Mrs S, a 72-year-old woman, presented with abdominal pain and fever and was found to have ascending cholangitis, portal vein thrombosis, and pneumonia. Her condition deteriorated and she developed septic shock and multi-organ failure. She underwent surgery including splenectomy but her condition continued to worsen. She eventually suffered cardiac arrest and passed away due to septic shock and multi-organ failure resulting from transverse colon diverticulitis and severe pneumonia.

1. MORTALITY REVIEW

2. PATIENT DETAILS
• Name: Mrs S
• ID: AS00488730
• Age: 72 years
• Race: Malay
• Date of admission: 19/02/2020
• Date of death: 25/02/2020

3. HOPI
Presented with
• SOB x 1/7
• abdominal discomfort x 1/7
• passing out flatus and BO
• fever x5/7
• no h/o ill contact
• not lives in dengue prone
area
• lethargic x5/7
• vomiting x5/7
• - 3 to 4 x episodes
• - no blood
• - fluid content
• + LOA and LOW since 3 years
ago

4. UNDERLYING
1. Hypertension
- under KK Kepala Batas f/up
- On T. Nifedipine 10mg OD
2. Dyslipidemia
- on T. Simvastatin 40mg ON
PAST SURGICAL HISTORY:
• History of operation of dynamic hip screw for closed fracture basicervical neck of left
femur in 2017
• done in HSB under GA + Fasciailliaca block
• uneventful , able to discharge 1 day after op

5. PHYSICAL EXAMINATION
• alert, concious
• not tachypneic
• BP : 114/61
• PR : 140
• Temp : 38
• Heart : DRNM
• Respiratory: clear, equal air entry
• Abdomen : soft, not distended, non tender

6. BLOOD INVESTIGATION
• WCC : 39.01/ Hb 11/PLT 195
• RP : Na 137/ K 3.1/ Urea 13.4/
Creat 152
• ALP: 262, Bilirubin 46
BEDSIDE ULTRASOUND
• gallstones
• thickened gallbladder wall
• no free fluid
• CXR: patchy consolidation over
right MZ
• no air under diaphragm
IMPRESSION
1. Treat as ascending cholangitis
2. Cover for CAP
3. AKI secondary to (1) and (2)

7. Initial plan
• IV Rocephine 2g STAT and 1g BD
• KNBM with IVD 4 pint (2 pint NS+ 2 pint D5%)/24H

8. • Uptriaged to red zone for hypotension, BP: 85/64
• on IVI noradreanaline 5mls/H
• BP 126/58 - on IVI noradrenaline 5ml/H
• PR 74
• SPO2 98%
• IMP: ascending cholangitis in sepsis
• Ix:
• WCC: 39.01/ hb 11/ plt 195
• RP : 137/3.1/ 13.4/ 152
• ALP: 262, Bilirubin 46 ( Direct bilirubin 30)

9. US HBS performed on 19.02.2020
Findings
• Liver is normal in echogenecity, no focal lesion.
• Intrahepatic ducts are not dilated. CBD is not dilated.
• Gallbladder well distended with multiple calculi within. No pericholecystic
edema.
• Echogenic thrombus noted within the portal vein. No flow seen within. No
collaterals.
• Presence of periportal echogenecity.
• Spleen measures 11.2cm, no focal lesion.
Impression
1. Periportal echogenecity suspicious of cholangitis.
2. Portal vein thrombosis.
3. Cholelithiasis.

10. On 21/2/2020 around 5 pm,
• Patient started to have low grade
fever and appeared more
tachypneic with RR: 40, NPO2 was
changed to FMO2
• BP:113/68, PR:114, SpO2:100%
• GCS dropped to E3V2M5, 10/15
(On admission, E4V5M6, 15/15)
• On auscultation of the
lungs:generalised ronchi crepts
over right side
• Hence was given Neb Combivent
x2, Neb Salbutamol x 3
• Imp of primary team:
 CAP with bronchospasm
• At around 8pm , patient still
tachypneic and appeared more
lethargic , hence decided for
intubation
• Intubated with ETT size 7 cm,
anchored at 20 cm, CL 1,
• Post intubation,
• lungs: equal air entry
• CXR: Consolidation of right
lower zone
• ECG: Sinus rythm ,T-inversion of
V4, no acute ischemic changes

11. CT Abdomen 22/02/2020
Findings:
• Numerous gallbladder calculi seen. No gallbladder wall thickening. No pericholecystic collection.
There is another calculus seen at the cystic duct.
• Intrahepatic ducts are dilated. CBD is dilated. Common duct wall is thickened and enhancing.
There is a calculus seen at the distal CBD measuring about 0.3cm.
• Free fluid noted.
• There is filling defect seen in the portal vein, splenic vein and IMV.
• No focal liver lesion.
• Pancreas, spleen, both adrenals and both kidneys are normal.
• No hydronephrosis seen bilaterally.
• Ryle's tube seen insitu into the stomach.
• Urinary bladder is underdistended with Foley's catheter in-situ. No bladder calculus. No pooling
of contrast seen.
• Uterus is normal.
• Streak artifact seen at the right femur suggestive of metalic implants.
• No suspicious bony lesions.
• Mild degenerative spine changes.
• Right pleural effusion in visualised right lung basal. It is associated with adjacent consolidation.

12. Impression (CT Abdomen 22/02/2020) :
1. Distal CBD calculus causing biliary duct obstruction and cholangitis
2. Cholelithiasis
3. Portal vein thrombosis
4. Right pleural effusion with right lower lobe consolidation suggestive
of lung infection

13. • Thus, decided for op, underwent Exploratory laparotomy + peritoneal
washout + splenectomy + splenic bed packing 23/02.
• Intraop findings:
• Transverse colon appeared viable,intact with no signs of perforation. No
duskiness of colonic length noted. Sigmoid colon and rectum were normal.
• Appendix normal
• Small bowel intact, normal with no signs of perforation
• Stomach normal including posterior surface
• Lesser sac contained minimal amounts of pus (<20 ml)
• Caudate lobe appeared normal with no signs of ruptured abscess

14. Intraop findings (2):
• Transverse mesocolon (anterior and posterior aspects) revealed to have pockets
of scattered microabcesses with no signs of devascularisation
• Inflammation of mesocolon noted to extend downwards into root of mesentery
and retroperitoneum
• Bleeding from splenic body encountered during dissection - did not resolve
despite attempt at splenorrhapy. Splenic parenchyma friable and not holding
sutures at area of haemmorhage
• Decision made to proceed with splenectomy
• Dense adhesions at right subphrenic space
• Post splenectomy noted pus oozing upwards from splenic bed with
concommitant bleeding
• Prolene 3/0 figure of 8 sutures placed with reduction in bleed
• Area of bleed packed with 2 small abdominal packs after surgicel applied
• bleeding reduced on packing with sustained rise of blood pressure

15. • Specimens sent:
- HPE Spleen
- Pus C+S
- Peritoneal fluid C+S
• Post op diagnosis  Transverse colon diverticular abscess with splenic
haemorrhage
• Post operatively, noted AKI to be worsening, with lactate increasing
• Metabolic acidosis noted, not improved by sodium bicarbonate infusion x1, then
decided for SLED
- Duration 4 hours
- heparin free
- Qb 150-180
- ext nil
• Also, planned for relaparotomy, removal of packing and ERCP KIV right
hemicolectomy on 24/2/2020

16. • Worsening severe metabolic acidosis despite dialysis with persistent
transaminitis and multiorgan failure.
• Mr Giresh (HPB Specialist) spoken with family members (son, daughter and
husband) explain regarding current condition which is multi organ failure,
further surgery would not confer additional benefit for the patient. Patient
condition is critically ill. Family understood regarding prognosis. Family
member also agreed not for CPR and for comfort care .
• Patient develop asystole. Attended STAT by Dr Clarence (MO Surgery).
Upon arriving, patient has no spontaneous breathing, pupil fixed dilated,
cold peripheries, no palpable pulse.
• On auscultation no heart sound heard. Informed family members regarding
condition, they understood.

17. Time of death : 16:10 H on 25/02/2020
Cause of death :
1) Septic shock secondary to transverse colon diverticulitis with
multiorgan failure.
2) Respiratory failure secondary to severe pneumonia

18. THANK YOU