Mental Status Changes after Cholecystectomy - Forum

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Paranoid

Mental Status Changes after Cholecystectomy - Ärzteforum

Post#1 »

Interesting case recently I'll summarize for members:

64 year-old female on coumadin for history of CVA secondary to intracranial vascular disease, presented with acute cholecystitis. Begun on antibiotics, converted to heparin, heparin held 4 hours preop, underwent lap chole converted to open due to adhesions obscuring anatomy. Heparin restarted 12 hours postop, coumadin resumed. Clear liquids POD#3, some diarrhea POD#5, C.diff titer negative, felt well, eating solids POD#6, discharged home.

Returned 24 hours later with mental status changes--confusion, hypotension (SBP 95-105), low-grade temp (100.5). Some crampy abominal pain but no tenderness. WBC 10,000, AST, ALT, GGT normal. Total Bilirubin normal. Sodium 128, Potassium 5.6. Creatinine normal. Blood gas normal. EKG normal.

Blood cultures taken, broad spectrum antibiotics begun. CT Head--normal. Abd plain films--normal.

Over next 24 hours mental status deteriorated--confusion, lethargy, coma. Low-grade fever continued.

Diagnosis?


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Surgeon

Re: Mental Status Changes after Cholecystectomy - Ärzteforum

Post#2 »

Sounds like this patient is septic. My personal bias for this type of history is that I reexplore them. I would perhaps get an US pre-op, with the sole intention of percuraneous drainage if an abscess is found. I would proceed with the plan to re-explore if the US is negative.

In my series, more than half the patients have a surgically correctable lesion, including some with normal CT scans. I don't think that the morbidity of a negative re-lap is significat.

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Billroth

Re: Mental Status Changes after Cholecystectomy - Ärzteforum

Post#3 »

Firstly, why have you not considered the obvious, i.e hyponatraemia ?

Secondly, what were the results of arterial blood gases, serum creatinine and urea? Did he appear fluid depleted?

Lastly, you failed to mention whether there were any lateralising signs which may indicate a stroke (stroke in evolution)

From your description I would hedge my bets on a metabolic neurological disorder.

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Billroth

Re: Mental Status Changes after Cholecystectomy - Ärzteforum

Post#4 »

Two more things:

Is the patient on potasssium sparing diuretics?

It is interesting that she should have a picture akin to increased aldosterone secretion.

Lastly, what were here urine and plasma osmolality?

Chirurgia

Re: Mental Status Changes after Cholecystectomy - Ärzteforum

Post#5 »

I'd think your patient presented an intracranial vascular arrest.

Chirurgia

Re: Mental Status Changes after Cholecystectomy - Ärzteforum

Post#6 »

I meant intracranial hemorrhage due to the use of anticoagulants.

Paranoid

Re: Mental Status Changes after Cholecystectomy - Ärzteforum

Post#7 »

Thanks to all who replied. Based on her course, I obtained an abdominal CT scan. No abscess, fluid or ductal dilatation but incidentally noted were massive bilateral adrenal hemorrhages. Two hours later her serum cortisol level, sent off when she presented, came back markedly low. Based on this evidence, treated her for acute adrenal insufficiency with hydrocortisone, within 10 hours she was alert and oriented, hemodynamically stable, afebrile and eating solids. Subsequent ACTH stimulation test confirmed Dx. Literature review by me confirms this relatively rare postoperative complication is more common in patients on coumadin, which I did not know.

Hans

Re: Mental Status Changes after Cholecystectomy - Ärzteforum

Post#8 »

Whilst your CT would exclude a bleed at such an early stage after onset of symptoms it might not show an infarct. It would bear repeating. Unfortunately an elderly comatose patient may well not manifest much in the way of clinical signs if there was an abdominal catastrophe such as a bile leak. Unless she had a flat abdomen I would be inclined to have a look before she went off to ICU and I doubt if CT abdo or USScan would do much to put me off. Sounds bad though.

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