Case Discussion <Chief Complain> The 48-year-old man was admitted on April 4, 2001 because of shortness of breath for one day and recurrent VT transferred from local hospital. <Brief History> This 48 year-old man had history of hypertension without regular medical control. He suffered from sudden onset of chest tightness, shortness of breath and cold sweating on March 3, 2001. He was sent to a local hospital where ECG revealed ST segment elevation over V2-V5. Elevated cardiac enzyme was also noticed (CK: 3227, CK-MB: 112, LDH: 3406). He was admitted to CCU under the impression of AMI, anterior wall, Killip II. No thrombolytic therapy was given because the golden hour passed. The cardiac enzyme returned to normal value gradually under IV NTG and heparin treatment. However, recurrent wide QRS-complex tachycardia developed despite antiarrhythmic agents including lidocaine, amiodarone and procainamide use. He was then transferred to our hospital on April 4, 2001.  Emergent coronary angiography revealed CAD, 1-V-D. PTCA to LAD was performed smoothly. Recurrent VT happened during ICU stay despite adjustment of anti-arrhythmic agent. An episode of Vf with consciousness loss occurred on April 20, 2001. EP study on the same day revealed multiple（more than 6） sustained monomorphic VTs and no SVT. Procainamide was prescribed and intermittent DC shock was performed. He was intubated again on April 22 because of acute lung edema. Heart transplantation was suggested for frequent VT and poor cardiac reserve. On June 4, 2001 morning, he complained of right side chest pain. No cold sweating, dyspnea or fever was noted. Local tenderness over right chest and right upper quadrant were also found. Chest X-ray did not reveal new pulmonary lesion. The pain was migratory and shifted to right lower quadrant in the afternoon. His appetite was as usual though no stool passage for two days. On examination, the abdomen was soft. Bowel sound was hypoactive. RLL tenderness was noted. No rebound tenderness or peritoneal sign was found at that time. The results of laboratory and radiographic studies were as following: 1.CBC/DC:   WBC RBC Hb Hct PLT   /ul M/ul G/dL % K/ul 90-05-29 9520 3.35 10.1 30.9 361 90-06-01 11140 3.6 10.6 33.4 417 90-06-04 21930 3.95 12.0 36.0 489 90-06-06 19010 3.02 9.0 2.6 329 2.BCS+e   BUN Cre Na K Cl Amyla Lipas GOT T-Bil Mg/dL Mg/dL mmol/L Mmol/L Mmol/L U/L U/L U/L mg/dL 90-05-29 24.4 1.52 132.3 3.78 106         90-06-01 22.3 1.37 132.5 4.02 101         90-06-04     131.4 3.72           90-06-05 28.2 2.17 130.3 4.1 99 59 16 30 0.85 3. Abdominal CT scan: <Figur1,Figure2> <病案討論> 本病人因反覆性心室速動（Ventricular Tachycardia）入院接受治療。病人最近罹患前壁急性心肌梗塞，Killip II，經心導管檢查，發現為左前降枝冠心症（CAD，1-V-D，LAD），雖經冠狀動脈擴張術，病人仍復發心室速動，並曾併發心室顫動（ventricular fibrillation），接受氣管插管及電擊治療。病人同時接受多種抗心率不整藥物治療，包括：amiodarone、phenytoin、lidocaine等，並準備接受接受心臟移植。  病人於加護病房治療期間出現右側胸痛，疼痛並轉移至右上腹部及右下腹部，此外病人長期即患有慢性便秘問題。身體檢查發現病人體溫升高，右上及右下腹部輕微壓痛，莫非氏徵候（Murphy’s sign）不明顯，但並無反彈性壓痛或腹膜炎徵候。  血液檢查發現白血球增高，肝功檢查：GOT及Bil-T正常，Amylase及Lipase亦正常。因懷疑腹腔內感染存在，故安排腹部超音波檢查，發現膽囊壁雖未水腫增厚（3mm），但膽囊明顯擴大，而且病患出現輕微超音波下的莫非氏徵候，因此安排腹部電腦斷層檢查。檢查結果發現，膽囊明顯擴大，同時附近軟組織有發炎現象（dirty fat plane around the gall bladder），並未發現膽結石。因此診斷為「無結石性膽囊炎」(acalculous cholecystitis)，病人接受開刀治療，施行膽囊切除術。術中發現為壞死性膽囊炎（gangrenous cholecystitis with empyema）。手術採全身麻醉進行，術中並未發生心室過速或顫動狀況，術後病患復原狀況良好，感染徵候消失。病理檢查發現膽囊壁已出現壞死性變化（gangrenous change）。 繼續教育考題 1. (C) Sustained VT is mostly defined as persistent VT for ? A 15 secs. B 20 secs. C 30 secs. D 45 secs. E 60 secs. 2. (A) Which one is wrong in the following statement about VT from AMI ? A Prophylactic use of lidocaine can reduce the mortality  B Hyoxemia, hypokalemia or hypomagnesemia may precipitate torsade de point. C Within the first 24 hrs of AMI, VT can occur without prior warning signs. D VT associated with hypotension should be terminated with electrical cardioversion. E  None of the above. 3. (D) Which one is wrong in the following statement about VT from AMI ?  A Sustained VT developed within the frirst 6 week folowing AMI carried 75% mortality rate at 1 yrear. B Sustained VT following AMI have a threefold greater risk of death than AMI without VT. C . Sustained VT occurrs most commonly within 24 hr of the onset. D . None of the above. 4. (C) What is the best initial test of choice for suspicious acute cholecystitis ?  A Abdominal CT scan. B Abdominal MRI. C Abdominal ultrosonography. D Laparoscopy. E Laparotomy. 5. (D) Which is wrong in the following statement about cholescintigraphy ? A The normal GB and biliary tract visualize after radionuclide injection (Tc-99m) B Morphine could increase the sensitivity of cholescintigraphy. C The sensitivity of this test reached 90%. D Metoclopramide could be used to increase the sensitivity. E None of above. 6. (A) What is the proportion of acute cholecystitis, in which biliary stone can not be found ?  A 5-10%. B 15-20%. C 25-30%. D 35-40%. E 45-50%. 7. (D) Which is characteristic of acalculous cholecystitis ? A Mechanical obstruction of cystic duct. B Easy to be diagnosed. C Easy to be cured by pharmacological treatment. D The presence of severe underling illness including burn, trauma or cardiopulmonary disease. E Normal gall bladder size. 8. (C) What is the most possible pathogenesis of acalculous cholecystitis in this patient ?  A Total parenteral nutrition. B Bile stasis. C Hypotension and ischemia. D vasculitis. E Gall bladder sludge. 9. (E) What is not suitable for the treatment for acalculous cholecystitis ? A Laparoscopic cholecystectomy. B Laparotomy cholecystectomy. C PTCCD. D Antibiotics. E None of the above. 10. (C) Which of the following statement is not correct? A The mortality was higher in acalculous cholecystitis than in calculous cholecystitis. B 50% of acalculous cholecystitis develop gangrene. C Female is more prevalent than male. D 8-15% of acalculous cholecystitis develop perforation. E None of the above.