acute abdomen case presentation......ppt

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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!