Upper Gastrointestinal
CASE 23: Fever, pain anD jaunDiCe
history
As the junior doctor on call, you are asked to review the blood results of an 87-year-old man who was admitted that morning with possible appendicitis. He is confused and unable to give an accurate history. He had been spiking temperatures during the afternoon and had increasing right-sided abdominal pain.
examination
The observation chart shows he has a temperature of 38°C and a tachycardia of 120/min. You notice he has a yellow discolouration of the skin and sclera, and abdominal examination reveals that the maximal tenderness is in the right upper quadrant. There are no palpable masses or abdominal herniae. Rectal examination demonstrates normal stool with no palpable rectal mass. A plain abdominal radiograph, done that morning, was normal.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
15 g/dl |
11.5–16.0 g/dl |
mean cell volume |
82 fl |
76–96 fl |
White cell count |
21 × 109/l |
4.0–11.0 × 109/l |
platelets |
344 × 109/l |
150–400 × 109/l |
Sodium |
136 mmol/l |
135–145 mmol/l |
potassium |
4.5 mmol/l |
3.5–5.0 mmol/l |
urea |
6 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
72 μmol/l |
44–80 μmol/l |
amylase |
69 iu/dl |
0–100 iu/dl |
aSt |
68 iu/l |
5–35 iu/l |
alp |
442 iu/l |
35–110 iu/l |
ggt |
121 iu/l |
11–51 iu/l |
bilirubin |
92 mmol/l |
3–17 mmol/l |
albumin |
42 g/l |
35–50 g/l |
blood glucose |
4.0 mmol/l |
3.5–5.5 mmol/l |
C-reactive protein (Crt) |
212 mg/l |
0–6 mg/l |
Questions
•What is the likely diagnosis?
•What are the classical characteristics to indicate this?
•What are the most common causes?
•Which are the most common organisms?
•How should the patient be managed?
•What investigations should be performed?
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100 Cases in Surgery
ANSWER 23
The collective symptoms of pain, jaundice and fever are known as Charcot’s biliary triad and are characteristic of ascending cholangitis. Gallstones within the common bile duct (choledocholithiasis) are the most common cause of acute cholangitis, followed by ERCP and tumours. The most common causative organisms are Escherichia coli, Klebsiella, Enterobacter, enterococci, and group D streptococci.
!Causes of ascending cholangitis
•Cholelithiasis
•erCp
•tumours: pancreatic, periampullary, cholangiocarcinoma
The patient needs intravenous fluid resuscitation and a urinary catheter, with strict hourly urine output measurements. Blood cultures should be taken on at least two separate occasions from two different sites, and broad-spectrum antibiotics should be commenced. Imaging studies are essential to confirm the presence and cause of the biliary obstruction and also help to rule out other conditions. Ultrasonography is the most commonly used initial imaging modality. Gallstones may not be directly visualized by ultrasound or CT, so obstruction is diagnosed on the basis of the common bile duct (CBD) diameter. The upper limit of the normal diameter for the CBD is 5 mm. Greater than 7 mm indicates obstruction, although the bile duct diameter increases in the elderly and after cholecystectomy. Magnetic resonance cholangiopancreatography (MRCP) can be used if the presence of choledocholithiasis remains unclear. Once an obstruction of the CBD is confirmed, the patient should proceed to ERCP. The obstruction can then be relieved by removing the stone or inserting a biliary stent.
KEY POINTS
•pain, fever and jaundice are classical features of ascending cholangitis.
•gallstones are the most common cause.
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Upper Gastrointestinal
CASE 24: SuDDen-onSet epigaStriC pain
history
A 41-year-old publican presents to the emergency department with epigastric pain and vomiting. The pain began suddenly 2 h previously, followed by 3–4 episodes of bilious vomiting. He had been previously fit and well. He is a smoker and drinks 40–60 units of alcohol per week.
examination
The patient is sweaty and only comfortable while lying still. His blood pressure is
170/90 mmHg, pulse 110/min and temperature 37.5°C. The upper abdomen is tender and rigid on palpation.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
12.0 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
13.2 × 109/l |
4.0–11.0 × 109/l |
platelets |
250 × 109/l |
150–400 × 109/l |
Sodium |
137 mmol/l |
135–145 mmol/l |
potassium |
3.5 mmol/l |
3.5–5.0 mmol/l |
urea |
5 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
62 μmol/l |
44–80 μmol/l |
amylase |
250 iu/dl |
0–100 iu/dl |
aSt |
30 iu/l |
5–35 iu/l |
ggt |
242 iu/l |
11–51 iu/l |
albumin |
45 g/l |
35–50 g/l |
bilirubin |
12 mmol/l |
3–17 mmol/l |
glucose |
5 mmol/l |
3.5–5.5 mmol/l |
lDh |
84 iu/l |
70–250 iu/l |
total serum calcium |
2.35 mmol/l |
2.12–2.65 mmol/l |
Figure 24.1 shows an erect chest x-ray. |
|
|
Figure 24.1 erect chest x-ray.
Questions
•What is the likely diagnosis?
•How should this patient be managed?
•How should this patient be managed after discharge?
51
100 Cases in Surgery
ANSWER 24
The x-ray shows free intraperitoneal gas beneath the hemidiaphragms, consistent with a perforated intra-abdominal viscus.
The most common cause is a perforation of a peptic ulcer. Ulcers situated on the anterior duodenal wall perforate into the abdominal cavity, resulting in free intraperitoneal gas. Posteriorly, ulcers erode into the gastroduodenal artery, which is more likely to result in bleeding.
!Common causes of a pneumoperitoneum
•Ruptured hollow viscus: perforated peptic ulcer or diverticulum, necrotizing enterocolitis, toxic megacolon, inflammatory bowel disease
•Infection: infection of the peritoneal cavity with gas-forming organisms and/or rupture of an adjacent abscess
•Iatrogenic factors: recent abdominal surgery, abdominal trauma, a leaking surgical anastomosis, misplaced chest drain, endoscopic perforation
It is important to be sure that the chest x-ray is taken in the erect position. However, 10 per cent of perforations will still not demonstrate free gas on an erect chest x-ray. A lateral decubitus radiograph can be taken if the diagnosis is unclear. If there is any diagnostic doubt, then a CT scan will confirm the presence of a perforation.
The patient requires prompt fluid resuscitation, with central venous pressure monitoring and hourly urine output measurements. Nasogastric intubation, broad-spectrum antibiotics and analgesia should also be given. Most patients require surgery after appropriate resuscitation. Conservative management may be considered if there is significant comorbidity. Postoperatively, patients should be considered for Helicobacter pylori eradication therapy and should continue on a proton pump inhibitor.
The recommended weekly intake of alcohol is <28 units per week for males and <21 units for females. He will require follow-up with his general practitioner (GP) to help modify his lifestyle to prevent relapse.
KEY POINTS
• pneumoperitoneum is not evident on an erect chest x-ray in 10 per cent of cases.
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