Wednesday, May 25, 2005

The abdomen is like a box of chocolates....

On call today, and the old aphorism is true -- it's always bad to be an "interesting patient." A 64 year old obese, hypertensive lady is brought to the ED with 3 days of terrible abdominal pain, nausea, and vomiting. This was described as excruciating, and eventually was bad enough for her to pass out while at the blackjack table at a local casino (she must have been winning to not have come sooner). Denies ETOH use. Heavy NSAID user. On proton pump inhibitors for "years," but denies ever having an upper endoscopy. On iron for recent discovery of anemia, but no other workup to date.

She arrives in the ED with a BP of 70/40, heart rate of 130, diaphoretic, and in pretty obvious distress. Her abdomen is rigid. A quick ultrasound was performed in the ED to rule out a ruptured aneurysm. Blood work showed evidence of somebody who has been sick for at least 24-48 hours --- hemoconcentrated with hemoglobin of 18.5, creatinine of 3.2, liver enzymes in the 200 range, bilirubin 4, lipase 3,000, INR 1.8, myoglobin 1600, white count 10 with a big left shift (and likely on its way down). Almost no urine in her bladder when the foley is placed.

Her BP comes up to the mid 90s with 3 liters of crystalloid. Her CT was done without contrast due to acute renal insufficiency -- the images are therefore harder to interpret. Hope you can make out the arrows:

The first thing I see is a lot of gas in the portal region --- not typical for portal venous air, which tends to be peripheral. On subsequent cuts, this does not appear to be in the biliary tree either.

[1] A few cuts lower, there is extensive air around the duodenal sweep, and the pancreas looks boggy, especially proximally. There is also air in the falciform ligament.

[2] There is extensive air surrounding the head of the pancreas.

[3] The gallbladder wall is indistinct, but it appears normal. As there is no contrast, delineation of the biliary tree is difficult, but there does not appear to be biliary dilatation. Her portal venous system looks reasonable given the constraints of this exam.

By this time, while she is mildly better hemodynamically, this lady is quite sick. Given her history (NSAIDS, recent diagnosis of anemia) her exam (rigid abdomen), and after reviewing the CT with 3 radiologists, we all suspected she had a perforated posterior duodenal ulcer burrowing into the pancreas, with worsening sepsis due to delay in presentation. This would explain to some degree the lack of typical extensive free air on CT, and her sepsis secondary to delay would cause renal failure, hepatic injury, etc.

I was wrong. In the OR, she had a gallbladder that was as green-black as a mile wide tornado, bile tinged fluid throughout the abdomen, necrotic and gas filled fat in the porta hepatis, and evidence of pancreatitis in the head of the pancreas --- but no perforated ulcer. Out came the dead gallbladder, but because of the emphysematous changes around the common bile duct, we opened it as well; it was normal in caliber, and not filled with pus. By this point, the poor anesthesiologist is having conniptions with an unstable patient, so when the cholangiogram shows an impacted distal common duct stone, I decided to simply drain the biliary tree with a T-tube and settle that another day. Two big drains, G-tube, J-tube, and we're off to the ICU.

I have seen emphysematous cholecystitis before, as well as plenty of cholangitis and biliary pancreatitis, but this patient's presentation was certainly unusual. Essentially all of the soft tissue gas was surrounding the common bile duct, duodenum, and pancreas, mimicking a perforated ulcer. Patients with cholangitis do better when treated with ERCP, rather than common duct exploration, but there was no way to stay out of the OR here. She's at least making urine and on less pressor support at this point, but we'll have to see how the next few days go.

UPDATE: I just realized that many of my pictures weren't showing up -- now they're too large! Still struggling with how to put multiple photos in one post using Blogger and Picassa/Hello.

UPDATE: Trying again with photos linked. No surprise -- blood cultures grew Clostridium perfringens within hours of their collection.