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Acute abdomen Case presentation. M K Alam. Case No. 1. A 19-year old male presents with abdominal pain since last night. He has vomited once early this morning. History Examination Differential diagnosis Investigations Pathophysiology Complications of delayed presentation/ treatment

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case no 1
Case No. 1

A 19-year old male presents with abdominal pain since last night. He has vomited once early this morning.

  • History
  • Examination
  • Differential diagnosis
  • Investigations
  • Pathophysiology
  • Complications of delayed presentation/ treatment
  • Treatment
history
History
  • Location: Initially periumbilical, now RIF
  • Severity: started mild, now severe
  • Onset: gradual
  • Progress: worsening
  • Radiation and shift: Initially periumbilical, now RIF
  • Exacerbating factors:none
  • Relieving factors: none
  • Associated symptoms: vomiting once, no anorexia
  • Systemic inquiry, family, social, drug, past history- none
examination
Examination
  • Appearance: Looking ill
  • Temperature: 38.5°C
  • Abdomen:Inspection- flat, moving with respiration, no cough tenderness
  • Palpation- guarding & tenderness in RIF and at McBurney’s point, Rovsing’s sign –ve
  • Percussion- tender RIF
  • Auscultation- diminished bowel sounds
  • Rectal examination not done
differential diagnosis
Differential diagnosis
  • Children: Meckel’s diverticulitis, intussusception, gastroenteritis, mesenteric lymphadenitis
  • Adults: Crohn’s disease, pyelonephritis, ileo-cecal neoplasm, bowel obstruction
  • Female: Ectopic pregnancy, mid cycle pain, tubo-ovarian pathology, PID
investigations
Investigations
  • Leucocytosis with high neutrophil
  • Very high WBC > 20,000 in complicated app.
  • Urinalysis to rule out urinary infection
  • Ultrasonography: Not done. Indicated in children and pregnant. Thick wall, non-compressible, edema and fluid
  • CT: Not done. Distended, thick wall periappendiceal edema and fluid
pathophysiology
Pathophysiology
  • Obstruction of the lumen
  • Fecalith, lymphoid hyperplasia, vegetable, seeds, parasites, neoplasm
  • Small lumen, obstruction lead to closed loop
  • Bacterial overgrowth
  • Continued mucous secretion lead to distension and typical visceral pain in periumbilical area
  • Inflammation of adjacent parietal peritoneum gives rise to localized RIF (parietal) pain
delayed presentation
Delayed presentation
  • Inflammatory progress to gangrene
  • Localized perforation- abscess formation
  • Free perforation- peritonitis (secondary)
treatment
Treatment
  • Nil orally
  • IV fluid
  • Pre-op. antibiotics: cefuroxime+ metronidazole
  • Non-perforated: single pre-op. dose
  • Perforated: continue post-op. until afebrile
  • Consent for surgery
  • Appendectomy- laparoscopic or open surgery
  • Appendicular abscess- image guided drainage
  • Free perforation- Open/ laparoscopic appendectomy
case no 2
Case No. 2

A 30-year old female presents with right hypochondrial pain for 2 days associated with fever.

  • History
  • Examination
  • Differential diagnosis
  • Investigations
  • Pathophysiology
  • Management
history1
History
  • Location: right hypochondrium
  • Severity: started mild, now severe
  • Onset: gradual
  • Progress: worsening
  • Radiation: back and right shoulder
  • Exacerbating factors:fatty food
  • Relieving factors: analgesics
  • Associated symptoms: fever, no vomiting , no anorexia
  • Systemic inquiry, family, social, drug history- none
  • Past medical history- similar pain of shorter duration 2 months back
examination1
Examination
  • Appearance: In pain
  • Temp. 38.6°C
  • No jaundice
  • Abdomen: Inspection- normal, few striae gravidarum
  • Palpation- tenderness & guarding in RH, Murphy’s sign +ve( tenderness & arrest of inspiration while palpating at costal margin)
  • Percussion, auscultation- none
differential diagnosis1
Differential diagnosis
  • Chronic cholecystitis
  • Biliary colic
  • Obstructive jaundice
  • Liver abscess
  • Viral hepatitis
investigations1
Investigations
  • Leucocytosis
  • LFT: very slight elevation of bilirubin, normal alkaline phosphatase and transaminase
  • Abdominal ultrasonography: gall stones, gall bladder wall thickening, edema, pericholecystic fluid
pathophysiology1
Pathophysiology
  • Obstruction of the cystic duct
  • Bacterial inflammation
  • If obstruction persists- ischemia and gangrene of the gall bladder
  • Eventually perforation
management
Management
  • Nil by mouth
  • IV fluid
  • Parenteral antibiotics- (gram –ve and gram +ve organisms)- cephalosporin
  • Consent for surgery
  • Early laparoscopic cholecystectomy