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 Treatment

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 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 Recatl examination not done

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

Acute appendicitis

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 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 Inflammatory progress to gangrene Localized perforation- abscess formation Free perforation- peritonitis (secondary)

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 A 30-year old female presents with right hypochondrial pain for 2 days associated with fever. History Examination Differential diagnosis Investigations Pathophysiology Management

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

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 diagnosis Chronic cholecystitis Biliary colic Obstructive jaundice Liver abscess Viral hepatitis

Acute cholecystitis

Investigations Leucocytosis LFT: very slight elevation of bilirubin, normal alkaline phosphatase and transaminase Abdominal ultrasonography: gall stones, gall bladder wall thickening, edema, pericholecystic fluid

Pathophysiology Obstruction of the cystic duct Bacterial inflammation If obstruction persists- ischemia and gangrene of the gall bladder Eventually perforation

Management Nil by mouth IV fluid Parenteral antibiotics- (gram –ve and gram +ve organisms)- cephalsporins Consent for surgery Early laparoscopic cholecytectomy

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