Tim Ridgway MD FACP
Associate Professor of Medicine
University 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.
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Hypertension
Anxiety
Osteoarthritis with predominant knee
involvement
No surgeries
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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
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
Abdomen: Nondistended and soft. Bowel
sounds present but decreased. No focal
tenderness to palpation
Neurologic: Disoriented and minimally
responsive. No focal neurologic deficit noted
WBC 15.7 (90% neutrophils and 24% bands)
Hemoglobin 9.8 g/dl Hematocrit 29%
AST 67 U/L, ALT 49 U/L
Alk Phos 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
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Progressive respiratory failure requiring
endotracheal intubation
Progressive neurologic deterioration leading
to unresponsiveness
Marked hypotension requiring pressor
support
Broad spectrum antibiotics started after
appropriate cultures
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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
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Gradual clinical improvement leading to
weaning of pressors and extubation
Streptococcus Intermedius bacteremia
Liver abscess developed in area adjacent to
pnumobilia-percutaneous drainage
performed
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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
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Fistulous connection between duodenal bulb
and left lateral segment of liver
(hepatoduodenal fistula)
Liver abscess adjacent to gallbladder
Left lateral segment abscess/mass
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Drainage of liver abscess
Cholecystectomy
Repair of duodenal ulcer/fistula with a
Graham patch
Open hepatic segmentectomy (segment 3)
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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
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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
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Completed course of Vancomycin
Eventual bilateral Total Knee Arthroplasty
Full recovery!
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< 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
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NSAIDS highest risk for perforation and
penetration
Few cases resolve without surgical
management
Complications include GI bleeding and
hepatic abscess
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A thick gallbladder wall seen on imaging is a
nonspecific finding
Chronic NSAID use-BEWARE!
Pneumobilia without previous interventionSERIOUS!
Sepsis presentation-you have a narrow
window of opportunity