We report the case of a 76-year-old woman who was admitted to the Vascular Surgery Department due to a post-flabitic syndrome.
During his stay in the plant he presented clinical deterioration, reason why he was admitted to the ICU on May 10, 2003.
Hypertension, obesity, arthrosis and resection of tubular adenoma of the colon were the most important antecedents.
In August 2000, a cholecystectomy was performed due to a lithiasic episode, which resulted in a subheptic inflammatory process leading to subtotal resection of the gallbladder.
On admission he developed DVT of the posterior IBD with atrial fibrillation, starting treatment with amiodarone and coumarins.
In an outpatient study the last month for nonspecific gastrointestinal symptoms observed in analytical control elevation of GGT and AF.
On examination in the ICU she was stupor, icc and with hypotension.
O2 saturation was preserved with a mask.
Auscultation cardiac arrhythmia.
Pulmonary consolidation was normal.
The abdomen was glossal, painful to palpation right hemiabdomen, although without signs of peritoneal irritation and IBD showed good evolution of its thrombosis.
Laboratory tests revealed leukocytes bilirubinl000/mm3, neutrophilia, urea 1.83 g/l, creatinine 4.2 mg/dl total 8.6 mg/dl, AST 106 mg/dl, ALT direct fraction of 5.7 mg/dl
With the diagnosis of sepsis of biliary origin, treatment was initiated with fluid therapy, dopamine, and empirical antibiotic with piperacillin/tapezil obtaining good initial response.
Complementary tests performed: CT-abdominal (11/5/03) showing multiple images hypodense hepatic parenchyma suggestive of abscesses.
Transthoracic and transesophageal echocardiography confirmed the presence of endocarditis at the subvalvular mitral level that conditioned grade II insufficiency.
After this finding vancomycin and gentamicin were discovered for antibiotic treatment.
FNAC of liver injury.
The patient had no bile duct dilatation, although papillotomy was performed to ensure biliary drainage.
The subsequent evolution was unfavorable with the establishment of refractory MODS and exitus 96 hours after admission to the ICU.
Autopsy revealed multicentric cholangiocarcinoma with multiple nodules throughout the organ, local extension to the gallbladder bed and extrahepatic bile ducts, regional metastases to lymph nodes of the hepatic hilium and distant focal points.
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Extensive intratumoral necrosis with cloacae superinfection, also isolated in blood and FNAB samples, was also observed, suggesting that it was the germ responsible for the septic picture.
