest. Endosc. 1991; 37: 383-91<br />Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6.<br />Polson J, Wians FH Jr., Orsulak P, et al. False positive acetaminophen concentrations in patients with liver injury. Clinica ChimicaActa. 2008; 391 (1-2): 24-30.<br />Washington Manual pp. 385, 460-61, 489-90.<br />
  24. 24. The End<br />
  25. 25. Title: Under the Birches<br />Artist: Pierre-Étienne-Théodore Rousseau<br />Date: 1842-1843<br />Source/ Museum: Toledo Museum of Art, Ohio<br />Medium: oil on wood panel<br />Size: 16 5/8 x 25 3/8" (42.2 x 64.4 cm)<br />
  26. 26. John AR, Haghighi KS, Taniere P, Esmat ME, Tan YM, Bramhall SR. Is a raised CA 19-9 level diagnostic for a cholangiocarcinoma in patients with no history of sclerosingcholangitis? Dig Surg. 2006; 23 (5-6): 319-24.<br />The aim of this study is to assess the role of CA 19-9 in patients with a cholangiocarcinoma without PSC.<br />METHODS: The prospectively collected information on patients with biopsy-proven cholangiocarcinomas who had the CA 19-9 level measured was obtained (n = 68) from our computer database and medical records. These patients were compared with patients who had benign liver tumors (n = 25) and benign bile duct strictures (n = 13) who also had their CA 19-9 concentration measured.<br />RESULTS: Sensitivity and specificity of CA 19-9 in the diagnosis of a cholangiocarcinoma were 77.9 and 76.3%, respectively, when using a cut-off value of 35 kU/l, while sensitivity and specificity were 67.5 and 86.8%, respectively, when the cut-off value was raised to 100 kU/l. The specificity was found to be higher in patients with peripheral cholangiocarcinomas (96%) using a CA 19-9 cut-off value >100 kU/l. A CA 19-9 value >600 kU/l was associated with non-resectabletumors (p = 0.05).<br />CONCLUSIONS: This study demonstrates that CA 19-9 is a useful adjunct in the diagnosis of cholangiocarcinomas without primary sclerosingcholangitis, especially in the diagnosis of peripheral cholangiocarcinomas. However, it does not provide a reliable guide for the pathological staging of these tumors<br />