Acute Abdominal Pathology Case presentation

1
Acute Abdominal PathologyCase presentation

• Boris Vinogradsky, MD
• Department of Surgery
• Medical College of Ohio
• January 18, 2002

2
Acute Abdominal Pathology

• 69 yo wf admitted to St.Vincents hospital ER 1
  hour after onset of acute abdominal pain
• Pain is moderate to severe, constant, dull,
  located in the lower abdomen
• Nausea, vomiting x 1
• Last flatus, stool (day of admission)
• No fever, chills

3
Acute Abdominal Pathology

• PMHx Diverticulitis, HTN
• PSHx Appendectomy as a child, Hysterectomy
  in 70s
• Meds None
• Allgs PCN, MSO4
• Soc Hx Smoking 1 ppd, no EtOH, no drugs
• Fam Hx Father MI, mother MI, HTN, DM

4
Acute Abdominal Pathology

• PE wd wn wf in moderate distress Abdomen
  soft, mildly distended, old hysterectomy scar,
  faint bowel sounds, moderately tender on
  palpation, no rebound
• Rectal Guaiac ()

5
Acute Abdominal Pathology

• Of note pt stated that this pain feels exactly
  like her pain during the last episode of
  diverticulitis

6
Acute Abdominal Pathology

• Labs WBCs 10.6, Hgb 15.0, Plts - 322
• Na 138, K 4.2, Cl 105, HCO3 24
• Glu 160, BUN 12, Cre 0.7,
• Amyl 36, Lip - 35

7
Acute Abdominal Pathology

• AAS Lungs clear, no free air, no air-fluid
  levels, mild dilation and calcifications of aorta
• CT abdomen Small amount of fluid around the
  liver, spleen and in the pelvis. Fluid-filled
  distended loops of SB predominantly in the R
  hemiabdomen. Infrarenal aorta 2.8 cm

8
Acute Abdominal Pathology

• Pt admitted with the diagnosis of exacerbation of
  diverticulitis for observation, hydration and IV
  Abx (Cipro/Flagyl)
• Overnight condition worsened in early AM, pain
  increased, urine output initially adequate,
  dropped. Pt required 3 boluses of 1L NS to
  maintain adequate UO.

9

• 6AM next morning on PE pain in the RLQ, severe,
  hyperactive BS, no flatus, no stool.
• WBC 15.6, lactate 5.7, K 5.2, HCO3 18,
  Cre 1.7, Glu 299

10
Acute Abdominal Pathology

• Pt went to the OR urgently for exploratory
  laparotomy
• Findings multiple old adhesions, several
  ischemic loops of small bowel in the RLQ twisted
  around single adhesion, clear margins of ischemia
• LOA, resection of 2 ft of SB, 10 stapled
  anastomosis

11
Acute Abdominal Pathology

• Post-op course unremarkable, extubated in
  recovery room. Next 2 days - afebrile, UO
  adequate, WBC down to 12.6. Clear liquid diet,
  ambulates well.
• Of note on admission in the ER pt was asking if
  she will be able to go to Australia on the 3rd of
  February