ER Interesting Case Rounds. Visit #1 18 yo female…. 4 day history of.. Fevers Nausea/Emesis Diarrhea Lower abdominal pain.

ER Interesting Case Rounds

Visit #1

• 18 yo female…. 4 day history of..

• “Fevers”

• Nausea/Emesis

• Diarrhea

• Lower abdominal pain

Pain..

RLQ = LLQ

7/10 at worst

No radiation

“crampy”

Worse with movement

Pain with BMs (diarrhea)

• Diarrhea…

• Non-bloody

• 3-4x/day

• “mucousy”

• No PV symptoms

• No urinary symptoms

Physical Exam

• Vitals = normal

• Chest = clear

• CV = normal

• Abdo =

• Tender to direct palpation. RLQ = LLQ

• No rebound/guarding etc.

• No mass

LABS

• Hgb = N

• WBC = 13.5 (neuts = 11, monocytes 1.2)

• Lytes = N

• BG = N

• Lipase = N

• LEs…

• ALP = N (104)

• ALT = N (16)

• GGT = 64 (8-35)

• Bili T = 46 (0-20)

• Bili D = 24 (0-7)

• Urine dip

• Beta = negative

• 3+ ketones

• 2+ bilirubin

• Tx—fluids, anti-emetic, booked for abdo u/s in am. Dx “abdo pain NYD/mild LFT abnormality”

VISIT #2

• Returned next day post u/s:

• “Well seen and NORMAL liver, GB, ducts, pancreas, kidneys, spleen, aorta, para-aorta areas, bowel, uterus, overies, adnexa. No free fluid.”

• Repeat labs

• Bili 29 (down from 46)

• GGT 56 (down from 64)

• WBCs 12.2 (down from 13.5)

• K = 3.4

• Dx: “gastroenteritis”

Visit #3

• Returns 5 days later…

• Persistent diarrhea

• Malaise

• ABDO PAIN!!

• 9 lb wt loss in 10 days

OTHER HX?

• No travel

• No well water exposure

• No recent ABX

• No sick contacts

• No exposure to uncooked meats

• Phx = healthy, no surgeries, PAP 6 months prior was normal

• No meds (was on OCP in past)• Social = infrequent EtOH, no IVDU,• No risky sexual behaviour• 1 partner. Using condoms.• Tattoo at end of June• Fam Hx: No IBD

• VS: HR 100, Temp 38

• ABDO=

• Tender lower quadrants

• Rebound

• Involuntary guarding

• +RUQ pain

• WBC: 19.9 (neuts 13, bands 4.2)

• GGT 109

• ALP 175

• Bili T = 23

• Stool C + S = negative

• Stool O + P = negative

• Hep Serology = negative

• C. diff = negative

• Stool Fat Globules = negative

• Speculum Exam:

• thick yellow d/c from cervical os

• Bimanual Exam:

• + cervical motion tenderness

• CT Abdo/Pelvis: complex fluid collection in pouch of Douglas, compressing rectum, consistent with large tubo-ovarian abscess

• DIAGNOSIS???

Fitz-Hugh-Curtis

• Perihepatitis in association with pelvic inflammatory disease

• Originally described by Carlos Stajano (1919) in Uroguay.

• 1930’s… re-described by Thomas Fitz-Hugh and Arthur Curtis.

Etiology

• Originally felt only to be secondary to N. gonorrhea (Fitz-Hugh discovered gram negative diplococci on smears taken from the liver capsule)

• 1970s, Chlamydia trachomatis implicated and remains the most common pathogen

• Case reports... strept milleri, tuberculosis

Organisms Associated with PID• Aerobes:• N. gonorrhea• C. trachomatis• U. urealyticum• Mycoplasma sp. (genitalium, hominus)• Gardnerella vaginalis• Strept Pyogenes• Coag – staph• E. Coli• H. influenzae• S. pneumoniae• Mycobacterium tuberculosis• Anaerobes:• B. fragilis• Peptostreptococcus• Clostridium bifermentans• Fusobacterium sp.• Viruses:• HSV• Echovirus• Cocksackie

Diagnosis

• RULING IN pelvic inflammatory disease

• RULING OUT other causes of RUQ pain +/or elevated liver enzymes

Pathogenesis

Multiple Theories:

• Direct Infection of Liver?

• Hematogenous Spread?

• Lymphatic Spread?

• Exaggerated Immune Response?

How Common?

• Studies show broad ranges

• 4%-27% of patients with PID

• RISK FACTORS:

• IUDs, pelvic surgery, multiple partners, lack of barrier protection etc.

Symptoms

• Symptoms of PID (fever, abdominal pain, vaginal discharge, vaginal bleeding)

• Right Upper Quadrant Pain—usually pleuritic.

• Possible for patient to present with RUQ pain only (subacute/chronic PID)

Atypical Presentations

• Ileus/obstruction• Peri-splenitis• Peri-appendicitis• Fitz-Hugh-Curtis in a male• Chilaiditi syndrome• Ovarian Ca• Perforated Ulcer• Pleural effusion

Physical Exam

• Cervical motion tenderness

• Adnexal/uterine tenderness

• Lower Abdominal tenderness

• RUQ tenderness (may occur on its own)

• +/- friction rub over right anterior costal margin

Radiographic Studies

• Ultrasound:

• Excludes cholelithiasis, cholecystitis etc.

• Insensitive for FHC

• May demonstrate “violin-string” adhesions, loculated fluid in the hepatorenal space.

• “Violin String” also in Familial Mediterranean Fever, Diaphragmatic Endometriosis

Radiographic Studies

• CT Scan:

• Helpful IF can demonstrate contrast enhancement of the liver capsule

• Sensitivity of only 28%! (Joo et al. 2007)

• Depends if biphasic CT vs. portal phase only

LAB TESTS

• Liver Enzymes: often normal but can be elevated

• Litt and Cohen (JAMA, 1978) found ALT most likely, but ‘cholestatic’ enzyme elevations also reported

• +/- ESR• +/- Leukocytosis• Cultures: N gonorrhea, C Trachomatis from

cervix. Cultures from pelvic aspirates tend not to correlate. (mixed anaerobes, aerobes etc.)

Treatment

• Similar to that of PID

• Generally focused on N gonorrhea and C trachomatis, gram negative rods, anaerobes

• Direct therapy according to cultures

• Drain abscesses

PID tx

• Tx regimens:

• Ceftriaxone 250 mg IM/Doxy 100 bid x 14 days• Levo od/Flagyl bid x 14 days• Cefoxitin 2g IV q6/Doxy 100 bid

• IV for 48 hours afebrile, then PO• Poor response to ABX = laparoscopy

Complications

• Those of PID:

• Infertility

• Adhesions

• Chronic pain

• Ectopic pregnancy

• Reiter’s syndrome

• Culture results:• Streptococcus milleri (heavy)• B fragiles (moderate)• E. Coli (scant)

• NAAT:• Negative for both Chlamydea and

Gonorrhea