DOCSLIB.ORG

Fever, Abdominal Pain, and Jaundice in a 43-Year-Old Woman

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Fever, Abdominal Pain, and Jaundice in a 43-Year-Old Woman INTERNAL MEDICINE BOARD REVIEW DAVID L. LONGWORTH, MD, EDITOR JAMES K. STOLLER, MD, EDITOR KSRTI SHETTY, MD Dr. Shetty is a resident in internal medicine at the Cleveland Clinic. WILLIAM D. CAREY, MD Dr. Carey is head of the Section of Hepatology and director of the liver transplantation pro- gram at the Cleveland Clinic. He was recently president of the American College of Gastroenterology. Fever, abdominal pain, and jaundice in a 43-year-old woman WHAT IS THE DIAGNOSIS? 4 3-year-old Caucasian woman comes to the emergency room because of right On the basis of the clinical picture and upper abdominal pain that has lasted 2 1 laboratory data, what is the most likely days. The pain is dull and aching, is diagnosis? unrelated to food, and does not radiate. • Acute viral hepatitis AShe notes that her skin tone has become more • Acute cholecystitis yellowish lately, and her urine is dark. • Alcoholic hepatitis The patient says she has drunk three to • Acetaminophen toxicity four beers every day since the age of 18, and • Acute hepatic venous occlusion occasional drinks of vodka or gin on weekends. She abused intravenous drugs in her 20s, but This woman has the classic clinical triad of quit after successful drug rehabilitation. She alcoholic hepatitis: fever, jaundice, and tender has no history erf jaundice, hematemesis, mele- hepatomegaly.1 However, it is imperative to na, ascites, or encephalopathy. She has lost exclude other causes of abdominal pain, such approximately 15 lb over the past 6 months, as biliary tract obstruction, impaired hepatic and her appetite is poor. She takes no medica- venous outflow, and intra-abdominal or sys- tions, except for two to four acetaminophen temic infection. tablets daily. Nothing else in her medical his- Alcoholic hepatitis is caused by excessive tory is remarkable. ethanol consumption, but it develops in only On physical examination, the patient a minority of persons who drink heavily. appears cachexic, and her sclerae are deeply Autopsy studies reveal liver disease in fewer icteric. Her temperature is 39°C. Both parotid than 20% of alcoholics. The amount of glands are enlarged, but she has no palmar ery- ethanol necessary to produce clinically signif- thema or spider nevi. The liver is enlarged and icant disease varies markedly, but most tender to palpation. The spleen is not palpa- patients with alcoholic hepatitis have con- ble, the bowel sounds are normal, and there is sumed more than 80 g/day for at least 15 no ascites. Cardiac auscultation discloses a years—a daily intake of 1 cup of 80-proof loud first heart sound, with a systolic ejection whiskey, 1 liter of 12% wine, or eight 12- murmur (grade 1/6) along the left sternal bor- ounce 6% beers.1 Women who drink are more der. The lung examination is normal. The prone to alcoholic liver disease than are men, patient is drowsy with asterixis, but displays perhaps because they have lower gastric alco- no focal neurologic deficits. hol dehydrogenase activity, leading to less gas- TABLE 1 summarizes the patient's relevant tric detoxication and a greater fraction of laboratory values. alcohol reaching the liver.2 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 64 • NUMBER 4 APRIL 1997 2 1 3 Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. Liver function tests in alcoholic hepatitis ties of the gallbladder TABLE 2 Alcoholic hepatitis differs from viral hepatitis and biliary tract with a THE PATIENT'S LABORATORY in its biochemical profile. sensitivity approach- VALUES Aminotransferase levels. Typically, in ing 95%. Liver alcoholic hepatitis, the serum level of AST enlargement and het- Study Value (aspartate aminotransferase) is less than five erogeneity of texture times the upper limit of normal (ie, less than suggest intrinsic liver Hemoglobin 10.9 g/dL 200 IU/L in 95% of cases, and rarely more disease. Cultures of Hematocrit 30.1 % than 300 IU/L). The ALT (alanine amino- the blood and of any Mean corpuscular volume 102 fL transferase) level is typically less than half the ascitic fluid would White blood cell count 14.9 X 109/L AST level. In contrast, acute viral hepatitis supplement the diag- Platelet count 97 X 109/L and drug-induced hepatic injury produce nostic workup, as Sodium 133 mEq/L extremely high levels of aminotransferases (up would serologic tests Potassium 3.6 mEq/L to 10 times normal). for hepatitis. Glucose 72 mg/dL An AST/ALT ratio greater than 2 has Blood urea nitrogen 11 mg/dL been suggested as a diagnostic test for alco- PREDICTING Creatinine 0.8 mg/dL holic hepatitis. However, in a Veterans THE OUTCOME Aspartate aminotransferase 214 U/L 5 Administration study, only 58% of patients Alanine aminotransferase 62 U/L with alcoholic hepatitis had a ratio that What are the Alkaline phosphatase 225 U/L exceeded 2. 2 most important Gamma-glutamyltransferase 674 U/L In contrast, the ALT level in viral hepati- determinants of Albumin 2.8 g/dL tis is usually higher than the AST level. prognosis in this Bilirubin (total) 12.0 mg/dL Gamma-glutamyltransferase (GGT) lev- patient? Prothrombin time els are almost invariably elevated in alcoholic • Age Patient 17.0 seconds hepatitis. However, increases may reflect • Serum amino- Control 12.0 seconds microsomal enzyme induction rather than transferase levels • SEHBBa liver injury, and as a result, this enzyme is less Serum bilirubin useful for diagnosis and management. • level and prothrombin time Serum bilirubin and alkaline phos- Signs of portal hypertension phatase levels are usually elevated in alco- holic hepatitis, with values that tend to paral- A combination of clinical and laboratory fea- lel one another. Biliary tract obstruction, usu- tures predict the short-term prognosis of ally extrahepatic, is easily confused with alco- patients with alcoholic hepatitis. holic hepatitis, given that both produce dis- proportionate increases in alkaline phos- Indices of mortality phatase and exquisite hepatic tenderness. Two indices can be used to estimate the risk of Further tests, such as ultrasonography, are dying: the composite clinical and laboratory required to tell the difference (see below). index devised by Orrego et al4 (TABLE 2) and the The prothrombin time and albumin con- discriminant function proposed by Maddrey et centration are both used as measures of hepat- al.5 The former is used less in clinical practice, ic synthetic function; although these are often because it uses so many variables. abnormal in alcoholic hepatitis, they provide The discriminant function is much sim- little assistance in the initial diagnosis. pler to calculate: Acute hepatic venous occlusion (Budd- Chiari syndrome) is characterized by sudden 4.6 X[prothrombin time - control (in seconds)] + onset of abdominal pain and tender serum bilirubin (in mg/dL) hepatomegaly. It is almost invariably accom- panied by ascites (95% of cases), and the liver More than 50% of patients with a discrimi- function tests are usually surprisingly normal nant function greater than 32 die while in the or only mildly deranged. hospital. This formula has been validated prospectively as a predictor of survival and, The role of ultrasonography because it is readily applicable to clinical situ- The diagnostic test that would yield the most ations, is the indicator most often used in information at the least cost and degree of practice. invasiveness would be ultrasound scanning of Recent evidence6 suggests that serum the right upper quadrant. In experienced cytokine levels correlate with mortality in hands, ultrasonography can detect abnormali- acute alcoholic hepatitis, and may be useful in CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 64 • NUMBER 4 APRIL 1997 2 07 Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. HEPATITIS • SHETTY AND CAREY refining the prognos- the short term, and should be hospitalized to COMPOSITE CLINICAL AND tic accuracy of the optimize her chances of survival. LABORATORY INDEX SCORE discriminant func- FOR ALCOHOLIC HEPATITIS tion. Other risk fac- Sobriety is essential tors for mortality Patients with alcoholic hepatitis must stop Sign or laboratory value Grade Score* include advanced drinking, but few can achieve total absti- age, encephalopathy, nence—fewer than 20% on questioning,3 and Encephalopathy 1-3 and low serum albu- fewer than 10% on objective testing.8 Referral Collateral circulation 1-2 min levels. None, to chemical dependence programs and various 3 however, is as accu- community-based resources is therefore para- Edema 1 rate as Maddrey's mount. 2-3 discriminant func- However, abstinence does not guarantee Ascites 1-3 tion. improvement. In a study from Emory Spider nevi > 10 9 Weakness The AST and University, no patient recovered who con- Anorexia ALT levels do not tinued to drink, and of these, the hepatitis Prothrombin time correlate significant- progressed to cirrhosis within 18 months in 1 (seconds over control) 4-5 ly with survival. 38%. Nevertheless, only 27% of abstainers > 5 The clinical features returned to normal by the seventh month, Hematocrit (% of normal) 75-89.9 of portal hyperten- and hepatitis progressed to cirrhosis in as < 75 sion are not useful as many as 18%. Albumin level (g/dL) 2.5-2.9 prognostic indica- <2.5 tors.1 Diet therapy is difficult but important Bilirubin level (mg/dL) 2.1-8 Few studies have Malnutrition, often a prominent feature of addressed prognostic alcoholic hepatitis, increases the risk of Alkaline phosphatase level indicators in the dying.3 Experi-mental evidence suggests that (lU/dL) >330 long term. One of correction of malnutrition is essential for these used regression improvement of the liver disease. *A total score > 10 Indicates a risk of dying > 60% analysis to identify Unfortunately, the anorexia associated From Orrego et al, reference 4 three variables that with hepatitis often limits the replenishment predict a high risk of of nutrients.
Load more

Recommended publications
  • Utility of the Digital Rectal Examination in the Emergency Department: a Review
    The Journal of Emergency Medicine, Vol. 43, No. 6, pp. 1196–1204, 2012 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2012.06.015 Clinical Reviews UTILITY OF THE DIGITAL RECTAL EXAMINATION IN THE EMERGENCY DEPARTMENT: A REVIEW Chad Kessler, MD, MHPE*† and Stephen J. Bauer, MD† *Department of Emergency Medicine, Jesse Brown VA Medical Center and †University of Illinois-Chicago College of Medicine, Chicago, Illinois Reprint Address: Chad Kessler, MD, MHPE, Department of Emergency Medicine, Jesse Brown Veterans Hospital, 820 S Damen Ave., M/C 111, Chicago, IL 60612 , Abstract—Background: The digital rectal examination abdominal pain and acute appendicitis. Stool obtained by (DRE) has been reflexively performed to evaluate common DRE doesn’t seem to increase the false-positive rate of chief complaints in the Emergency Department without FOBTs, and the DRE correlated moderately well with anal knowing its true utility in diagnosis. Objective: Medical lit- manometric measurements in determining anal sphincter erature databases were searched for the most relevant arti- tone. Published by Elsevier Inc. cles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive , Keywords—digital rectal; utility; review; Emergency rate of fecal occult blood tests (FOBT) from stool obtained Department; evidence-based medicine by DRE or spontaneous passage, and the correlation be- tween DRE and anal manometry in determining anal tone. Discussion: Sixteen articles met our inclusion criteria; there INTRODUCTION were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood.
    [Show full text]
  • General Signs and Symptoms of Abdominal Diseases
    General signs and symptoms of abdominal diseases Dr. Förhécz Zsolt Semmelweis University 3rd Department of Internal Medicine Faculty of Medicine, 3rd Year 2018/2019 1st Semester • For descriptive purposes, the abdomen is divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. • Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or suprapubic Common or Concerning Symptoms • Indigestion or anorexia • Nausea, vomiting, or hematemesis • Abdominal pain • Dysphagia and/or odynophagia • Change in bowel function • Constipation or diarrhea • Jaundice “How is your appetite?” • Anorexia, nausea, vomiting in many gastrointestinal disorders; and – also in pregnancy, – diabetic ketoacidosis, – adrenal insufficiency, – hypercalcemia, – uremia, – liver disease, – emotional states, – adverse drug reactions – Induced but without nausea in anorexia/ bulimia. • Anorexia is a loss or lack of appetite. • Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation. – in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter • Ask about any vomitus or regurgitated material and inspect it yourself if possible!!!! – What color is it? – What does the vomitus smell like? – How much has there been? – Ask specifically if it contains any blood and try to determine how much? • Fecal odor – in small bowel obstruction – or gastrocolic fistula • Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. • Brownish or blackish vomitus with a “coffee- grounds” appearance suggests blood altered by gastric acid.
    [Show full text]
  • Abdominal Pain - Gastroesophageal Reflux Disease
    ACS/ASE Medical Student Core Curriculum Abdominal Pain - Gastroesophageal Reflux Disease ABDOMINAL PAIN - GASTROESOPHAGEAL REFLUX DISEASE Epidemiology and Pathophysiology Gastroesophageal reflux disease (GERD) is one of the most commonly encountered benign foregut disorders. Approximately 20-40% of adults in the United States experience chronic GERD symptoms, and these rates are rising rapidly. GERD is the most common gastrointestinal-related disorder that is managed in outpatient primary care clinics. GERD is defined as a condition which develops when stomach contents reflux into the esophagus causing bothersome symptoms and/or complications. Mechanical failure of the antireflux mechanism is considered the cause of GERD. Mechanical failure can be secondary to functional defects of the lower esophageal sphincter or anatomic defects that result from a hiatal or paraesophageal hernia. These defects can include widening of the diaphragmatic hiatus, disturbance of the angle of His, loss of the gastroesophageal flap valve, displacement of lower esophageal sphincter into the chest, and/or failure of the phrenoesophageal membrane. Symptoms, however, can be accentuated by a variety of factors including dietary habits, eating behaviors, obesity, pregnancy, medications, delayed gastric emptying, altered esophageal mucosal resistance, and/or impaired esophageal clearance. Signs and Symptoms Typical GERD symptoms include heartburn, regurgitation, dysphagia, excessive eructation, and epigastric pain. Patients can also present with extra-esophageal symptoms including cough, hoarse voice, sore throat, and/or globus. GERD can present with a wide spectrum of disease severity ranging from mild, intermittent symptoms to severe, daily symptoms with associated esophageal and/or airway damage. For example, severe GERD can contribute to shortness of breath, worsening asthma, and/or recurrent aspiration pneumonia.
    [Show full text]
  • Acute Abdomen
    Acute abdomen: Shaking down the Acute abdominal pain can be difficult to diagnose, requiring astute assessment skills and knowledge of abdominal anatomy 2.3 ANCC to discover its cause. We show you how to quickly and accurately CONTACT HOURS uncover the clues so your patient can get the help he needs. By Amy Wisniewski, BSN, RN, CCM Lehigh Valley Home Care • Allentown, Pa. The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity. NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 43 suspects Determining the cause of acute abdominal rapidly, indicating a life-threatening process, pain is often complex due to the many or- so fast and accurate assessment is essential. gans in the abdomen and the fact that pain In this article, I’ll describe how to assess a may be nonspecific. Acute abdomen is a patient with acute abdominal pain and inter- general diagnosis, typically referring to se- vene appropriately. vere abdominal pain that occurs suddenly over a short period (usually no longer than What a pain! 7 days) and often requires surgical interven- Acute abdominal pain is one of the top tion. Symptoms may be severe and progress three symptoms of patients presenting in www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 43 NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 44 the ED. Reasons for acute abdominal pain Visceral pain can be divided into three Your patient’s fall into six broad categories: subtypes: age may give • inflammatory—may be a bacterial cause, • tension pain.
    [Show full text]
  • Review of Systems
    code: GF004 REVIEW OF SYSTEMS First Name Middle Name / MI Last Name Check the box if you are currently experiencing any of the following : General Skin Respiratory Arthritis/Rheumatism Abnormal Pigmentation Any Lung Troubles Back Pain (recurrent) Boils Asthma or Wheezing Bone Fracture Brittle Nails Bronchitis Cancer Dry Skin Chronic or Frequent Cough Diabetes Eczema Difficulty Breathing Foot Pain Frequent infections Pleurisy or Pneumonia Gout Hair/Nail changes Spitting up Blood Headaches/Migraines Hives Trouble Breathing Joint Injury Itching URI (Cold) Now Memory Loss Jaundice None Muscle Weakness Psoriasis Numbness/Tingling Rash Obesity Skin Disease Osteoporosis None Rheumatic Fever Weight Gain/Loss None Cardiovascular Gastrointestinal Eyes - Ears - Nose - Throat/Mouth Awakening in the night smothering Abdominal Pain Blurring Chest Pain or Angina Appetite Changes Double Vision Congestive Heart Failure Black Stools Eye Disease or Injury Cyanosis (blue skin) Bleeding with Bowel Movements Eye Pain/Discharge Difficulty walking two blocks Blood in Vomit Glasses Edema/Swelling of Hands, Feet or Ankles Chrohn’s Disease/Colitis Glaucoma Heart Attacks Constipation Itchy Eyes Heart Murmur Cramping or pain in the Abdomen Vision changes Heart Trouble Difficulty Swallowing Ear Disease High Blood Pressure Diverticulosis Ear Infections Irregular Heartbeat Frequent Diarrhea Ears ringing Pain in legs Gallbladder Disease Hearing problems Palpitations Gas/Bloating Impaired Hearing Poor Circulation Heartburn or Indigestion Chronic Sinus Trouble Shortness
    [Show full text]
  • Chilaiditi's Syndrome Complicated by Colon Perforation
    CASE REPORT Chilaiditi’s syndrome complicated by colon perforation: a case report Turan Acar, M.D., Erdinç Kamer, M.D., Nihan Acar, M.D., Ahmet Er, M.D., Mustafa Peşkersoy, M.D. Department of Surgery, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir ABSTRACT Hepatodiaphragmatic interposition of the small or large intestine is known as Chilaiditi syndrome, whichis a rare disease diagnosed incidentally. Chilaiditi syndrome is typically asymptomatic, but it can be associated with symptoms ranging from intermittent, mild ab- dominal pain to acute intestinal obstruction, constipation, chest pain and breathlessness. A 54-year-old male patient was admitted to the hospital with a history of abdominal pain, nausea and vomiting. Chest X-ray revealed an elevation of the right hemidiaphragma caused by the presence of a dilated colonic loop below. The patient underwent urgent surgery with perforation as preliminary diagnosis. The pa- tient underwent right hemicolectomy and ileocolic anastomosis because of the intestinal obstruction related to Chilaiditi’s Syndrome. Due to the rarity of this syndrome and typical radiological findings, this case was aimed to be presented. Key words: Abdominal pain; Chilaiditi’s syndrome; surgery. INTRODUCTION CASE REPORT Interposition of the bowel (usually transverse colon or he- A 54-year-oldmale patient was admitted to the Emergency patic flexura) or the small intestine between the liver and Department of Surgery, Izmir Katip Celebi University Ataturk diaphragm, which is a rare anomaly, was first defined by the Training and Research Hospital with a 24-hour history of right Greek radiologist Demetrius Chilaiditi in 1910.[1,2] It is inci- upper abdominal pain, nausea and vomiting.
    [Show full text]
  • En 17-Chilaiditi™S Syndrome.P65
    Nagem RG et al. SíndromeRELATO de Chilaiditi: DE CASO relato • CASE de caso REPORT Síndrome de Chilaiditi: relato de caso* Chilaiditi’s syndrome: a case report Rachid Guimarães Nagem1, Henrique Leite Freitas2 Resumo Os autores apresentam um caso de síndrome de Chilaiditi em uma mulher de 56 anos de idade. Mesmo tratando-se de condição benigna com rara indicação cirúrgica, reveste-se de grande importância pela implicação de urgência operatória que representa o diagnóstico equivocado de pneumoperitônio nesses pacientes. É realizada revisão da li- teratura, com ênfase na fisiopatologia, propedêutica e tratamento desta entidade. Unitermos: Síndrome de Chilaiditi; Sinal de Chilaiditi; Abdome agudo; Pneumoperitônio; Espaço hepatodiafragmático. Abstract The authors report a case of Chilaiditi’s syndrome in a 56-year-old woman. Although this is a benign condition with rare surgical indication, it has great importance for implying surgical emergency in cases where such condition is equivocally diagnosed as pneumoperitoneum. A literature review is performed with emphasis on pathophysiology, diagnostic work- up and treatment of this entity. Keywords: Chilaiditi’s syndrome; Chilaiditi’s sign; Acute abdomen; Pneumoperitoneum; Hepatodiaphragmatic space. Nagem RG, Freitas HL. Síndrome de Chilaiditi: relato de caso. Radiol Bras. 2011 Set/Out;44(5):333–335. INTRODUÇÃO RELATO DO CASO tricos, com pressão arterial de 130 × 90 mmHg. Abdome tenso, doloroso, sem irri- Denomina-se síndrome de Chilaiditi a Paciente do sexo feminino, 56 anos de tação peritoneal, com ruídos hidroaéreos interposição temporária ou permanente do idade, foi admitida na unidade de atendi- preservados. De imediato, foram solicita- cólon ou intestino delgado no espaço he- mento imediato com quadro de dor abdo- dos os seguintes exames: amilase: 94; PCR: patodiafragmático, causando sintomas.
    [Show full text]
  • Successful Conservative Treatment of Pneumatosis Intestinalis and Portomesenteric Venous Gas in a Patient with Septic Shock
    SUCCESSFUL CONSERVATIVE TREATMENT OF PNEUMATOSIS INTESTINALIS AND PORTOMESENTERIC VENOUS GAS IN A PATIENT WITH SEPTIC SHOCK Chen-Te Chou,1,3 Wei-Wen Su,2 and Ran-Chou Chen3,4 1Department of Radiology, Changhua Christian Hospital, Er-Lin branch, 2Department of Gastroenterology, Changhua Christian Hospital, 3Department of Biomedical Imaging and Radiological Science, National Yang-Ming University, and 4Department of Radiology, Taipei City Hospital, Taipei, Taiwan. Pneumatosis intestinalis (PI) and portomesenteric venous gas (PMVG) are alarming radiological findings that signify bowel ischemia. The management of PI and PMVG remain a challenging task because clinicians must balance the potential morbidity associated with unnecessary sur- gery with inevitable mortality if the necrotic bowel is not resected. The combination of PI, portal venous gas, and acidosis typically indicates bowel ischemia and, inevitably, necrosis. We report a patient with PI and PMVG caused by septic shock who completely recovered after conservative treatment. Key Words: bowel ischemia, computed tomography, pneumatosis intestinalis, portal venous gas, portomesenteric venous gas (Kaohsiung J Med Sci 2010;26:105–8) Pneumatosis intestinalis (PI) and portomesenteric CASE PRESENTATION venous gas (PMVG) are alarming radiologic findings that signify bowel ischemia [1]. PI and PMVG are A 78-year-old woman who presented with intermittent often described as an advanced sign of bowel injury, fever for 3 days was referred to the emergency depart- indicating irreversible injury caused by transmural ment of our hospital. The patient had a history of ischemia [2]. Bowel ischemia may be associated with type 2 diabetes mellitus, congestive heart failure, and perforation and has a high mortality rate. Many au- prior cerebral infarct.
    [Show full text]
  • Travelers' Diarrhea
    Travelers’ Diarrhea What is it and who gets it? Travelers’ diarrhea (TD) is the most common illness affecting travelers. Each year between 20%-50% of international travelers, an estimated 10 million persons, develop diarrhea. The onset of TD usually occurs within the first week of travel but may occur at any time while traveling and even after returning home. The primary source of infection is ingestion of fecally contaminated food or water. You can get TD whenever you travel from countries with a high level of hygiene to countries that have a low level of hygiene. Poor sanitation, the presence of stool in the environment, and the absence of safe restaurant practices lead to widespread risk of diarrhea from eating a wide variety of foods in restaurants, and elsewhere. Your destination is the most important determinant of risk. Developing countries in Latin America, Africa, the Middle East, and Asia are considered high risk. Most countries in Southern Europe and a few Caribbean islands are deemed intermediate risk. Low risk areas include the United States, Canada, Northern Europe, Australia, New Zealand, and several of the Caribbean islands. Anyone can get TD, but persons at particular high-risk include young adults , immunosuppressed persons, persons with inflammatory-bowel disease or diabetes, and persons taking H-2 blockers or antacids. Attack rates are similar for men and women. TD is caused by bacteria, protozoa or viruses that are ingested by eating contaminated food or beverages. For short-term travelers in most areas, bacteria are the cause of the majority of diarrhea episodes. What are common symptoms of travelers’ diarrhea? Most TD cases begin abruptly.
    [Show full text]
  • Case Report Young Man with Hepatomegaly: a Case of Glycogenic Hepatopathy
    Hindawi Case Reports in Hepatology Volume 2018, Article ID 6037530, 5 pages https://doi.org/10.1155/2018/6037530 Case Report Young Man with Hepatomegaly: A Case of Glycogenic Hepatopathy Walid Abboud ,1 Saif Abdulla,1 Mohammed Al Zaabi,2 and Ramzi Moufarrej3 1 Department of Internal Medicine, Zayed Military Hospital, Abu Dhabi, UAE 2Department of Gastroenterology, Zayed Military Hospital, Abu Dhabi, UAE 3Department of Critical Care, Zayed Military Hospital, Abu Dhabi, UAE Correspondence should be addressed to Walid Abboud; [email protected] Received 19 December 2017; Accepted 3 March 2018; Published 15 April 2018 Academic Editor: Manuela Merli Copyright © 2018 Walid Abboud et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Glycogenic hepatopathy is a rare but potentially reversible condition characterized by hepatomegaly and elevated liver enzymes occurring in poorly controlled type 1 diabetes mellitus patients and ofen requires a liver biopsy to confrm the diagnosis. We present the case of a young man who was admitted with diabetic ketoacidosis in the setting of poorly controlled diabetes mellitus type 1 and was noted to have signifcantly elevated transaminases that continued to worsen despite appropriate treatment of the diabetic ketoacidosis. A liver biopsy confrmed the diagnosis of glycogenic hepatopathy and the patient improved with diabetes control. Te aim of this report is to shed light on possible causes of signifcant elevation of liver enzymes in patients presenting with diabetic ketoacidosis. In addition, we would like to raise awareness about the diagnosis, management, and prognosis of glycogenic hepatopathy and how to diferentiate it from other hepatic conditions that have a similar presentation.
    [Show full text]
  • Evaluation of Acute Abdominal Pain in Adults Sarah L
    Evaluation of Acute Abdominal Pain in Adults SARAH L. CARTWRIGHT, MD, and MARK P. kNUDSON, MD, MSPh Wake Forest University School of Medicine, Winston-Salem, North Carolina Acute abdominal pain can represent a spectrum of conditions from benign and self-limited disease to surgical emergencies. Evaluating abdominal pain requires an approach that relies on the likelihood of disease, patient history, physical examination, laboratory tests, and imag- ing studies. The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis. Certain elements of the history and physical examination are helpful (e.g., constipation and abdominal distension strongly suggest bowel obstruction), whereas others are of little value (e.g., anorexia has little predictive value for appendicitis). The American College of Radiology has recommended dif- ferent imaging studies for assessing abdominal pain based on pain location. Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recom- mended for right and left lower quadrant pain. It is also important to consider special popula- tions such as women, who are at risk of genitourinary disease, which may cause abdominal pain; and the elderly, who may present with atypical symptoms of a disease. (Am Fam Physi- cian. 2008;77(7):971-978. Copyright © 2008 American Academy of Family Physicians.) bdominal pain is a common pre- disease (e.g., vascular diseases such as aor- sentation in the outpatient setting tic dissection and mesenteric ischemia) and and is challenging to diagnose. surgical conditions (e.g., appendicitis, cho- Abdominal pain is the present- lecystitis).
    [Show full text]
  • Abdominal Pain
    10 Abdominal Pain Adrian Miranda Acute abdominal pain is usually a self-limiting, benign condition that irritation, and lateralizes to one of four quadrants. Because of the is commonly caused by gastroenteritis, constipation, or a viral illness. relative localization of the noxious stimulation to the underlying The challenge is to identify children who require immediate evaluation peritoneum and the more anatomically specific and unilateral inner- for potentially life-threatening conditions. Chronic abdominal pain is vation (peripheral-nonautonomic nerves) of the peritoneum, it is also a common complaint in pediatric practices, as it comprises 2-4% usually easier to identify the precise anatomic location that is produc- of pediatric visits. At least 20% of children seek attention for chronic ing parietal pain (Fig. 10.2). abdominal pain by the age of 15 years. Up to 28% of children complain of abdominal pain at least once per week and only 2% seek medical ACUTE ABDOMINAL PAIN attention. The primary care physician, pediatrician, emergency physi- cian, and surgeon must be able to distinguish serious and potentially The clinician evaluating the child with abdominal pain of acute onset life-threatening diseases from more benign problems (Table 10.1). must decide quickly whether the child has a “surgical abdomen” (a Abdominal pain may be a single acute event (Tables 10.2 and 10.3), a serious medical problem necessitating treatment and admission to the recurring acute problem (as in abdominal migraine), or a chronic hospital) or a process that can be managed on an outpatient basis. problem (Table 10.4). The differential diagnosis is lengthy, differs from Even though surgical diagnoses are fewer than 10% of all causes of that in adults, and varies by age group.
    [Show full text]