66-Year-Old Man With Hypotension and Abdominal Pain
66-Year-Old Man With Hypotension and Abdominal Pain
A 60-year-old man presented to the emergency department with dizziness, hypotension, and a 3-week history of abdominal pain, nausea, and vomiting. Three weeks prior to admission he had experienced 1 episode of chills and developed acute abdominal pain that radiated to his back. He was prescribed oxycodone with acetaminophen and his pain improved over a 4-day period, but he still had residual pain and began to experience anorexia, nausea, and vomiting twice a day. By the time he presented to the emergency department, he had lost 12 lb. He was having regular bowel movements and reported no melena. His relevant past history included a Billroth I procedure for duodenal ulcer in 1971.
On examination he was afebrile (temperature, 97.3°) and his heart rate was 92 beats per minute; respiratory rate, 18 breaths per minute; and blood pressure, 76/48 sitting and 90/53 supine. Oxygen saturation was 94% on room air. He had normal mental status, normal neurologic examination, no scleral icterus, and cardiorespiratory evaluation was unremarkable. There was no hepatosplenomegaly or evidence of ascites or varices. The abdomen was not distended, but there was tenderness to palpation in the right upper quadrant.
Results of laboratory evaluation revealed a white blood cell count of 15,800 cells/dL and hematocrit of 40.5% (43.9% 2 months prior to presentation). He had a platelet count of 87,000/dL (287,000/dL 2 months prior to presentation). Electrolytes were as follows: serum sodium, 126 mg/L; potassium, 5.0 mg/dL (from hemolyzed samples); bicarbonate, 16 mg/dL; chloride, 87 mg/dL; with an anion gap of 23. Blood urea nitrogen was 82 mg/dL, and serum creatinine was 4.4 mg/dL (last on 11/04 was 0.7 mg/dL). Serum phosphate was 7.6 mg/dL; and calcium, 7.4 mg/dL. International normalized ratio was 1.5. Initial bilirubin specimens were hemolyzed. Lactate dehydrogenase was 773 mg/dL; aspartate aminotransferase, 912 mg/dL; alanine aminotransferase, 980 mg/dL; and alkaline phosphatase, 748 mg/dL.
A right upper quadrant ultrasound examination was performed (Figures 1a-d).
(Enlarge Image)
Ultrasound of right upper quadrant (RUQ) shows gallstone in gallbladder, and echogenic structure without Doppler signal adjacent to the neck of gallbladder.
(Enlarge Image)
RUQ ultrasound shows gallbladder containing gallstone. No pericholecystic fluid or gallbladder wall thickening is present.
(Enlarge Image)
Color Doppler ultrasound (transverse through liver) shows thrombosis in the main portal vein that appears echogenic with no flow (arrowed). Color flow anterior to this represents hepatic artery and collateral flow.
(Enlarge Image)
Ultrasound through right lobe shows diffuse irregular echogenic appearance, with "dirty" shadows suggesting presence of complex mass with fluid, with no clear margins.
The ultrasound showed absence of flow in the right portal and main portal vein; the left portal vein was patent, with collaterals adjacent. There was no gallbladder wall thickening. A gallstone was present in the gallbladder. No pericholecystic fluid was present, and an ultrasonic Murphy sign was not elicited. There was an echogenic structure near the neck of the gallbladder. A diffusely echogenic, heterogeneous area was present in the right lobe. The common duct was not enlarged. No ascites was seen.
On the basis of the ultrasound and laboratory findings, which of the following diagnoses seems the least likely?
View the correct answer.
<p>A, B, and C all appear to be the least likely diagnoses</p><br/><b>Discussion</b><br/><br/><sec sec-type="content"><p>Although there is a gallstone present, absence of gallbladder wall thickening, pericholecystic fluid, and an ultrasonic Murphy sign make the presence of acute cholecystitis unlikely. Diffuse fatty infiltration would appear as echogenicity of the entire liver, not a focal area in the right lobe. There are shadows associated with this area, as well as evidence of enhanced through-transmission, which is seen as more echogenic "shadows," suggesting the presence of fluid. The patchy changes in the right lobe could represent a liver abscess in this setting, although the absence of fever is a little surprising. However, some patients with abscess present with no fever but with liver function abnormalities and other evidence of sepsis. Absence of flow in the main and right portal vein is associated with echogenic material in the vessels, consistent with portal vein thrombus. Collaterals appeared to be perfusing the left portal vein, suggesting that this was a subacute process, but there is no evidence of splenomegaly, ascites, or contour abnormality of the liver to suggest underlying infiltrative liver disease.</p></sec>
A 60-year-old man presented to the emergency department with dizziness, hypotension, and a 3-week history of abdominal pain, nausea, and vomiting. Three weeks prior to admission he had experienced 1 episode of chills and developed acute abdominal pain that radiated to his back. He was prescribed oxycodone with acetaminophen and his pain improved over a 4-day period, but he still had residual pain and began to experience anorexia, nausea, and vomiting twice a day. By the time he presented to the emergency department, he had lost 12 lb. He was having regular bowel movements and reported no melena. His relevant past history included a Billroth I procedure for duodenal ulcer in 1971.
On examination he was afebrile (temperature, 97.3°) and his heart rate was 92 beats per minute; respiratory rate, 18 breaths per minute; and blood pressure, 76/48 sitting and 90/53 supine. Oxygen saturation was 94% on room air. He had normal mental status, normal neurologic examination, no scleral icterus, and cardiorespiratory evaluation was unremarkable. There was no hepatosplenomegaly or evidence of ascites or varices. The abdomen was not distended, but there was tenderness to palpation in the right upper quadrant.
Results of laboratory evaluation revealed a white blood cell count of 15,800 cells/dL and hematocrit of 40.5% (43.9% 2 months prior to presentation). He had a platelet count of 87,000/dL (287,000/dL 2 months prior to presentation). Electrolytes were as follows: serum sodium, 126 mg/L; potassium, 5.0 mg/dL (from hemolyzed samples); bicarbonate, 16 mg/dL; chloride, 87 mg/dL; with an anion gap of 23. Blood urea nitrogen was 82 mg/dL, and serum creatinine was 4.4 mg/dL (last on 11/04 was 0.7 mg/dL). Serum phosphate was 7.6 mg/dL; and calcium, 7.4 mg/dL. International normalized ratio was 1.5. Initial bilirubin specimens were hemolyzed. Lactate dehydrogenase was 773 mg/dL; aspartate aminotransferase, 912 mg/dL; alanine aminotransferase, 980 mg/dL; and alkaline phosphatase, 748 mg/dL.
A right upper quadrant ultrasound examination was performed (Figures 1a-d).
(Enlarge Image)
Ultrasound of right upper quadrant (RUQ) shows gallstone in gallbladder, and echogenic structure without Doppler signal adjacent to the neck of gallbladder.
(Enlarge Image)
RUQ ultrasound shows gallbladder containing gallstone. No pericholecystic fluid or gallbladder wall thickening is present.
(Enlarge Image)
Color Doppler ultrasound (transverse through liver) shows thrombosis in the main portal vein that appears echogenic with no flow (arrowed). Color flow anterior to this represents hepatic artery and collateral flow.
(Enlarge Image)
Ultrasound through right lobe shows diffuse irregular echogenic appearance, with "dirty" shadows suggesting presence of complex mass with fluid, with no clear margins.
The ultrasound showed absence of flow in the right portal and main portal vein; the left portal vein was patent, with collaterals adjacent. There was no gallbladder wall thickening. A gallstone was present in the gallbladder. No pericholecystic fluid was present, and an ultrasonic Murphy sign was not elicited. There was an echogenic structure near the neck of the gallbladder. A diffusely echogenic, heterogeneous area was present in the right lobe. The common duct was not enlarged. No ascites was seen.
On the basis of the ultrasound and laboratory findings, which of the following diagnoses seems the least likely?
Acute cholecystitis
Diffuse fatty infiltration of liver
Cirrhosis
Intrahepatic abscess
Portal vein thrombosis
A, B, and C all appear to be the least likely diagnoses
View the correct answer.
<p>A, B, and C all appear to be the least likely diagnoses</p><br/><b>Discussion</b><br/><br/><sec sec-type="content"><p>Although there is a gallstone present, absence of gallbladder wall thickening, pericholecystic fluid, and an ultrasonic Murphy sign make the presence of acute cholecystitis unlikely. Diffuse fatty infiltration would appear as echogenicity of the entire liver, not a focal area in the right lobe. There are shadows associated with this area, as well as evidence of enhanced through-transmission, which is seen as more echogenic "shadows," suggesting the presence of fluid. The patchy changes in the right lobe could represent a liver abscess in this setting, although the absence of fever is a little surprising. However, some patients with abscess present with no fever but with liver function abnormalities and other evidence of sepsis. Absence of flow in the main and right portal vein is associated with echogenic material in the vessels, consistent with portal vein thrombus. Collaterals appeared to be perfusing the left portal vein, suggesting that this was a subacute process, but there is no evidence of splenomegaly, ascites, or contour abnormality of the liver to suggest underlying infiltrative liver disease.</p></sec>
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