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
 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

Thank you!