Author Archives: Joseph Bales

Acute Cholecystitis, Classic

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Interesting case from a couple weeks ago.

20ish yo white male, no significant past medical diagnoses. Overweight. Family history of gallbladder disease. No OTC or Rx medications. Patient smokes, does not drink, and has used IV drugs in the past.

Here in the ER due to RUQ abdominal pain for one week, was coming and going and is now constant. On further questioning, admits that his mom made him come because of her history of gallstones and cholecystectomy. On exam patient has jaundiced sclera and urine on table is dark brown, pain in right upper quadrant of abdomen is exquisite. States he has been vomiting especially after eating and all food makes him sick. No documented fevers, but feeling chills.

Urine: Large bilirubin, otherwise normal

Pertinent blood: WBC 8.4, Hgb 14.2, Plt 430. Alk Phos 140, AST 734, ALT 1417, Total Bili 9.5. Lipase 22. Tylenol neg.

Didn’t expect this guys ‘acute chole’ to cause liver failure.  Either way, he was getting further imaging to find out more. No ultrasound coverage at 5am so CT for now, then ultrasound at 7am. Added tox screens and hepatitis panel at this time.

CT abdomen/pelvis with contrast: “Markedly thickened/edematous wall of the gallbladder indicating cholecystitis. No calcified stone visualized. Additional imaging maybe obtained with ultrasound.” Also, normal liver.

The results of the ultrasound showed a “nondistended gallbladder with marked wall thickening, edema and a positive sonographic Murphy sign. Given lack of clear visualization of the posterior wall, highly worrisome for complicated cholecystitis, possibly gangrenous or with a focal posterior perforation.” Normal liver and mildly dilated bile duct.

Now with labs showing liver failure and two forms of imaging showing acute cholecystitis, it had to be. Admitted to the general surgery team though the ‘acalculous cholecystitis’ with liver failure was enough to peak my interest in follow-up.

Hepatitis panel comes back later same day showing reactivity for Hep C. Discharge 5 days later, no surgery, no acute interventions, with down-trending liver function panel and follow-up with the GI clinic.

While most commonly associated with cholecystitis, a quick literature search reveals multiple reasons besides cholecystitis to have gallbladder wall thickening… congestive heart failure (right sided), gallbladder carcinoma, adenomyomatosis (chronic gallbladder inflammation or degeneration), renal failure, pancreatitis, cirrhosis and other forms of liver failure.

Case #2

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Case #2:

30 yo F h/o morbid obesity and DM2 not well controlled on insulin and metformin presents after high speed MVA vs pole. 5 month old baby in back carseat sent the the Ped’s ED, unharmed. EMS called, prolonged extrication about 30 min, vitals en route stable, BP 120/76 and HR 96 just PTA (hmm?). No IVs established, axox3, talking, calm and cooperative.

On exam, breath sounds normal, seat belt sign obvious on lower abdomen with mild LUQ abdominal tenderness on exam, main c/o left thigh pain. Appears twisted but unsure if broken. Patient is morbidly obese, probably 350-400 lbs, which causes some problems next: placed on the monitor and HR 130, check pulses and does have pulses in distal extremities though weak, BP unable to get multiple times, then manual BP unable to obtain. Ask nurse why no BP, states “cuff not big enough to work properly,” also trying on leg.

IV placed in right AC no problem, placed NS on pressure bag. HR during xrays comes down from 130–>115.

CXR done nothing obvious, PXR done, again nothing obvious and left femur show proximal 3rd shaft fx, traction splint placed by intern, FAST scan neg in cardiac window, but very positive in pelvic window as well and slightly positive in RUQ and LUQ. Level 1 called after FAST and finally a BP obtained 80/40 as trauma walks in the door!!! Patient no longer with palpable peripheral pulses, good central pulses, a&ox3.

Ever feel like an idiot…just watched this lady with HR 130 and BP 80/40 for 18 minutes prior to level 1 trauma call!

Blood, central line, another peripheral IV. Trauma dawdled a little in ED more than should have, repeated the very positive FAST scan, though we did resuscitate her with blood and fluids, central line, trauma attempted a-line (apparently they didn’t trust the very low BP either) and finally went to CT scanner (another 25 min) and thought to have SMV avulsion (yikes) prior to taking her to the OR.

Diagnosis: avulsion of superior mesenteric artery (even worse). left femur fracture.

Patient spent more than one month in the SICU, never extubated, multiple loops of bowel resected for necrosis and never closed her abdomen, family decided to withdraw care after she continued to go downhill and quality of life would have been an issue.

Let me point out the obvious, I should have called a level 1 earlier. 10 min earlier when  had HR in 130s and unable to obtain BP x 2 would have been enough. Unsure if her outcome would have been different, but sure makes me wonder.

Often times it is hard to get a BP on a morbidly obese person, esp when have peripheral pulses and axox3, but it is much better to be safe than sorry, call the level 1 when in doubt. Better for the patient’s sake to feel like an idiot earlier than to feel like an idiot later in the game.

The other thing is, we had her packaged for the OR when trauma arrived, peripheral IV and blood obtained, 1L fluids, HR 110, CXR, PXR and femur, traction splint to femur, FAST done and very positive. Should have gone straight to the OR as soon as trauma arrived. Trauma fellow wanted CT scan and further resuscitation (why try an a-line?) which took time.

Feedback and comments appreciated.

Couple of recent cases…

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One of the most interesting posts recently was Zach’s post about what he could have done differently. Thought I would continue this trend and post a couple of cases that could have gone better and leave some things up for discussion. Case one here and two next post.

Case #1: 90 yo F h/o HTN and arthritis, restrained passenger of moderate speed MVA, driver was unharmed but car was going too fast and struck the back of a semi-truck. Extrication about 10 minutes. Patient c/o right leg pain and right forearm pain, skin tear to right arm and obvious Colles fracture and femur fracture likely as well on initial exam. No chest or abdominal pain. Kept in R9 for the potential femur fracture and age. Vital signs all been stable, patient a&ox3, talkative and despite mild pain appears in good spirits.

On initial exam, HR 96 and regular, 125/70, RR and temp normal. Pain controlled as long as not moving. Good breath sounds, minimal chest tenderness on palpation of sternum, abdomen and pelvis unremarkable. Placed in traction splint in R9 for significant pain and shortening of right leg. CXR normal, PXR normal, and R femur with proximal femur fx minimally displaced. FAST neg. Give tdap and bag of LR. Further eval shows pain in right leg from femur/knee/tib/ankle and also left femur/knee/tib. As mentioned obvious fx right Colles, with pain in right elbow/forearm/wrist/hand and  also pain left forearm and wrist. That makes for man scan + a whole ton of xrays in all extremities.

Spoke with ortho on the phone in R9 due to known femur fracture. Vitals on R9 exit unchanged. To the CT scanner. Nurse calls from xray after CT done and asks for small amount pain meds as patient now c/o more pain, especially in right leg and arm. Dilaudid 0.5mg ordered. Patient comes into main ER literally 90 minutes after initial presentation due to so many xrays! (This is my fault). Labs unremarkable, Hgb 11. I see the CT scans but nothing obvious to me, no head bleed, no c-spine fx, no PTX, no obvious free fluid in belly. See patient as she as she comes back bc ask for more pain meds. HR now 120s, irregular?, BP 95/65. Ask nurse how long this has been going on, states “oh, just the last 30 min or so.” Ortho at bedside as well, wants to do sedation.

EKG done, show afib rate 120s (no h/o afib). BP cont to be 90/60s. Giving 2nd L LR, nurse start 2nd IV and get L NS going. Patient still talking and states she feels ok other than the pain in her leg. Call to Trauma (should have called earlier in 90 yo with known femur fx), but by now its been more than 100 min total time in ER. Trauma arrives pretty quickly, patient now been here 2 hrs. Agree with fluid boluses, talk about patient condition with fellow and wedge and all agree think likely due to trauma in afib and that why BP sucks.

Tell ortho that too high risk patient and unstable to do sedation. Does hematoma block right Colles fracture with reduction as well and leaves the femur in traction. Admitted to SICU after just over 2 hours in ER. CT head and c-spine only scans back and are neg at admission. About 30 min later rest of man scan comes back. Small nondisplaced sternal fx and very small hematoma (but possibly active bleeding) to right retroperitoneal area. Again speak to trauma about this. Asked about the retroperitoneal bleed and fellow states it very small and should wall off without intervention based on place. Possibly afib due to contusion? Cards was consulted by Trauma who saw patient and said to control pain, resuscitation and other trauma factors (unhelpful but true, not much for them to do).

Brings up a question I had, in setting of trauma, what medicines should be given for afib with RVR? Cardiac contusion? Or just let it ride? Trauma asked the nurse to give metoprolol but this was never given mainly due to nursing concerns about BP.

Ok, long story short, HR cont to be 120-130s, afib, BP 90/60s, after being ICU hold for about 2 hours patient had decreasing mentation. Trauma placed central line and a-line and ABG showed pH 6.8! Istat Hgb 8.0. Blood given, minimal response.

Patient intubated by trauma, arrested during intubation, one round CPR and came back, went to SICU same vitals, called in IR and intervention showed minimal bleeding, thought to likely be venous, but did have several coils placed. More blood and then pressors through the night. Arrested 2 more times throughout the next 6 hrs, family still wanted all interventions. Finally about 12 total hrs after ER presentation, arrested for about 20 min and TOD called.

Couple of main points from this case that I learned and hopefully helpful for you all:

1. As Coleman says, old people go down hill quickly, be on your guard no matter how good they may look on presentation.

2. Be careful of ordering too many xrays, me not seeing the patient for over an hour while in xray is unacceptable, I should have known the change in her vitals either by seeing it directly or have nursing tell me.

3. I knew this was a trauma admit as soon as she hit the door being 90 yo and femur fx, but I didn’t call them for a long time, why? Bc I didn’t have much to tell them (couple xrays, stable VS, man scan taking 3 hrs to get read). But just be sure to get them involved early.

4. We don’t typically repeat labs or get istat too often, but for someone like this who takes a turn for the worse, would have been worth it to get hgb after her vitals became unstable.

5. Her mentation decreased after admission, but I could have been more aggressive with central line and resuscitation (blood), she got 4L crystal but needed products.

6. This one was pretty clear cut that should not do sedation, but don’t be afraid to tell ortho ‘no’ if you’re worried about their safety.

7. I’m sure there is more, would appreciate your thoughts and comments…