acute abdomen - nebraska surgical researchnebraskasurgicalresearch.com/s...
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Acute AbdomenCase Presentations
Mark A. Carlson, MD
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Case #1
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Case #1
CC: severe abdominal pain
HPI: 32 yo man, 4 hr H/O severe abdominalpain, acute onset, nonradiating, 1 episode clear emesis
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Case #1
PMH: previously healthy; no surgery.
Meds: ibuprofen 2-3x weekly
SH: construction worker; 2 PPD smoker;2-3 sixpack beer on weekends
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Case #1
FH: noncontributory
ROS: musculoskeletal aches & pains;heartburn; chronic cough; night wakenings with abdominal pain, relieved with Tums
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Case #1
PE
Temp = 38.8˚CPulse = 124, regularRR = 26BP = 106/85
General: thin, looks 10 yr older than stated age, ill-appearing, lying very still
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Case #1
PE
Chest: CTA, RRRAbd: scaphoid, rigid, no BS, exquisitely
tender throughout, cannot toleratefull exam
Rectal: no masses; brown stool is heme occult positive
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Case #1
Labs
Hct = 54WBC = 15.7, 80% segsElectrolytes = WNLChem 20 = unremarkableU/A = dark yellow, sg = 1.035
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PACXR
Case #1
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Case #1
Diff Dx:
1. Perforated ulcer2. Perforated ulcer3. Perforated ulcer
4. Other stuff
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Case #1
Rx: IVFABXlaparotomylaparoscopynonoperative (?)
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Case #2
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Case #2
CC: nausea & abdominal pain
HPI: 47 yo woman, 3 day history of nausea,has had worsening abdominal pain inpast 2 days, constant, in lower abdomen, 1 clear emesis this AM
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Case #2
PMH: C-section x 2; moderate obesity;elevated cholesterol; DJD; depressivedisorder
Meds: various NSAIDs, SSRI, various anxiolytics
SH: receptionist, 1 PPD smoker, nondrinker
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Case #2
FH: breast CA, CAD, colon CA
ROS: multiple somatic complaints; dysuria;intermittent bleeding between periods; headaches;SOB; chest pains; dyspepsia; dysphagia; constipation alternating with diarrhea (no BM in past 3 days)
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Case #2
PE
Temp = 38.2˚CHR = 96RR = 16BP = 160/92
General: obese, NAD, flush
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Case #2
PE
Chest: CTA, RRRAbd: moderately obese, LTCS scar,
small umbilical hernia, +BS,RLQ tenderness ± rebound,no masses
Rectal: noncontributoryPelvic: no D/C, no CMT; right adnexal
tenderness
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Case #2
Labs
Hct = 33WBC = 9.8 (15% bands)Chem 20 = WNLU/A = no bacteria or WBCurine pregnancy neg
Differential Dx?
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Case #2
Diff Dx:
1. Appendicitis2. Diverticulitis3. Cholecystitis
4. Rare and unusual Dx
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Case #2
KUB
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Case #2
Rx:
ABXLaparoscopy or laparotomy
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Case #3
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Case #3
CC: collapse; back pain
HPI: 73 yo man, cutting grass early this AMwhen apparently had LOC. Found ongrass, initially unresponsive, thenwoke up and complained of back pain.Wife called 911; pt noted to have low BPen route in ambulance.
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Case #3
PMH: MI 12 yr ago; bilat groin hernia repair,both recurrent, last repaired 5 yr ago;several SCCA skin, excised, NAD;GERD; HTN
Meds: occasional nitro SL; PPI; atenolol,mini-ASA
SH: retired plumber; quit smoking 12 yr ago;occasional drinker
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Case #3
FH: CAD, CVA, HTN, DM, sudden death
ROS: can do yard work usually without anychest pains; has not had a stress test in years; sees his family MD yearly forPE only; bowel & bladder “no problems”
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Case #3
PE
Temp = 36.1˚CHR = 66, occasionally irregularRR = 19BP = 96/45
General: elderly, obese man,laying on cart with IVF running,A & O x 3.
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Case #3
PE
Neck: no carotid bruitsChest: systolic murmur, regular rhythm
with premature beats, distant clearbreath sounds
Abd: generous, few BS, soft, tender todeep palpation in epigastrium;bilat groin hernia
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Case #3
PE
Rectal: no mass, heme(–)Extremities: mottled, decreased foot
pulses; bilat swelling in popliteal fossae
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Case #3
Labs
Hct = 38WBC = 12.7amylase = 259U/A = normalEKG = old AW infarct; no acute Δ’sCXR = flat diaphragm, calcified
aortic knob, mild cardiomegaly
Differential Dx?
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Case #3
Diff Dx:
1. AAA2. Aortic dissection3. Aortic stenosis4. CVA5. MI
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CT scan
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Case #3
Rx:
resuscitate
laparotomy orendovascular repair
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Case #4
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Case #4
CC: fever, abdominal pain
HPI: 29 yo man with a 1 week H/O feverswith sweats. Abd pain began 4 days ago, mild to moderate, diffuse and constant. Also has had bloody bowelmovements x 2 days.
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Case #4
PMH: none
Meds: none
SH: graduate student; heterosexually active;nonsmoker; light drinker
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Case #4
FH: mother, father, siblings healthy
ROS: 10 lb wt loss, unintentional, in past 3months; diarrhea with cramps intermittently x 6 months, no blood;recent HIV test = neg
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Case #4
PE
Temp = 39.5˚CHR = 130RR = 25BP = 105/78
General: thin ill-appearing young man; having sweats
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Case #4
PE
Skin: clammy, no rashENT: no adenopathyChest: CTA; tachy & hyperdynamicAbd: mildly distended, no BS,
+percussion tendernessGU: WNLRectal: no masses, heme+ mucous
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Case #4
Labs
WBC = 28,000 (92% segs, 5% bands)Hct = 50BUN/Cr = 30/0.5Alb = 3.0Amylase = 130Rest of Chem 20 = WNL
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Case #4: KUB
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Case #4
Diff Dx
1. Toxic megacolon2. Large bowel obstruction3. Enteritis4. Diverticulitis
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Case #4
Rx
resuscitationIV ABXwater-soluble contrast study if
Dx is in questionbowel restTPNIV steroids
laparotomy if no improvement
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Case #5
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Case #5
CC: fever & chills
HPI: 62 yo diabetic woman with a 4 day H/Osubjective fever with chills. Anorexic. 2 days of watery BM’s. Disoriented per husband as of this AM
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Case #5
PMH: insulin dependent DM; glaucoma;HTN; CAD; lower extremity arterial insufficiency; diverticulosis; remote PUD; GERD; breast CA; DJD; COPD
Surgery: Left MRM, cholecystectomy, appendectomy, bilateral toe amputations
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Case #5
Meds: insulin, ACE inhibitor, eye drops,β-blocker, PPI, colace, tamoxifen, NSAIDs prn, bronchodilators prn
SH: lives with husband, active socially;40 pack year smoker, quit 5 yr ago,social EtOH
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Case #5
FH: DM, CAD, breast & GI cancer
ROS: cannot get accurate review 2˚disorientation of pt (above infofrom husband & old records)
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Case #5
PE
Temp = 37.5˚CHR = 93RR = 32BP = 100/54
General: elderly woman, moaning,disoriented, looks very ill and ready to arrest
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Case #5
PE
Chest: shallow rapid breaths; RRR;well healed mastectomy scar
Abdomen: well-healed scars in RUQand RLQ; obese, soft, tender in lower quadrants
Rectal: firm mass anteriorlyExtremities: mottled; well-healed toe
amp sites
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Case #5
Labs
ABG
pH = 7.12pCO2 = 55pO2 = 51HCO3 = 12O2 sat = 80%
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Case #5
Priorities
intubationICU admissioncentral line empiric ABX
get Dx
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Case #5
Labs
Hct = 42WBC = 3.1 (50% bands)plt = 87,000INR = 1.8gluc = 758BUN/Cr = 45/2.2Alb = 2.6
U/A = wbc’s
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Case #5
EKG: sinus tach, new T-wave depressionlaterally
CXR: COPD, no acute changes, no F/A
KUB: ng in place; clips in RUQ; gas in small & large bowel; aortic calcifications
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Case #5
Abdominal CT with IV and rectal contrast
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Case #5
Diff Dx
1. Diverticulitis with pelvic abscess2. Perforated colon CA with pelvic abscess3. Perforated appendicitis with pelvic abscess4. Perforated GU/DU with pelvic abscess5. Peforated gallbladder with pelvic abscess6. Perforated small bowel etc.
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Case #5
Rx
stabilize medicallyurgent transrectal drainage; if not possible,
then percutaneous approachIV ABX
interval elective colectomy
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Case #6
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Case #6
CC: abd pain
HPI: 51 yo woman, had sudden onset of severe “doubling over” pain this AM during an office meeting, mostly right sided with radiation into right groin. Comes & goes, reminiscent of labor pain.
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Case #6
PMH: MVA with rib fractures and pulmonary contusion 6 months ago; carpal tunnel;remote EtOH abuse, dry x 10 yr; anxietydisorder
Surgery: breast biopsy x 2, benign
Meds: SSRI; laxative prn
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Case #6
SH: VP in high tech company; 1/2 PPD smoker; no EtOH; married, 1 adult child
FH: both parents A & W
ROS: no chest symptoms; menopause x 2 yr;constipation
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Case #6
PE
Temp = 37.1˚CHR = 105RR = 24BP = 154/95
General: laying on side in semi-fetalposition, groaning, in moderatedistress
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Case #6
PE
Chest: CTA & RRRAbd: flat, +BS, soft, nontenderGU: no herniaRectal: no mass, heme(–)
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Case #6
Labs
CBC = WNLlytes = WNLBUN/Cr = 28/0.7Ca = 10.1
U/A: dark yellow, sg = 1.036,many rbc’s
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Case #6
KUB
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Case #6
Diff Dx:
1. Ureteral stone2. Irritable bowel/diverticulosis3. Biliary colic
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Case #6
Rx
hydratenarcotic analgesiaabdominal U/S to look for other DxIVP or retrograde pyelogram
Urology consult (ureteroscopy,lithotripsy)
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Case #7
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Case #7
CC: abdominal distension
HPI: 83 yo man who underwent pinning of aright femoral neck fracture 4 days ago.He now has painless abdominal distension; the orthopedic surgeonhas asked for a general surgeryconsultation.
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Case #7
PMH: DM, CAD, CVA, dementia, HTN
Meds: insulin, β-blocker, bowel regimen(oral cathartics & suppositories), ASA,ativan & haldol prn; morphine postsurgery; sq heparin post surgery
SH: nursing home resident
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Case #7
FH: unknown
ROS: little information from nursing home
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Case #7
PE
Temp = 36.5˚CHR = 103, irregularRR = 22BP = 177/98
General: poorly communicative elderlyman; NAD; somewhat emaciated
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Case #7
PE
Skin: warm & dryChest: frequent premature beats; systolic
murmur; dry cracklesAbd: distended, high tinkling BS, soft,
nontender, tympany, no scars, no hernias
GU: foley in place, otherwise WNLRectal: full of hard brown stool, heme(+)
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Case #7
Labs
Hct = 25.7WBC = 5.4, normal diffNa = 132K = 3.1Ca, Mg, P = lowgluc = 305
O2 sat = 90% on RA
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Case #7
EKG: ST with frequent PVC’s, old IWMI
CXR: mild cardiac enlargement; NAPD
U/A: 3+ WBC’s and bacteria
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Case #7
KUB
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Case #7
Diff Dx
1. Ogilvie syndrome (colonicpseudoobstruction)
2. Obstructing colon CA3. Volvulus
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Case #7
Rxsupplemental O2D/C narcotics & haldolcorrect electrolytes & BSconsider transfusionurgent colonoscopy & decompressionserial abdominal x-rays
operative decompression if colonoscopy fails
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End