28 yo F Right Upper Quadrant Pain

[Doczilla]

28 yo obese F comes to the ER on a Saturday with a chief complaint of RUQ abdominal pain. She says the pain has been steady for 3 days, waxing and waning in severity. It was not associated with eating or drinking. She has had some nausea and 2 episodes of nonbilious, nonbloody vomiting. She has had no fevers, no rash, no vaginal bleeding or discharge, no diarrhea, melena (black digested blood in stool), or hematochezia (bright red blood in stool). She has not had any dysuria (pain with urinating) or urinary urgency. She denies flank pain. Review of systems is otherwise negative.

She visited the ER 2 days ago for it, had CBC, BMP, UA, UHCG, and a noncontrast abdominal CT done at that time, all of which were normal/negative. She was sent home with instructions to follow up if the pain persisted/got worse or if she had any fever, inability to eat or drink, or other symptoms.

On physical exam, she is smiling and pleasant, not in acute distress.
T: 98 P: 76 R:14 BP: 140/86 Sa)2 99% on room air.
Lung sounds clear and equal bilaterally.
Heart sounds reveal regular rate and rhythm, S1, S2, no murmurs, rubs, or gallops.
Abdomen is soft without any organomegaly. RUQ is tender to palpation, with percussion tenderness. Normal bowel sounds. No pelvic tenderness.
Pelvic exam is unremarkable, with no adnexal or cervical motion tenderness or cervical discharge.
Extremities reveal no rash, cyanosis, or edema.
Neuro exam is grossly intact.

CBC, BMP, LFTs, Lipase, UA, UHCG are all normal. GC and chlamydia cultures are sent and won't be resulted for 2 days.
Ultrasound of the gall bladder shows no stones, ductal dilation, wall thickening, or pericholecystic fluid.
D-Dimer is positive at 1500, so CT of the chest for PE is ordered. There is no PE, but the radiologist notes fluid around the spleen, which is nonspecific.
CT scan of the abdomen is obtained based on the finding from the chest CT, and other than the fluid around the spleen, is normal as read by the radiologist.

The patient is sent home with Nexium and Vicodin, and follow-up is arranged for Monday with surgery to obtain a HIDA scan (nuclear gall bladder scan).

The ER doc Sunday morning is called by the radiologist on the over-read of the abdominal CT. The radiologist says there is some "nonspecific weirdness" in the pelvis, and recommends a transvaginal ultrasound. The patient is contacted to return to the ER, which she does, Monday morning.

When she returns at 9am Monday morning, her RUQ pain continues. Exam is unchanged from previous. Vitals are normal and she is afebrile. She has no RLQ or LLQ tenderness, but based on the fact that the CT was weird, and that it's cheap, harmless, and fast, transvaginal ultrasound is obtained. This is read as having some nonspecific free fluid in the pelvis, but nothing out of sorts. The data from previous visit is reviewed, and other than the cultures not being back yet, there is nothing missing or abnormal. Because of her continued RUQ pain, and the fact that this is her 3rd ER visit for this complaint, I order the HIDA scan, which takes roughly all damn day.

CBC, BMP, LFTs, Lipase, UA, UHCG, are all again normal. HIDA scan is read as normal, with normal gall bladder uptake and 61% EF.

Pelvic exam is repeated. There is no discharge or adnexal tenderness, but this time there is cervical motion tenderness. Based on this, I tell her that I'm going to treat her for cervicitis empirically with the usual antibiotics. I return to the desk to order her rocephin and zithromax, and recheck the cultures from the previous visit. The chlamydia PCR is positive. I return to the room to tell her the confirmed diagnosis, and that her boyfriend is a schmuck.

The patient has Fitz-Hugh-Curtis syndrome, a disease of inflamed liver capsule that is caused by chlamydia or gonorrhea. This is often diagnosed by laparoscopy when the patient is referred to surgery. Treatment with azithromycin and doxycycline is curative in the case of chlamydia, and rocephin in the case of gonorrhea (fluoroquinolones no longer recommended for GC).

I bring this up because many of the folks in this forum will be taking care of young women in the clinic and in the sandbox, and it was interesting to have a case of PID with no pelvic symptoms (and initially a normal pelvic exam). This mimicked an acute surgical issue, and had we not had a wide range of diagnostic data available, she might very well have gone to have her gallbladder out. It also brings home the point that the pelvic exam is important in young women with abdominal pain, no matter where the pain is.

'zilla

[Surgicalcric]

Thanks for the Case Study.

Please feel free to share more.

Crip

[AngelsSix]

The chlamydia PCR is positive. I return to the room to tell her the confirmed diagnosis, and that her boyfriend is a schmuck.

And she's the genius that decided that it was okay to have unprotected sex.

On a side note, why did the culture come back negative if there was no discharge? I know that sometimes it may take over a week for symptoms to develop, but her boyfriend was probably scratching like crazy.

I have to wonder about people sometimes........

[Red Flag 1]

Zilla,

This is really a great case! Multiple visits to the ER with great follow-up, saved her from an application of "tincture of cold surgical steel" to get a diagnosis and treatment.

This was not an easy or routine case. IMHO this is an example of patient care with a great outcome. It has everything to do with the art and science of medicine, not how the disease was transmitted.

Thanks Zilla!!

RF 1

[AustinT]

Out of curiosity, do you recall if her skin or eyes were at all jaundiced? I was leaning towards a hepatitis/ cirrhosis Dx without any real formal training on lab values or radiological imaging. Had the pain been associated with eating I would have been leaning to a gallbladder problem more than a liver problem.
How advanced is the medical training you receive in the 18D course? From reading into the case presented above there seems to be some pretty advanced procedures/ tests, and if you do get trained in such advanced imaging techniques and laboratory procedures through the 18D course, then I am truly impressed.

[frostfire]

thank you for the case, Doczilla.
I'm getting the ED LISM checklists to a second nature.

Maybe I'm a little slow today, but how did you draw the connection from inflamed cervix to inflamed liver capsule?

[Doczilla]

Originally Posted by AustinT

Out of curiosity, do you recall if her skin or eyes were at all jaundiced? I was leaning towards a hepatitis/ cirrhosis Dx without any real formal training on lab values or radiological imaging. Had the pain been associated with eating I would have been leaning to a gallbladder problem more than a liver problem.
How advanced is the medical training you receive in the 18D course? From reading into the case presented above there seems to be some pretty advanced procedures/ tests, and if you do get trained in such advanced imaging techniques and laboratory procedures through the 18D course, then I am truly impressed.

There was no jaundice. The bilirubin has to be fairly high before jaundice appears. Jaundice usually starts at the head and becomes more evident peripherally as the bilirubin increases. An overlooked area of assessment is under the tongue, which is one of the first places to see it. Folks with naturally dark skin may have a yellow/brown discoloration to the sclera naturally. Looking at the sublingual mucosa can help you figure out if this is natural scleral tone or if it is jaundice.

Bilirubin is a breakdown product of hemoglobin. The liver conjugates bilirubin (makes it water soluble) to facilitate excretion, which gives bile it's greenish color. In unconjugated hyperbilirubinemia, as seen with hemolysis or jaundice of the newborn, the skin is a bit more yellowish. In conjugated hyperbilirubinemia, as seen with biliary tract outflow obstruction from gallstones or a pancreatic tumor, conjugated (direct) bilirubin builds up, and the skin is a bit greener.

Her LFT's were normal on the first and 3rd visits. With FHC, sometimes a mild increase in the AST and ALT can be helpful.

I'm not an 18D, so I can't speak intelligently about the nature of the training they receive.

Originally Posted by frostfire

Maybe I'm a little slow today, but how did you draw the connection from inflamed cervix to inflamed liver capsule?

There actually was no inflammation or discharge of the cervix or any indication of PID on the first visit, but then the cervical motion tenderness on the second pelvic exam (3rd visit) was suspicious. The only other clue was the positive chlamydia culture that returned on the 3rd ER visit.

FHC is a well described complication of these sorts of infections, and is thought to result from travel of the infection to the peritoneum from the ends of the fallopian tubes With the positive chlamydia PCR, and exhaustive evaluation of the liver, pancreas, and gallbladder, this left FHC. Many of these patients have unremarkable pelvic exams and are diagnosed on laparoscopy when GB disease is suspected, where the classic "violin string adhesions" are found (picture link below). (given the profile, I understand frostfire knows this aspect well, but I leave it for the other readers).

Males are frequently asymptomatic carriers of the infections as well, so her boyfriend may not have been aware that he had it.

'zilla

http://archive.student.bmj.com/issue...es/view_16.jpg

[Dozer523]

Usually I read these and just marvel at the medical knowledge (and jargon). Sometimes I just think "Ewwwww, Yuck!"
Ocassionally I wonder how someone could be so stupid as to actually incur some of these injuries.
But this is the first time I have seen a radiologist says there is some "nonspecific weirdness". I like that! In an exact science, like medicine, no one in the hospital found that odd or didin't know exactly what he meant.
(You know what I mean.)