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Abdominal pain in obese female


Abdominal pain in obese female


حالة سريرية

الوصف الكامل Background
Here is case 2

Enjoy
Seventeen year old patient with sever abdominal pain in the epigastric region and right upper quadrant goes to the right. She had similar episodes before and last time she went to ER where she was told that she had Gallbladder stone. The patient went away for 2 months and recurred 2 days ago associated with vomiting, more sever and longer in duration. No fever , not chills no diarrhea . Her weight is the same for 4 years. No change in urine color , no appreciated jaundice by patient or family.

What is your next question?

What do you want to do?

المرجع

real life

ABIM's picture
by


what type of pain? What does aggrivate the pain? What does reduce it?
What type of vomiting?
When did her episodes begin?
Was they the same?

A.A's picture
A.A
طبيب مقيم

Was it a normal vomit ? or there was any blood with the vomit ?
More details about the pain ? Does it radiate anywhere ? the chronological association with meals ??
Is she married, regular menses ??
I'd do the vitals, PE, and I'll ask for a CBC, LFTs, and abdo sonogram ?
Green Wave's picture
Green Wave

CBC, LFTs, Amylase, Lipase, ultra sound
nafartete's picture
nafartete
السنة السادسة


what was she doing when this pain started (i.e: wa she having heavy meal)

Quote:
Her weight is the same for 4 years.

BTW how much does she weigh?

DR.OSH's picture
DR.OSH
السنة الثانية


Vomiting is associated with the pain and of food + bile. No clear relation to food (had two episodes of pain so far , so the relation to food can not be judged well by patient) The pain is sever and goes to the right and back. but with pan she can't eat. She is 17 years old , unmarried , no problems with menses

Past medical history ,none, past surgical history none, Allergies none, family history negative, social history : lives with parents unmarried, Review of systems also normal.
On examination Afebrile normal vital signs , morbidly obese (162 kg)
No pallor or jaundice
Normal lung and heart exam
Abdomen: Soft , epigastric tenderness and right upper quadrant tenderness no rebound or rigidity

Liver enzymes AST 899, ALT 676, Alk phos 455, Bilirubin 1.5 , Lipase Amylase normal
Repeat US with comparison: CBD diameter increased from 2 mm to 7 mm, No stones seen in the CBD. GB stones seen again but no features of cholecystitis.

What is next?

ABIM's picture
ABIM


is she taking any drugs?
about family history
smoking ' alcoholic ?
i do CBC , WBC, LFTs , Amylase , Lipase

Tariq1987's picture
Tariq1987
بعد التخرج


i m sorry i didn't see above Embarrased

Tariq1987's picture
Tariq1987
بعد التخرج


since gama GT is good Representative of bile ducts why not order it.

OmHa
السنة السادسة

Repeat US with comparison: CBD diameter increased from 2 mm to 7 mm, No stones seen in the CBD[/b+[b] GB stones seen again + no features of cholecystitis

With the presentation above, I'd consider Mirizzi syndrome and I'd do an ERCP ??

Green Wave's picture
Green Wave


blood glucose? ,copper???
CBC , WBC

barbie girl's picture
barbie girl


Copper??!!

What for? what are you thinking about?

Glucose is normal .

GGT will be very elevated (for sure) what is the point of letting the patient pay more ?
GGT is helpful when Alk phos is elevated and we are not sure if this is liver or bone origin.

Someone wanted ERCP ? WHat are you ging to achieve from ERCP?

ABIM's picture
ABIM

With this presentation of symptomatic gallstones ,why didn't they take out the gallbladder ??
I mean she had a biliary colic ,so why the delay of 2 years ....
Either I am missing sth here ,or ther's sth wrong with the Hx

--------------
Tayyeb ,with the current presentation I would also go with surgical consult for cholecystectomy as it's another episode of pain caused by gallstones .But I have some worries about the "that much elevated AST and ALT" especially with the flipped ration (AST is more than ALT)
--------
I think that Barbie gurl considered this when she asked for copper (AST more than ALT ,think Alcohol or wilson)

mbs2380's picture
mbs2380
بعد التخرج

Quote:
Either I am missing sth here ,or ther's sth wrong with the Hx

Embarrased
of course I don't mean with the one who took the Hx but rather that I missed sth in the Hx

mbs2380's picture
mbs2380
بعد التخرج

Quote:
ration

ratio

mbs2380's picture
mbs2380
بعد التخرج

Where is the CBC??

Tayyeb I would make it as an approach:

Heart problem: the age doesn't fit and the clinical scenario as well/
GU problems : ummmmmmmmm,really long shot with this typical presentation,but we have to consider it (I would go for UA)
the presentation also excludes other GI problems that might present with epigastric pain ; ulcer :b\c of the presentation-Pancreatitis:b\c of the nl enzymes as well as the presentation;dyspepsia:b\c of the presentation
Heatitis : well the LFTs are up ,but I think that the should be higher like in thousands with the hepatitis (and also the ALP and the presenation are more suggestive of biliary tract porblem)
Cholangitis : I need CBC
Cholecystitis: I don't feel comfortable to say that it might be ,but w\o fever??? and also we need CBC ,again.

mbs2380's picture
mbs2380
بعد التخرج


Forgive my clumsiness ,
I would make it more organized :
Next step:
CBC?
UA?

mbs2380's picture
mbs2380
بعد التخرج


La Ilah Ila Allah
Sorry again
totally forgot that I saw the echo,cholecystitis is out according to the echo

mbs2380's picture
mbs2380
بعد التخرج


Another theory :
She might have an increased TG and she is on fibrate which causes : elevated LFTs AND gallstones as well.
I mean ,that explains alllllllllllll the things,I guess!!

mbs2380's picture
mbs2380
بعد التخرج

Amylase normal => no pancreatitis
no cholecystits
CBD is dilated
we can rule out malignancies cuz there's no weight loss

thinking of
parasitic obstruction
cholangitis
hepatits??

by the way, isn't US of less value in obese patients?

nafartete's picture
nafartete
السنة السادسة


Ok
let take them one by one

1- Alcohol : first there is no history of it, you are talking about 17 year old girl . And remember that patients have to dring HEAVILY for years minimum 5-10 before they get alcoholic pancreatitis . So ETOH is OUT

2- Wilson is a reasonable thought with elevated liver enzymes in young patients : but do you expect that to be painful with acute presentation as such ?

3- You are right about "why surgery was not done before" TWO MONTHS AGO (not years)
and the reson is that the patient felt well soon and the family did not follow up

4-here is the CBC
WBC 5.8, HB 9.6, MCV 78, , plateltes 349,Neutrophil % 83

5 UA not done

6-

Quote:
by the way, isn't US of less value in obese patients?

SO what ? It already showed you the stones in Galbladder : if it did not show we may see ok it could be that stone are not seen , i,e sensitivty of US for gallbladder stone may decrease but specificty is still very high and unchanges (regardless of weight)

7- No ANswer to my question : FOr the ones who want to do ERCP What are you looking for and what do you want to do with it

ABIM's picture
ABIM


sorry I ment alcoholic hepatitis in point 1

ABIM's picture
ABIM


We can see why CBD is dilated
We can remove GB stones by ERCP

I have to remove viral hepatitis

Tariq1987's picture
Tariq1987
بعد التخرج

Quote:
Alcohol : first there is no history of it, you are talking about 17 year old girl . And remember that patients have to dring HEAVILY for years minimum 5-10 before they get alcoholic pancreatitis . So ETOH is OUT

2- Wilson is a reasonable thought with elevated liver enzymes in young patients : but do you expect that to be painful with acute presentation as such

Agree that they r excluded ,I was just talking in general about the AST\ALT ratio

Quote:
here is the CBC
WBC 5.8, HB 9.6, MCV 78, , plateltes 349,Neutrophil % 83

Aha!1
so she has anemia ,MCV is 78 ,some ppl consider the lower limit of it 78 and some say it's 80 (Hem guys in the hospital consider 78 as the lower cut)
Either way ,Anemia of chronic dz (which we don't know what it's) is included.
I would order Iron study as well ( I would postpone other tests that could tell us about the etiology of IDA till I see the results ;like occult blood ,and stool test )

Does she have pain now ?? if she does ,we should put her on pain meds .

--------------------
I don't think there's a reason for the ERCP .
And as for the Mirizzi ,as I reckon ,it was cholecystitis WITh Jaundice (the Jaundice thing is the odd feature ) ;Add to that,it's rare .

mbs2380's picture
mbs2380
بعد التخرج

Still, my management is the same
Pain meds for now
Surgical consult for cholecystectomy ( I don't know whether a pt w this Hb can undergo surgery or not??)
mbs2380's picture
mbs2380
بعد التخرج

Really "weird" case .

If we want a thing that connect the dots ;
I would go with a parasite (-don't lough plz-) ;I would say a body like Clonorchis sinensis
(still with that nl WBC ??? A long shot I know )
So is it reasonable to order the stool test ??

mbs2380's picture
mbs2380
بعد التخرج


Tayyeb :
A more extended DDx :
Autoimmune hepatitis : But Again,don't feel comfortable w such presentation (but it's cool especially w anemia + age+ Labs).

mbs2380's picture
mbs2380
بعد التخرج

Quote:
We can remove GB stones by ERCP

SO you are saying that ERCP can remove the GB stone and there is not need for cholecystectomy?

Where is Nafartete? Did not tell comment on my answer to here question?

OK mbs2380
Patient was admitted to hospital , IV fluids given with pain control (tramadol) yet her pain was only slightly better. Surgery were consulted but they said : their book says that if the liver enzymes are high not to touch the patient and do surgery.
Where do we go from here?

People who want to do ERCP ? WHy no one answered me

ABIM's picture
ABIM

Quote:
Copper??!!

What for? what are you thinking about?

لأن (AST ) مرتفعة بشكل أكبر من ( ALT) فاتجهت باتجاه ويلسون وخاصة أن عمر المريض صغير فالاحتمال وارد ...
الكحولية مستبعدة بكل تأكيد تماماً كما أوضحت

Quote:
1- Alcohol : first there is no history of it, you are talking about 17 year old girl . And remember that patients have to dring HEAVILY for years minimum 5-10 before they get alcoholic pancreatitis . So ETOH is OUT

Quote:

2- Wilson is a reasonable thought with elevated liver enzymes in young patients : but do you expect that to be painful with acute presentation as such

ليش لأ Rolling Eyes ....وحسب القصة المريضة عانت من نوب سابقة من الألم !!!! Rolling Eyes

ماذا عن اختبارات الأضداد الفيروسية ... ؟؟ ما هي نتيجتها ؟؟

barbie girl's picture
barbie girl

Quote:
: their book says that if the liver enzymes are high not to touch the patient and do surgery.

Aha!

Quote:
Where do we go from here?

I would go with more workup ...

Follow me on this ,plz :

Hep viral panel
Autoimmune hepatitis workup( ASMA and ANA ) ,don't know that much which is better to order
Stool sample for my theory of the worm .

.

mbs2380's picture
mbs2380
بعد التخرج


here is the US image

look at the black (fluid and stone : white with shadows_

[img]https://www.hakeem-sy.com/images/med/2-1_st_(2).jpg[/img]

ABIM's picture
ABIM
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