ER-GS COMBINE CONFERENCE

Transcription

1 ER-GS COMBINE CONFERENCE 報告者 :R3 許力云指導者 :VS 連楚明 Patient Data 44 y/o, male E4V5M6 TPR: 37.1 /087/18 BP:141/075 mmhg SpO2: 96% 檢傷主訴 : 病患來診為腹痛 Triage: 2 History RUQ pain for 2 days Persistent and progressive No radiate to back No migration pain ( initial RUQ pain) Hunger and post prandial pain Past history Allergy : NKDA Denied PUD Hx Abd OP hx denied Heroin addiction under methadone Tx Physical Examination impression Cons: E4V5M6 Neck: supple Chest: clear BS Abdomen: soft, RUQ tenderness, no rebound tenderness Extremity: freely movable Impression: Fever caused? -R/O GI upset -R/O cholecystitis RUQ pain r/o acute cholecystitis 5

2 Initial management CXR day NPO Keto 1amp IV st CBC/DC/PLT Panel1, T-bil PT/aPTT N/S 80ml/hr CXR, KUB KUB Lab Data CBC/DC Biochemistry PT/aPTT WBC (x10 3 /ul) 14.3 Glucose 123 PT 11.9 Hb (g/dl) 14.6 GOT(AST) 95 INR 1.14 PLT (x10 3 //ul) 210 BUN 4 aptt 31.4 Seg (%) 79.7 Creatinine 0.8 Lymph (%) 10.9 Na 140 Mono (%) 9.4 K 3.6 Band (%) 0 T-Bil 1.3 Orders Abd CT Day Bedside echo( poor echo window) Abd CT with and without contrast Bain 4mg IV st (still pain)

3 Orders Day B/C * 2 Cefmetazole 1G IV st Bain 5 mg IV st( severe pain) 轉 EC 留觀 Day Flumarin 2 G IV Q8H EC course (5/20) Imp 1. Susp. RLL pneumonia Tx with Flumarin 2. Elevated GOT caused? 3. Heroin addiction Tx with Methadone P t 表示, 深吸氣較痛 Abg G3 and CXR at day (felt SOB) Sputum culture * 1 with Gram stain Fever 38.4 noticed at 0535 CXR Sputum Gram stain EC Course (5/21) Imp : 1. RLL PN Tx with flumarin 2. Elevated GOT caused? 3. Heroin addiction Tx with Methadone P t 表示有比較不痛 Add klaricid ( INF doctor suggest) HIV screen, Alk-P, r-gt, Lipase, GPT Sputum TB culture QD * 3 days (INF doctor suggest) Lab data Biochemistry GPT 102 ALK-P 63 r-gt 131 Lipase 10 HIV screen - Sputum AFS : negative

4 EC Course (day1) IMP : 1. RLL PN Tx with flumarin 2. Elevated liver enzyme 3. Heroin addiction P t 本已較不痛了, 又痛起來 do bedside echo at 1800 susp acute cholecystitis Consult GS GS consultation CR doctor 魏 : Highly susp acute cholecystitis suggest arrange surgery OP finding GB wall thickening, severe Suppurative, edematous and gangrenous change of GB 0.8 cm pigmented stones in GB Turbid and white bile content Perforation Bile stained ascites Admission course Final diagnosis Cystic duct stone with acute cholecystitis with gangrenous change with peritonitis, sepsis and bile stained ascites s/p LC Reactive right pleural effusion and pneumonia

5 DISCUSSION Pathophysiologic condition Symptoms Physical findings Laboratory findings Acute cholecystitis Acute cholecystitis Impacted stone in cystic duct 75% preceded by attacks of biliary colic Moderate to severe epigastreic pain, RUQ Pain lasting > 6hr Mild fever (<38.9 C) Murphy s sign One-third palpable GB Mild jaundice: 20% (elderly) Leukocytosis( ) Serum Bil 2-4mg/dL ALT, ALP may be elevated Amylase >1000U/L, Bil>4mg/dL suspect CBD stone Acute cholangitis Impacted stone in CBD causing bile stasis Charcot s triad ( pain, jaundice, fever) 70% Reynold s pentad (+ hypotension, cons. change) Mild, transient pain accompanied by chills Fever in 95% RUQ tenderness in 90% Jaundice in 80% Leukocytosis in 80% Bil>2mg/dL in 80% ALP usually elevated Blood culture usually Positive Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. 對急性膽囊炎 delaying cholecystectomy 與 early 相比, 對 mortality, morbidity, rate of conversion to open surgery 之間並無差別但 early cholecystectomy 有意義減少住院天數所以對急性膽囊炎應考慮 : early cholecystectomy Cochrane Database Syst Rev Oct 18;(4):CD Percutaneous transhepatic cholecystostomy and delayed cholecystectomy in critically ill patients with acute calculus cholecystitis. Case report 何時建議病人先以引流方法治療? The main indications for PTHC 1. severely sick and high-risk patients was biliary sepsis and septic shock 2. severe comorbidities Conclusion : The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective. Am J Surg Jan;183(1):62-6.

6 Take home message A biliary origin for a right basal pneumonia In acutely ill patients with RUQ pain, sonography is the most useful imaging study. RLL Pneumonia with abd pain could caused by biliary related reactive pneumonitis Definitive therapy of acute cholecystitis consists of cholecystectomy. THANKS FOR YOUR ATTENTION