Lap Appy

[militarymd]

Surgeon adds on an appy.

30 year old otherwise healthy guy with 2 day history of anorexia, pain, nausea/vomiting, etc.

White count up.

low grade fever.

CT scann suggestive of acute appy.

Patient comes to preop...I review labs....AST/ALT are 300 + each.

No ruq pain.

No jaundice

no spiders

no acites on exam or on CT.

no palmar erythema..

essentially no physical evidence of liver disease.

No history of hepatitis....or social history that puts this guy at risk other than
a blood transfusion in the 70's.


What would you guys do?

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[Planktonmd]

Surgeon adds on an appy.

30 year old otherwise healthy guy with 2 day history of anorexia, pain, nausea/vomiting, etc.

White count up.

low grade fever.

CT scann suggestive of acute appy.

Patient comes to preop...I review labs....AST/ALT are 300 + each.

No ruq pain.

No jaundice

no spiders

no acites on exam or on CT.

no palmar erythema..

essentially no physical evidence of liver disease.

No history of hepatitis....or social history that puts this guy at risk other than
a blood transfusion in the 70's.


What would you guys do?

Mild elevation of transaminase with a remote history of blood transfusion could suggest chronic viral hepatitis either Hep B or Hep C.
Since there is no clinical evidence of severe liver disease and the guy has acute appy he has to go to the OR.
Avoid hypotension and hypoxia
He needs hepatitis workup later.

 

[BADMD]

How much acetaminophen has he been taking for his belly pain?

 

[dhb]

Why did he get a transfusion when he was less than 2 y/o?

What would i do : put on gloves, smells like hep C. Could be the ischemic appy...
Follow up with hepatologist.

 

[militarymd]

How much acetaminophen has he been taking for his belly pain?

none

 

[quaker1996]

none

I can't see what you could do in the short term if this is emergent, just drive on but was there a history of Wilson's Disease in the family?

 

[militarymd]

I'm posting this not because anesthesia is UNsafe for this patient, because I had no problems taking him to the OR....

Although on visual inspection, his liver is cirrhotic.

What would you all had said if his enzymes were 1500 or so.....or let's say 2000 or so....

Or even better, he had evidence of chronic and acute liver disease....and his red palms were flapping away...

What would you do then?

 

[sevoflurane]

Emergent right?

then...

Awake A-line + fluids. RSI. Tube. Cisatracurium. Central line with good access. Quick TEE or TTE if it's handy. No epidural if you don't have coags (you could do this case with only epidural). Treat like liver tx. If he is flapping away he doesn't need much of anything.

 

[Jeff05]

RSI. no benzos.
A line pre/post induction.
avoid hypotension to maintain hepatic perfusion pressure.

 

[VentdependenT]

to or. Get coags intraop

 

[toughlife]

I'm posting this not because anesthesia is UNsafe for this patient, because I had no problems taking him to the OR....

Although on visual inspection, his liver is cirrhotic.
What would you all had said if his enzymes were 1500 or so.....or let's say 2000 or so....

Or even better, he had evidence of chronic and acute liver disease....and his red palms were flapping away...

What would you do then?

His presentation is consistent with hepatitis as someone mentioned earlier. LFts certainly support it. Acute cholangitis doesn't fit the picture and it doesn't sound like it was even a concern based on the imaging studies. NASH can also be a cause of his LFT elevation and could just be an incidental finding in this case.

Even if his enzymes were higher as you said and he showed evidence of hepatic encephalopathy, I would still take him emergently. The risk of perforation and sepsis are definitely there if the surgery is delayed. Any coagulopathy issues can be addressed intraop.

 

[Planktonmd]

I can't see what you could do in the short term if this is emergent, just drive on but was there a history of Wilson's Disease in the family?

I am curious:
Why Wilson's disease specifically?
There are many rare metabolic diseases that can involve the liver:
Hemochromatosis, Amiloidosis, Biliary Cirrhosis......
The differential list for elevated liver enzymes is very extensive including simple fatty liver,cirrhosis, viral hepatitis, chemical hepatitis, autoimmune hepatitis, even zebra's like suprahepatic thrombosis (Budd-Chiari).....
So is there a reason why Wilson's disease is the first differential you would consider?

 

[militarymd]

His presentation is consistent with hepatitis as someone mentioned earlier. LFts certainly support it. Acute cholangitis doesn't fit the picture and it doesn't sound like it was even a concern based on the imaging studies. NASH can also be a cause of his LFT elevation and could just be an incidental finding in this case.

Even if his enzymes were higher as you said and he showed evidence of hepatic encephalopathy, I would still take him emergently. The risk of perforation and sepsis are definitely there if the surgery is delayed. Any coagulopathy issues can be addressed intraop.

Usually not this high.

 

[Planktonmd]

Emergent right?

then...

Awake A-line + fluids. RSI. Tube. Cisatracurium. Central line with good access. Quick TEE or TTE if it's handy. No epidural if you don't have coags (you could do this case with only epidural). Treat like liver tx. If he is flapping away he doesn't need much of anything.

Are you serious?
This is a 20 minutes case in private practice world!
Why do you need all that stuff?

 

[militarymd]

As physicians, sometimes we have to offer ALTERNATIVE therapies to our patients OTHER than "put them to sleep".....which is almost always my answer.

Is there no other way to manage appendicitis? other than to go to the OR.

Check Pubmed about MEDICAL MANAGEMENT of acute appendicitis.

This patient was fine, BUT there ARE other options if you think the patient is too sick.

The point I was making is that appendicitis can be managed non-operatively.........I would have thought the academics would have considered it an option from the get go.

Not the case in this patient, but I've done it in the past.

 

[quaker1996]

So is there a reason why Wilson's disease is the first differential you would consider?

Not the first, but asymptomatic young male; fits this zebra.

 

[Noyac]

It was very common in the past and in our current VA system to watch acute appendicitis and even ruptured appy's. They would manage non operatively allowing the ruptured appy to wall off the abscess and then operate approximately 6 weeks later.

If this guy had a severe case of hepatitis then this is an option.

 

[Arch Guillotti]

Are you serious?
This is a 20 minutes case in private practice world!
Why do you need all that stuff?

You beat me to asking all those questions, to which I am curious as well.

 

[militarymd]

I can't see what you could do in the short term if this is emergent, just drive on but was there a history of Wilson's Disease in the family?

Although, metabolic diseases that lead to elevated Liver associated enzymes went through my mind, I didn't bother with a more detailed history.

I only took enough H&P to rule out show stoppers....things that would make me tell the surgeon, we're not going to the OR for this appy.

Having not finding any real show stoppers, I ran off to see another patient as the CRNA wheeled the patient back.

 

[militarymd]

I can't see what you could do in the short term if this is emergent, just drive on but was there a history of Wilson's Disease in the family?

However, I did care enough to go by the room during the case to :

1) ask the surgeon to visually inspect the liver
2) if abnormal, please take a biopsy

Surgeon buddy did number 1...which showed a nodular scarred down liver, but he declined on the biopsy because consent was not obtained.

 

[sevoflurane]

Are you serious?
This is a 20 minutes case in private practice world!
Why do you need all that stuff?

Because I'm in residency and still training. Academic and Private are two different beasts I'm sure. At my teaching institution... lap appys can take a lot longer than 20 minutes, especially if surg. intern is doing most of the work. "Ooops... is that a hole in the colon?" Unfortunately, I've seen lapp appys turn into disasters. I don't know if I've ever seen a twenty minute lap appy. I haven't seen private practice.

I'm imagining someone who is in liver failure, encephalopathic, has asterisix and is needing emergent surgery. I'd want to get as much info as I can if I sensed an unstable patient. A-line, Central line, TTE don't take that long. If this guy was sicko-liver-type dude... good chance he'd get all that stuff once he got back to the micu.

 

[toughlife]

As physicians, sometimes we have to offer ALTERNATIVE therapies to our patients OTHER than "put them to sleep".....which is almost always my answer.

Is there no other way to manage appendicitis? other than to go to the OR.

Check Pubmed about MEDICAL MANAGEMENT of acute appendicitis.

This patient was fine, BUT there ARE other options if you think the patient is too sick.

The point I was making is that appendicitis can be managed non-operatively.........I would have thought the academics would have considered it an option from the get go.

Not the case in this patient, but I've done it in the past.

you beat me to it. I wanted to suggest an abx course and observation as this is commonly done even with acute events of appendicitis if the patient's comorbidities preclude him from an emergent trip to the OR. Some surgeons prefer to 'cool things off" with abx before operating.

 

[militarymd]

you beat me to it. I wanted to suggest an abx course and observation as this is commonly done even with acute events of appendicitis if the patient's comorbidities preclude him from an emergent trip to the OR. Some surgeons prefer to 'cool things off" with abx before operating.

do a lit search, you may be surprised at how many patients with appys NEVER have to go to the OR.

Our reimbursement system does the following:

1) it pays for surgery to remove appy
2) it pays for anesthesia to allow appy removal
3) it does not pay for NOT removing appy
4) it does not pay the anesthesiologist to suggest medical management.


AND unfortunately, a lot of medicine is dictated by how people are getting paid.

 

[IlDestriero]

I don't know if I've ever seen a twenty minute lap appy. I haven't seen private practice.

I'm imagining someone who is in liver failure, encephalopathic, has asterisix and is needing emergent surgery. I'd want to get as much info as I can if I sensed an unstable patient. A-line, Central line, TTE don't take that long. If this guy was sicko-liver-type dude... good chance he'd get all that stuff once he got back to the micu.

The 20 min lap appy does exist, it is the half brother of the 45 min lap chole.
If the MICU wants some lines you don't need in the OR, they can place them.
I have seen the light.
Regards.

 

[VentdependenT]

As always, MMD gets me thinking on new tracks. I either forgot, or just plain didn't know, that the acute appy could be managed medically. At least initially. Cephalosporin and flagyl/clinda eh?

Thanks for the post holmes.

 

[joshmir]

what were the show stoppers that ran through your mind? what are they in general (ie, not spedifically this pt, but any emergent pt)

 

[militarymd]

what were the show stoppers that ran through your mind? what are they in general (ie, not spedifically this pt, but any emergent pt)

There aren't that many:

1) acute hepatitis (I cancelled one about a month ago....LAE about 4,000)
Surgeon pissed and moaned, but came back to me a week later and thanked me for checking the labs before heading to the OR

2) changing creatinine level or high creatinine level that is undiagnosed AND undergoing procedure that puts renal perfusion at risk (cancelled a FESS about a year ago when the Cr came back at a 4).....

3) recent stent ....less than 6 weeks...and need plavix off the surgery

4) evolving MI

5) anyone dumb enough not to understand the risks of heading to the OR

probably others that I can't think of right now because I'm post call