[Music]
so this 62 year old woman presents in
the emergency room with a fever and this
discomfort in her upper abdomen for two
days she took some antacids thinking it
was indigestion but didn't help on
physical exam her blood pressure is low
80 over 55 her heart rate is reasonable
at 88 and she has an elevated
temperature at 39 point five centimeter
or 103.1 Fahrenheit her jugular venous
pulse is flat so there's not right
atrial elevated pressure
she has clear lungs so we're not seeing
any sign of heart failure
she has an s4 but again as I said before
that just means her ventricle left
ventricle is a little bit stiff and that
could be due to aging or a whole variety
of cardiac conditions she has some
tenderness and guarding in the right
upper quadrant so when you feel here oh
she says that hurts when we press just
under the right rib and we're going to
show you ECG and some lab values by the
way what's going on here there's a fever
that suggests an infection there's no
signs of left ventricular failure and so
but she has some signs that there's
something going on in her abdomen
particularly on the right upper quadrant
here's her electrocardiogram look at it
and think about it for a moment
so if you looked at it you would note
that there's ST segment depression in
leads v2 through v6 squared-off ST
segment depression implying myocardial
ischemia notice for comparison the
normal ST segment in the little strip
below and the marked clear ST segment
depression so this implies that there's
myocardial ischemia going on well of
course with that she's taken to the cath
lab and there's a hundred percent
occlusion of her right coronary artery
which is opened with a stent but the
fever is something different you don't
have a high fever with a myocardial
infarct and you don't have right upper
quadrant discomfort so some blood
cultures are sent and the blood culture
shows a little bit of elevated troponin
um that suggests myocardial ischemia and
an injury to the heart but we already
know that there was a ski Mia from a
blocked coronary artery which we've
opened up now so what else is going on
well we do an echocardiogram and that
shows that there's lack of blood flow
inferiorly so presumably this lady had
had a myocardial infarct at some point
possibly it's relatively recent because
the troponin is elevated her left
ventricular ejection fraction is 40
percent so it's reduced normal the lower
limit of normal is 50% um but we're
still worrying about her abdominal
discomfort and her fever that doesn't go
with a myocardial infarct well we get an
ultrasound
we had an echo ultrasound of her heart
now we're getting an echo ultrasound of
her abdomen there stones in the
gallbladder
she has a dilated common bile duct which
is a sign of a stone in the bile duct
and sure enough she has an impacted
stone in the in the bile duct and that's
led to a acute infection in the gall
bladder acute cholecystitis at the same
time she had her heart attack so she has
to diagnosis an acute non-st elevation
MI and acute cholecystitis now that this
has been discussed much in the
literature is it possible that the acute
cholecystitis
Sibbett ated enough inflammation to
cause the clot to form in the coronary
arteries or to the myocardial
infarctions start first and somehow
result in a heightened activity in the
abdomen and in the bile system that led
to the acute cholecystitis where there
were already stones we don't know here
which is the chicken and which is the
egg but we know the lady has two
diseases so the diagnostic tests that
are subsequent we check her chest x-ray
make sure she's not in heart failure we
do a blood panel to assess kidney and
liver function because we're thinking
about possible surgical intervention on
her gallbladder we do a CBC which is a
hematocrit to make sure she's not anemic
and we look at a white blood cell count
in this case the white blood cell count
would be elevated because of the
infection she's already had her right
coronary artery opened and we get
gastroenterology and surgery
consultations to talk about the
management of her acute cholecystitis
with a recent myocardial infarct she
gets intravenous antibiotics to control
the infection in the gallbladder and
then we have a number of options one the
radiologist could put a tube in and just
drain the gallbladder and wait a few
weeks because surgeons don't like to
operate on people who've had a recent
heart attack or recent myocardial
infarct on the other hand one could do
laparoscopic cholecystectomy which is
much less traumatic and could go be done
very very quickly
some people would argue the best option
was laparoscopic some people would say
drainage followed by laparoscopic down
the road
in any case her gallbladder has to come
out because once it's been infected like
this there's a high likelihood that this
will happen again
[Music]