Rapidly Progressive Lethargy and Altered Mental Status: GI Etiology?

1. Rapidly Progressive Lethargy and Altered Mental Status: GI Etiology? Tim Ridgway MD FACP Associate Professor of Medicine University of South Dakota Sanford School of Medicine

2. 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.

3. Past Medical History • Hypertension • Anxiety • Osteoarthritis with predominant knee involvement • No surgeries

4. Medications • 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

5. Physical Examination Admitted to the Intensive Care Unit appearing acutely ill Temp 97.6 RR25 BP 87/63 Pulse 101 Oxygen saturation 70% on room air Lungs: Tachypneic with decreased breath sounds bilaterally without wheezes Cardiac: Hyperdynamic precordium without murmurs. No JVD

6. Physical Examination Abdomen: Nondistended and soft. Bowel sounds present but decreased. No focal tenderness to palpation Neurologic: Disoriented and minimally responsive. No focal neurologic deficit noted

7. Laboratory WBC 15.7 (90% neutrophils and 24% bands) Hemoglobin 9.8 g/dl Hematocrit 29% AST 67 U/L, ALT 49 U/L AlkPhos 522 U/L, Total bili 3.8 mg/dl ABG: pH 7.3, pCO2 48mm Hg, pO2 65mm Hg Bicarbonate 20 meq/L, Lactate 1.7mmol/L Electrolytes unremarkable Creatinine 1.8 g/dl

8. Clinical Course • Progressive respiratory failure requiring endotracheal intubation • Progressive neurologic deterioration leading to unresponsiveness • Marked hypotension requiring pressor support • Broad spectrum antibiotics started after appropriate cultures

9. Imaging • 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

10. CT ABDOMEN

11. CT ABDOMEN

12. CT ABDOMEN

13. ERCP

14. CT IMMEDIATELY AFTER ERCP

15. CT IMMEDIATELY AFTER ERCP

16. CT IMMEDIATELY AFTER ERCP

17. HOSPITAL COURSE • Gradual clinical improvement leading to weaning of pressors and extubation • Streptococcus Intermedius bacteremia • Liver abscess developed in area adjacent to pnumobilia-percutaneous drainage performed

18. HOSPITAL COURSE • 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

19. OPERATIVE FINDINGS • Fistulous connection between duodenal bulb and left lateral segment of liver (hepatoduodenal fistula) • Liver abscess adjacent to gallbladder • Left lateral segment abscess/mass

20. OPERATIVE INTERVENTION • Drainage of liver abscess • Cholecystectomy • Repair of duodenal ulcer/fistula with a Graham patch • Open hepatic segmentectomy (segment 3)

21. PATHOLOGY • 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

22. POST OPERATIVE COURSE • 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

23. OUTPATIENT FOLLOW-UP • Completed course of Vancomycin • Eventual bilateral Total Knee Arthroplasty • Full recovery!

24. HEPATODUODENAL FISTULA • < 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

25. HEPATODUODENAL FISTULA • NSAIDS highest risk for perforation and penetration • Few cases resolve without surgical management • Complications include GI bleeding and hepatic abscess

26. TAKE HOME POINTS • 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