1. Acute abdomen Case presentation
M K Alam

2. 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

3. 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

4. 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

5. 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

6. Acute appendicitis

7. 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

8. 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

9. Delayed presentation Inflammatory progress to gangrene
Localized perforation- abscess formation
Free perforation- peritonitis (secondary)

10. 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

11. 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

12. 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

13. 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

14. Differential diagnosis
Chronic cholecystitis
Biliary colic
Obstructive jaundice
Liver abscess
Viral hepatitis

15. Acute cholecystitis

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

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

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

19. Thank you!