Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 62-year-old Caucasian male (CM) is admitted to the hospital with a chief complaint (CC) of lower chest pain and epigastric pain for 6 hours.
The abdominal pain is reminiscent of an episode of pancreatitis 5 years ago. The chest discomfort is intermittent and occurs with deep inspiration, described as "pressure like". The abdominal pain is sharp and burning in nature and there are no other associated symptoms. The patient reports no radiation, nausea, vomiting, diarrhea or constipation (N/V/D/C), shortness of breath (SOB) or sweating. The onset of the symptoms was during rest and light activity. The pain is described as 5/10 on 0-10 scale.
One approach to the work-up the chief complaint (CC) by asking some questions using the mnemonic SOCRATESSS:
Past medical history (PMH)
Diabetes type 2 (DM 2), pancreatitis, hypertension (HTN), peripheral vascular disease (PVD).
Actos (pioglitazone), pentoxifylline (Trental), atenolol, triamterene and hydrochlorothiazide (Maxzide, Dyazide).
Social history (SH)
No smoking, drugs or alcohol.
Family medical history (FMH)
What is the most likely diagnosis?
It could be coronary artery disease (CAD). Ischemia should be the first thing on your mind. He is a diabetic, not on aspirin (ASA) and is at high risk for acute ischemia.
Peptic ulcer disease (PUD)
Pneumonia and pleurisy are less likely causes without (w/o) cough, fever or chills
Hepatitis due to nonalcoholic steatohepatitis (NASH) or Actos (pioglitazone)?
Obese male in non-apparent distress (NAD).
Vital signs: 36.6-87-16-153/79 mm/Hg.
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, RUQ tenderness, no rebound, Murphy negative, +BS.
Ext: no edema.
What laboratory workup would you suggest?
Firstly, you should treat the patient with the "chest pain rule out myocardial infarction (CP R/O MI)" protocol which includes Nitro SL, ASA, metoprolol, cardiac enzymes x 2 q 8 hrs, ECG and CXR.
Also, you have to do CMP, CBCD, amylase and lipase, UA.
The ECG shows an old inferior wall MI (click to enlarge the images).
The ECG showed normal sinus rhythm (NSR), poor R wave progression and deep Q waves in leads III and aVF. Not very reassuring...The patient remembered being told that he had some changes on the ECG years ago.
Mild elevation in LFT and CBC, differential was normal on day 1 but check what happened on day 2 (click to enlarge the images).
CMP, negative hepatitis profile (click to enlarge the images).
What would you do for this patient?
He was admitted and "ruled out" for ACS.
Hepatitis profile and liver ultrasound (U/S) were ordered.
Amylase and lipase were negative.
During the next day, the patient had no more pain and wanted to go home. The laboratory workup showed increased LFTs with a "jump" in bilirubin to 3 mg/dL and WBC increase to 18,000/mm3 with 22% bands.
Gallstones (left); U/S of the liver report (right) (click to enlarge the images).
Liver U/S showed a fatty liver and multiple gallstones. He became febrile and antibiotics (ABx) were started (blood cultures (BCx) were negative).
Treatment (click to enlarge the images).
The patient was scheduled for a cholecystectomy but a cardiology consult was requested for cardiac "clearance". The 2D echo showed wall motion abnormalities of the inferior wall and patient underwent a cardiac catheterization. The left heart catheterization showed 100% occlusion of right coronary artery (RCA) and the circumflex artery (Cx) with 30% stenosis of LAD.
What happened next?
The patient had fever, WBC and LFT elevation, and non-dilated bile ducts on liver U/S. He was diagnosed with cholangitis.
Fever in cholangitis (click to enlarge the images).
The cholecystectomy showed chronic cholecystitis and gallstones.
Intraoperative cholangiogram (left); pathology report (right) (click to enlarge the images).
The patient's condition improved and he was sent to a transitional care unit for rehabilitation.
What did we learn from this case?
You have to recognize the classic Charcot triad of fever, jaundice, and RUQ pain, typical of cholangitis (found in 70% of patients). The median age of onset is 50-60 years. Treatment may require decompression and drainage of the biliary system.
In cholangitis, 80% of patients have a WBC greater than 10,000. Expect elevated LFT. Bilirubin is elevated to a mean value of 6.6 mg/dL.
Liver U/S is the test of choice. Gallstones are visible on KUB in only 10-30% of cases with cholelithiasis.
CT scan is adjunctive to ultrasound.
R/O acute ischemia in DM patients with CP or abdominal pain.
Treat cholangitis promptly with antibiotics.
Cholangitis: eMedicine Emergency Medicine, 2010.
Cholangitis: eMedicine Gastroenterology, 2010.