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HB Morning Report


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  • 1. Title: The Oxbow (View from Mount Holyoke, Northampton, Massachussetts, after a Thunderstorm)
    Artist: Thomas Cole
    Date: 1836
    Source/ Museum: The Metropolitan Museum of Art, New York
    Medium: oil on canvas
    Size: 51 1/2 x 76" (1.31 x 1.94 m)
  • 2. HC Morning Report
    Cathy Larrain, MD, PGY2
    Cooper University Hospital
    November 4, 2009
  • 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.
    (+)tactile fever/chills
    unspecified weight loss over the past 4-5 mos.
    mild dyspnea
    shoulder pain
    epigastric fullness and sensation of tightness
    admits to using acetaminophen for URI and HA
  • 4. Denies tobacco or illicit drug use, (+)social alcohol use
    Works at a post office
    No known drug allergies
    Home medications: antihypertensives, Metformin, medication for cholesterol
    Family history: Mother died @75 y.o. from lung cancer. Otherwise noncontributory
  • 5. Differential Diagnoses
  • 6. Infectious Disorders (Specific Agent)
    Viral hepatitis
    Yellow fever
    Cirrhosis, syphilitic (Heparlobatum)
    Adenocarcinoma, ampulla of Vater
    Metastatic liver disease
    Adenocarcinoma, pancreatic
    Carcinoma, gallbladder
    Carcinoma, biliarytree
    Allergic, AutoImmuneDisorders
    Autoimmune hepatitis (Plasma cell)
    Cirrhosis, Primary Biliary
    Hereditary Disorders
    Cirrhosis/childhood Indian type
    Reference to Organ System
    Cirrhosis, cryptogenic
    Drug Induced
    Toxic hepatitis
  • 7. Physical Examination
    T 98.6, HR 67, BP 88/58, RR 12, SaO2 96% on RA
    NAD, AAOx3 with diffuse jaundice and scleralicterus, PERRLA, NC/AT
    No palpable LAD, supple neck, depressed JVP
    CTAB bilaterally no r/r/w, RRR no m/r/g
    Abd soft (+)BS (-)Murphy’s (+)hepatomegaly, ND, NT
    No c/c/e, no asterixis
  • 8. Laboratory and Imaging
    Albumin 3.2 {3.5-5.3}
    AlkPhos495 {39-117}
    Totalprot 6 {5.9-8.3}
    SGPT (ALT) 118 {0-40}
    SGOT (AST) 122 {0-37}
    Totalbili27.4 {0-1}
    Directbili20.3 {0-0.3}
    Influenza A&B (-)
    AG 16.8
    Amylase 60 {15-120}
    Lipase 30
    Ammonia 75 {28.2-80.4}
    GGT 199 {8-69}
    CK 180 {40-172}
    TnI 0.24 {0.01-0.4}
    Ca 8.2
  • 9. 10/28 Blood culture E.coli
    10/29 Blood culture E.coli
    10/29 Urine culture <10,000 cfu/ml mixed gram positive organisms, probable contamination
    UA negative
    UDS negative
  • 10. Electrocardiogram: NSR 80 bpm, left axis deviation
    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.
  • 11. Underaeration
    Patchy parenchymal opacities may represent atelectasis. Infectious vs inflammatory process cannot be excluded
  • 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.
  • 13. CBD 5-6 mm distal CHD 8 mm
    6 mm impacted calculus within the distal duct
    Biliarysphincterotomy was performed with stone removal
    10-Fr 7 cm biliaryendoprosthesis was placed for complete drainage of contrast
    Normal pancreatic duct
  • 14. Acute Cholangitis
  • 15. Charcot’s triad: RUQ pain, fever with chills, jaundice
    Usually in the setting of biliary obstruction
    Bacteremia and shock are common
    Medical emergency with high morbidity and mortality
    ERCP is an established mode of treatment
    The cause of biliary obstruction may influence the outcome, with malignant biliary obstruction having a worse prognosis
    Malnutrition, weakened immunity, effects of chemotherapy and the malignancy itself
  • 16. Primary SclerosingCholangitis
    Cholestatic liver disorder characterized by inflammation, fibrosis, eventual obliteration of the extrahepatic and intrahepatic bile ducts
    Middle aged men
    Presentation of jaundice, hepatomegaly, pruritis, weight loss, and fatigue
    Associated with IBD (70% with UC) and cholangiocarcinoma (6-20% patients)
    May progress to cirrhosis and ESLD
    Should be considered in individuals with IBD and increased AP
    Confirmation by ERCP or MRCP +/- liver biopsy
  • 17. Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6.
    Acute cholangitis associated with bile duct stones carries a considerable morbidity and mortality.
    Conservative treatment with antibiotics is effective in only 80% of cases.
    20% of patients who developed suppurativecholangitis do poorly without drainage.
    This is because complete bile duct obstruction affects the excretion and penetration of antibiotics into bile.
    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
  • 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.
    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.
    Methods: Endoscopic techniques were used to decompress bile ducts obstructed by stones (898 patients) or stenosis (49 patients).
    Endoscopic sphincterotomy (ES) was performed in 839 patientswith either 7-Fr stents or nasobiliary tubes.
    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.
    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%.
    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.
  • 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.
    Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliarysphincterotomynot without risk.
    Complications occur in about 10% of patients
    2 to 3% have a prolonged hospital stay, with a risk of mortality
    Emphasis on the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues
  • 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
  • 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.
    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.
  • 22.
  • 23. References
    Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest. Endosc. 1991; 37: 383-91
    Lai EC, Mok FP, Tan ES et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 1992; 326: 1582-6.
    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.
    Washington Manual pp. 385, 460-61, 489-90.
  • 24. The End
  • 25. Title: Under the Birches
    Artist: Pierre-Étienne-Théodore Rousseau
    Date: 1842-1843
    Source/ Museum: Toledo Museum of Art, Ohio
    Medium: oil on wood panel
    Size: 16 5/8 x 25 3/8" (42.2 x 64.4 cm)
  • 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.
    The aim of this study is to assess the role of CA 19-9 in patients with a cholangiocarcinoma without PSC.
    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.
    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).
    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