Rapidly Progressive Lethargy and Altered

Mental Status: GI Etiology?Tim Ridgway MD FACPAssociate Professor of MedicineUniversity of South Dakota Sanford School of Medicine

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.

Hypertension Anxiety Osteoarthritis with predominant knee

involvement No surgeries

Past Medical History

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

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

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

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

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

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

CT ABDOMEN

CT ABDOMEN

CT ABDOMEN

ERCP

CT IMMEDIATELY AFTER ERCP

CT IMMEDIATELY AFTER ERCP

CT IMMEDIATELY AFTER ERCP

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

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

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

Drainage of liver abscess Cholecystectomy Repair of duodenal ulcer/fistula with a

Graham patch Open hepatic segmentectomy (segment 3)

OPERATIVE INTERVENTION

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

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

Completed course of Vancomycin Eventual bilateral Total Knee Arthroplasty Full recovery!

OUTPATIENT FOLLOW-UP

< 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

NSAIDS highest risk for perforation and penetration

Few cases resolve without surgical management

Complications include GI bleeding and hepatic abscess

HEPATODUODENAL FISTULA

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