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Acute abdomen Case presentation

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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Acute abdomen Case presentation

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  1. Acute abdomenCase 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 • Rectal 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)- cephalosporin • Consent for surgery • Early laparoscopic cholecystectomy

  19. Thank you!

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