# Clinical Cases: Abdominal Emergencies

## Case 1: Acute Appendicitis - The Classic Presentation

### Patient Demographics
- **Age:** 24 years
- **Sex:** Female
- **Occupation:** Graduate student

### Chief Complaint
"I have terrible pain in my right side."

### History of Present Illness
A 24-year-old female presents with 18 hours of abdominal pain. Pain began periumbilically last night, described as dull and crampy. Over the past 6 hours, pain has migrated to the right lower quadrant and become sharper and more constant. She reports nausea with two episodes of vomiting and complete anorexia. She denies diarrhea but had one loose stool this morning.

### Initial Assessment

**ESI Level:** 3 - Urgent evaluation required

**First Impression:**
- Appearance: Uncomfortable, lying still, knees drawn up
- Work of breathing: Normal
- Circulation: Normal color

**Vital Signs:**
- Heart rate: 98 bpm
- Blood pressure: 118/72 mmHg
- Respiratory rate: 18 breaths/min
- SpO2: 99% on room air
- Temperature: 38.1C (100.6F)

### Primary Survey

**Airway:** Patent
**Breathing:** Normal effort, clear lungs
**Circulation:** Mild tachycardia, good perfusion
**Disability:** Alert, oriented, GCS 15
**Exposure:** No rashes, guarding RLQ on movement

### Secondary Survey

**SAMPLE History:**
- Symptoms: RLQ pain, nausea, vomiting, anorexia, low-grade fever
- Allergies: None
- Medications: Oral contraceptives
- PMH: Healthy
- LMP: 2 weeks ago, regular cycles
- Last Meal: Dinner last night, nothing today
- Events: Gradual onset, classic migration pattern

**Physical Examination:**

**Abdominal Exam:**
- Inspection: No distension, no visible masses
- Auscultation: Hypoactive bowel sounds
- Percussion: Tender RLQ
- Palpation:
  - Maximal tenderness at McBurney's point
  - Voluntary guarding RLQ
  - Rovsing's sign: Positive (RLQ pain with LLQ palpation)
  - Psoas sign: Positive (pain with right hip extension)
  - Obturator sign: Negative
  - No rebound (early presentation)

**Pelvic Exam:**
- Cervical motion tenderness: Absent
- Adnexal tenderness: Mild right-sided (referred)
- No masses palpated
- No discharge

### Risk Stratification

**Alvarado Score:**
- Migration of pain: +1
- Anorexia: +1
- Nausea/vomiting: +1
- RLQ tenderness: +2
- Rebound: 0
- Fever: +1
- Leukocytosis: +2
- Left shift: +1
- **Total: 9/10** (High probability)

### Diagnostic Testing

**Labs:**
- WBC: 14,200 with 82% neutrophils, 8% bands
- Hgb: 13.2
- Platelets: 245,000
- BMP: Normal
- Lipase: Normal
- Urinalysis: 5-10 WBC (likely contamination from adjacent inflammation)
- Urine pregnancy test: Negative

**Imaging:**

*CT Abdomen/Pelvis with IV contrast:*
- Dilated appendix (11mm diameter)
- Appendiceal wall thickening and enhancement
- Periappendiceal fat stranding
- No abscess or free fluid
- No free air

**Diagnosis:** Acute uncomplicated appendicitis

### Management

**Preoperative:**
1. NPO status
2. IV fluid resuscitation
3. Pain management: Morphine 4mg IV
4. Antiemetic: Ondansetron 4mg IV
5. Antibiotics: Cefoxitin 2g IV (or ceftriaxone + metronidazole)
6. Surgical consultation

**Surgical Plan:**
- Laparoscopic appendectomy
- Patient consented and taken to OR within 4 hours

**Operative Findings:**
- Acutely inflamed appendix without perforation
- Successful laparoscopic appendectomy

### Disposition
- Post-operative recovery unit
- Discharged home POD 1
- Follow-up in 2 weeks
- Return precautions given

### Teaching Points

1. **Classic migration pattern:** Periumbilical pain migrating to RLQ occurs in ~50% of cases; absence doesn't rule out appendicitis
2. **Scoring systems:** Alvarado and AIR scores help risk-stratify but don't replace clinical judgment
3. **Imaging in women of childbearing age:** Consider transvaginal ultrasound first; CT if US inconclusive
4. **Pregnancy test:** Always obtain before CT in women of childbearing age
5. **Early antibiotics:** Reduce surgical site infection rates
6. **Atypical locations:** Retrocecal appendix may present with flank pain; pelvic appendix with urinary symptoms

### Clinical Image
![CT showing Acute Appendicitis](case_01_image.jpg)

**Image Description:** Axial CT scan of the abdomen/pelvis with IV contrast demonstrating a dilated, fluid-filled appendix (arrow) measuring greater than 6mm in diameter with surrounding fat stranding, consistent with acute appendicitis.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/acute-appendicitis-ct

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## Case 2: Small Bowel Obstruction - The Surgical Abdomen

### Patient Demographics
- **Age:** 68 years
- **Sex:** Male
- **Occupation:** Retired engineer

### Chief Complaint
"I've been vomiting all night and my belly is huge."

### History of Present Illness
A 68-year-old male presents with 24 hours of progressive abdominal distension, crampy abdominal pain, and intractable vomiting. Initially vomited food contents, now bilious. Reports complete obstipation (no flatus or stool) for 18 hours. Pain is diffuse, crampy, and comes in waves. History of exploratory laparotomy for gunshot wound 30 years ago.

### Initial Assessment

**ESI Level:** 2 - High-risk situation

**First Impression:**
- Appearance: Uncomfortable, diaphoretic, distended abdomen visible
- Work of breathing: Mildly labored (splinting)
- Circulation: Pale, dry mucous membranes

**Vital Signs:**
- Heart rate: 112 bpm
- Blood pressure: 98/62 mmHg
- Respiratory rate: 22 breaths/min
- SpO2: 95% on room air
- Temperature: 37.8C

### Primary Survey

**Airway:** Patent, but vomiting bilious material
**Breathing:** Tachypneic, diminished bases (diaphragm elevation)
**Circulation:** Tachycardic, hypotensive, dry mucous membranes, delayed capillary refill
**Disability:** Alert but uncomfortable, GCS 15
**Exposure:** Massive abdominal distension, well-healed midline surgical scar

### Resuscitation

**Immediate Interventions:**
1. NPO, nasogastric tube placement - 800mL bilious output
2. Two large-bore IVs
3. Aggressive fluid resuscitation: 2L LR bolus
4. Foley catheter - minimal output initially
5. Labs and imaging ordered

### Secondary Survey

**SAMPLE History:**
- Symptoms: Abdominal pain, vomiting, distension, obstipation
- Allergies: Sulfa drugs
- Medications: Lisinopril, metformin, aspirin
- PMH: Hypertension, type 2 DM, prior abdominal surgery
- Last Meal: Yesterday lunch
- Events: Progressive symptoms over 24 hours

**Surgical History:**
- Exploratory laparotomy 1992 (trauma)
- Cholecystectomy 2010

**Physical Examination:**

**Abdominal Exam:**
- Inspection: Significantly distended, midline and RUQ scars
- Auscultation: High-pitched, tinkling bowel sounds
- Percussion: Tympanitic throughout
- Palpation:
  - Diffusely tender, worse periumbilically
  - Moderate guarding but no rigidity
  - No focal peritoneal signs initially
  - No hernias at incision sites

**Concerning Features for Strangulation:**
- Tachycardia: Present
- Fever: Low-grade
- Localized tenderness: Developing
- Peritoneal signs: Not yet
- Leukocytosis: Pending

### Diagnostic Testing

**Labs:**
- WBC: 16,800 with left shift
- Hgb: 16.2 (hemoconcentration)
- BMP: Na 132, K 3.1, Cl 94, HCO3 20, BUN 42, Cr 1.8
- Lactate: 3.4 mmol/L (concerning)
- Lipase: Normal

**Imaging:**

*Abdominal X-ray:*
- Dilated loops of small bowel (>3cm)
- Multiple air-fluid levels
- No free air
- Minimal colonic gas

*CT Abdomen/Pelvis with IV contrast:*
- Small bowel obstruction with transition point in RLQ
- Dilated proximal small bowel up to 4.5cm
- Decompressed distal small bowel
- Adhesive band identified as cause
- Small bowel feces sign present
- **Concerning finding:** Bowel wall thickening and decreased enhancement at transition point, possible early ischemia

### Diagnosis

**High-grade small bowel obstruction** secondary to adhesive disease with concern for early strangulation

### Management

**Resuscitation Continued:**
- Total 4L crystalloid with improved hemodynamics
- Electrolyte repletion: K+ and Cl-
- NG tube on continuous low wall suction
- Foley monitoring (UOP improving with resuscitation)

**Surgical Consultation:**
- Given concerning CT findings (wall thickening, decreased enhancement, elevated lactate)
- Decision for operative intervention

**Operative Findings:**
- Single adhesive band causing complete SBO
- Loop of small bowel with serosal changes but viable after lysis
- No bowel resection required
- Return of peristalsis noted

### Disposition
- Post-operative ICU admission (given degree of resuscitation)
- Continued NGT decompression
- Serial abdominal exams
- Advance diet when NGT output minimal and bowel function returns
- Discharged home on POD 4

### Teaching Points

1. **Cardinal features of SBO:** Abdominal pain, vomiting, distension, and obstipation (absence of flatus/stool)
2. **Most common cause:** Adhesions from prior surgery (75% of SBO cases)
3. **Strangulation signs:** Fever, tachycardia, localized tenderness, peritoneal signs, leukocytosis, elevated lactate - warrant emergent surgery
4. **CT findings concerning for strangulation:** Bowel wall thickening, decreased enhancement, mesenteric haziness, closed-loop configuration
5. **Non-operative management:** Appropriate for partial SBO without strangulation; failure rate ~25%
6. **Third-spacing:** Massive fluid shifts require aggressive resuscitation; monitor UOP

### Clinical Image
![CT showing Small Bowel Obstruction](case_02_image.jpg)

**Image Description:** Coronal CT image demonstrating multiple dilated loops of small bowel with air-fluid levels proximal to a transition point (arrow), with decompressed distal small bowel, consistent with high-grade small bowel obstruction.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Andrew Dixon. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/small-bowel-obstruction-adhesive

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## Case 3: Mesenteric Ischemia - The Pain Out of Proportion

### Patient Demographics
- **Age:** 76 years
- **Sex:** Female
- **Occupation:** Retired nurse

### Chief Complaint
"Something is terribly wrong with my stomach."

### History of Present Illness
A 76-year-old female presents with 6 hours of severe, diffuse abdominal pain. Pain was sudden in onset, initially crampy, now constant and severe (10/10). She describes the pain as "the worst of my life." She has had two episodes of bloody diarrhea. Notable history of atrial fibrillation - admits she stopped her warfarin 2 weeks ago due to cost.

### Initial Assessment

**ESI Level:** 1 - Critically ill presentation

**First Impression:**
- Appearance: Writhing in pain, appears acutely ill
- Work of breathing: Tachypneic, shallow
- Circulation: Pale, diaphoretic

**Vital Signs:**
- Heart rate: 124 bpm, irregularly irregular
- Blood pressure: 92/58 mmHg
- Respiratory rate: 28 breaths/min
- SpO2: 92% on room air
- Temperature: 36.4C (hypothermic - concerning)

### Primary Survey

**Airway:** Patent, moaning in pain
**Breathing:** Tachypneic, decreased breath sounds at bases
**Circulation:** Tachycardic (atrial fibrillation), hypotensive, cool extremities
**Disability:** Alert but distressed, GCS 15
**Exposure:** Diaphoretic, no rashes

### Critical Finding: Pain-Exam Discrepancy

**Classic Finding:**
- Patient describes 10/10 pain
- Abdominal exam: Soft, mildly tender, minimal guarding
- **"Pain out of proportion to exam"** - hallmark of mesenteric ischemia

### Resuscitation

**Immediate Interventions:**
1. High-flow oxygen
2. Two large-bore IVs, fluid resuscitation initiated
3. Continuous cardiac monitoring
4. Labs including lactate, coagulation studies
5. Blood type and crossmatch
6. Pain management: Fentanyl 50mcg IV
7. Emergent CT angiography ordered

### Secondary Survey

**SAMPLE History:**
- Symptoms: Severe abdominal pain, bloody diarrhea, nausea
- Allergies: None
- Medications: Warfarin (stopped), metoprolol, digoxin, lisinopril
- PMH: Atrial fibrillation, CHF, hypertension, prior MI
- Last Meal: Breakfast, limited appetite recently
- Events: Sudden onset severe pain

**Risk Factors for Mesenteric Ischemia:**
- Atrial fibrillation (off anticoagulation) - embolic risk
- CHF - low-flow state
- Age >60
- Atherosclerotic disease

**Physical Examination:**

**Abdominal Exam:**
- Inspection: Non-distended, no surgical scars
- Auscultation: Absent bowel sounds
- Percussion: Mildly tympanitic
- Palpation: Mild diffuse tenderness WITHOUT peritoneal signs (early)
- Rectal: Gross blood, no melena

**Cardiovascular:**
- Irregularly irregular rhythm
- No murmurs
- JVD present

### Diagnostic Testing

**Labs:**
- WBC: 22,400 with significant left shift
- Hgb: 14.8, Hct: 45% (hemoconcentration)
- Platelets: 198,000
- BMP: Na 138, K 5.8, Cl 98, HCO3 14, BUN 38, Cr 2.1
- Lactate: 8.6 mmol/L (markedly elevated)
- ABG: pH 7.22, pCO2 28, HCO3 12 (metabolic acidosis with respiratory compensation)
- INR: 1.1 (subtherapeutic - explains off warfarin)
- Amylase/Lipase: Mildly elevated
- LDH: 892 (elevated - ischemia marker)

**Imaging:**

*CT Angiography Abdomen/Pelvis:*
- Abrupt occlusion of superior mesenteric artery (SMA) 3cm from origin
- No flow in SMA branches
- Bowel wall thickening of jejunum and ileum
- Pneumatosis intestinalis present (air in bowel wall)
- Portal venous gas
- **Findings consistent with acute mesenteric ischemia with bowel infarction**

### Diagnosis

**Acute mesenteric ischemia** - embolic occlusion of SMA with evidence of bowel infarction

### Management

**Immediate Resuscitation:**
- Aggressive IV fluids (balanced crystalloid)
- Correct acidosis
- Broad-spectrum antibiotics: Piperacillin-tazobactam 4.5g IV
- Nasogastric tube decompression
- Foley catheter

**Emergent Surgical Consultation:**
- Findings discussed with vascular surgery and general surgery
- Patient taken emergently to OR

**Operative Management:**
- SMA embolectomy with Fogarty catheter
- Assessment of bowel viability
- Resection of 80cm of non-viable jejunum and ileum
- Primary anastomosis
- Planned second-look laparotomy in 24-48 hours

### Disposition
- Surgical ICU
- Vasopressors required post-operatively
- Anticoagulation (heparin) initiated post-op
- Second-look laparotomy at 36 hours - remaining bowel viable
- Prolonged ICU course, eventual discharge to rehab
- Lifelong anticoagulation for atrial fibrillation

### Teaching Points

1. **Pain out of proportion:** Classic finding; severe pain with benign-appearing abdomen suggests mesenteric ischemia
2. **High clinical suspicion required:** Mortality >50% if diagnosis delayed; early recognition is key
3. **Risk factors:** Atrial fibrillation, recent MI, CHF, atherosclerosis, hypercoagulable states
4. **Laboratory clues:** Elevated lactate, metabolic acidosis, leukocytosis, elevated LDH
5. **CT angiography:** Gold standard for diagnosis; identify occlusion and signs of infarction
6. **Pneumatosis and portal venous gas:** Late findings indicating bowel necrosis; associated with poor prognosis
7. **Treatment:** Emergent revascularization + bowel resection if infarction; second-look laparotomy often needed
8. **Anticoagulation compliance:** This case illustrates consequences of stopping anticoagulation

### Clinical Image
![CT showing Mesenteric Ischemia with Pneumatosis](case_03_image.jpg)

**Image Description:** Axial CT image demonstrating pneumatosis intestinalis (air within the bowel wall, arrows) and portal venous gas, findings consistent with advanced mesenteric ischemia with bowel infarction.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Matt Skalski. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/mesenteric-ischaemia-with-pneumatosis-intestinalis