Rapidly Progressive Lethargy and Altered Mental Status: GI Etiology?
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Rapidly Progressive Lethargy and Altered
Mental Status: GI Etiology?Tim Ridgway MD FACPAssociate Professor of MedicineUniversity of South Dakota Sanford School of Medicine
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A 63 year old female presents with increasing lethargy and altered mental status over the previous 2 days. She also complained of nonspecific colicky abdominal pain over the past 3 weeks. On the evening prior to admission, she noted shaking chills. The following day she developed increasing shortness of breath, prompting evaluation locally and transfer to our facility.
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Hypertension Anxiety Osteoarthritis with predominant knee
involvement No surgeries
Past Medical History
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Amlodipine 2.5mg daily Omeprazole 20mg daily (recently started) Temazepam 30mg nightly Diclofenac 75mg bid Paroxetine 40mg daily Quetiapine 100mg nightly Losarten-hydrochlorothiazide 100-25mg
daily
Medications
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Admitted to the Intensive Care Unit appearing acutely illTemp 97.6 RR25 BP 87/63 Pulse 101Oxygen saturation 70% on room airLungs: Tachypneic with decreased breath sounds bilaterally without wheezesCardiac: Hyperdynamic precordium without murmurs. No JVD
Physical Examination
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Abdomen: Nondistended and soft. Bowel sounds present but decreased. No focal tenderness to palpationNeurologic: Disoriented and minimally responsive. No focal neurologic deficit noted
Physical Examination
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WBC 15.7 (90% neutrophils and 24% bands)Hemoglobin 9.8 g/dl Hematocrit 29%AST 67 U/L, ALT 49 U/LAlk Phos 522 U/L, Total bili 3.8 mg/dlABG: pH 7.3, pCO2 48mm Hg, pO2 65mm HgBicarbonate 20 meq/L, Lactate 1.7mmol/LElectrolytes unremarkableCreatinine 1.8 g/dl
Laboratory
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Progressive respiratory failure requiring endotracheal intubation
Progressive neurologic deterioration leading to unresponsiveness
Marked hypotension requiring pressor support
Broad spectrum antibiotics started after appropriate cultures
Clinical Course
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Abdominal Ultrasound: Contracted gallbladder with wall thickening and pericholecystic inflammatory changes suggestive of cholecystitis. No gallstones or CBD stones seen. CBD 4.2mm diameter
CT Chest: Mild pleural effusions bilaterally and bilateral lower lung infiltrates suggestive of bilateral pneumonia
CT Head: No focal abnormality noted
Imaging
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CT ABDOMEN
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CT ABDOMEN
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CT ABDOMEN
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ERCP
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CT IMMEDIATELY AFTER ERCP
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CT IMMEDIATELY AFTER ERCP
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CT IMMEDIATELY AFTER ERCP
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Gradual clinical improvement leading to weaning of pressors and extubation
Streptococcus Intermedius bacteremia Liver abscess developed in area adjacent to
pnumobilia-percutaneous drainage performed
HOSPITAL COURSE
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F/U EGD on 11th hospital day: Severely deformed gastric antrum and deep necrotic ulcer along anterior wall of duodenal bulb
Biopsies negative for H. Pylori Biliary stent removed Operative intervention-15th hospital day
HOSPITAL COURSE
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Fistulous connection between duodenal bulb and left lateral segment of liver (hepatoduodenal fistula)
Liver abscess adjacent to gallbladder Left lateral segment abscess/mass
OPERATIVE FINDINGS
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Drainage of liver abscess Cholecystectomy Repair of duodenal ulcer/fistula with a
Graham patch Open hepatic segmentectomy (segment 3)
OPERATIVE INTERVENTION
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Liver segment: Liver parenchyma with abscess/fistula tract (containing fecal/vegetable material
Left lateral segment mass: Necrotic tissue with acute and chronic inflammation
Gallbladder: Mild chronic cholecystitis with adjacent focal abscess formation
PATHOLOGY
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Bilateral septic emboli to lungs-resolved Respiratory failure-resolved Acute Kidney Injury-resolving Central Nervous System dysfunction-
resolved Liver abscesses-resolved Discharge on hospital day 30 IV Vancomycin additional 2 weeks
POST OPERATIVE COURSE
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Completed course of Vancomycin Eventual bilateral Total Knee Arthroplasty Full recovery!
OUTPATIENT FOLLOW-UP
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< 20 cases reported in the medical literature
GI bleeding most common presentation Most are diagnosed by histologic exam of
endoscopic biopsies or at surgery This is the only known case which presented
as sepsis
HEPATODUODENAL FISTULA
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NSAIDS highest risk for perforation and penetration
Few cases resolve without surgical management
Complications include GI bleeding and hepatic abscess
HEPATODUODENAL FISTULA
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A thick gallbladder wall seen on imaging is a nonspecific finding
Chronic NSAID use-BEWARE! Pneumobilia without previous intervention-
SERIOUS! Sepsis presentation-you have a narrow
window of opportunity
TAKE HOME POINTS