# Clinical Cases: Acute Abdomen

## Case 1: Acute Appendicitis with Perforation

### Patient Demographics
- **Age:** 28 years
- **Sex:** Male
- **Occupation:** Software engineer

### Chief Complaint
"I have severe pain in my lower right abdomen that started around my belly button yesterday."

### History of Present Illness
The patient presents to the emergency department with a 24-hour history of abdominal pain. The pain initially began as vague periumbilical discomfort yesterday morning, associated with nausea and one episode of vomiting. Over the past 12 hours, the pain has migrated to the right lower quadrant and has become sharp and constant. He reports anorexia and low-grade fever. The pain worsens with movement, and he has been lying still on the stretcher with his right hip flexed. He denies urinary symptoms, diarrhea, or recent travel.

### Past Medical History
- No significant medical history
- No prior surgeries

### Medications
- None

### Allergies
- No known drug allergies

### Social History
- Non-smoker
- Occasional alcohol use
- Lives with girlfriend

### Physical Examination
- **Vitals:** BP 128/78 mmHg, HR 102 bpm, RR 18/min, Temp 38.4°C, SpO2 99% on room air
- **General:** Young male in moderate distress, lying still, reluctant to move
- **Abdomen:**
  - Inspection: No distension, no surgical scars
  - Auscultation: Hypoactive bowel sounds
  - Palpation: Maximal tenderness at McBurney's point, guarding present, rebound tenderness positive
  - Rovsing's sign: Positive (pain in RLQ with palpation of LLQ)
  - Psoas sign: Positive (pain with right hip extension)
  - Obturator sign: Negative
- **Rectal exam:** Tenderness on the right side of the rectum

### Laboratory Results
- WBC: 16,800/μL (92% neutrophils, 2% bands)
- Hemoglobin: 14.2 g/dL
- Platelets: 284,000/μL
- Creatinine: 0.9 mg/dL
- Glucose: 112 mg/dL
- Lactate: 1.4 mmol/L
- Urinalysis: Normal, no pyuria or hematuria
- CRP: 145 mg/L

### Imaging
**CT Abdomen/Pelvis with IV contrast:**
- Dilated appendix measuring 12 mm in diameter
- Appendiceal wall thickening with enhancement
- Periappendiceal fat stranding
- Small amount of free fluid in the pelvis
- No appendicolith visualized
- No evidence of abscess formation

### Clinical Assessment
**Alvarado Score:** 9/10
- Migration of pain: +1
- Anorexia: +1
- Nausea/vomiting: +1
- RLQ tenderness: +2
- Rebound tenderness: +1
- Elevated temperature: +1
- Leukocytosis: +2

### Differential Diagnosis
1. Acute appendicitis (most likely)
2. Mesenteric lymphadenitis
3. Right-sided colonic diverticulitis (less likely given age)
4. Meckel's diverticulitis
5. Crohn's disease

### Management
1. NPO status
2. IV fluid resuscitation
3. IV antibiotics (ceftriaxone and metronidazole)
4. Surgical consultation for appendectomy
5. Consent for laparoscopic appendectomy

### Operative Course
Laparoscopic appendectomy performed. Intraoperatively, the appendix was found to be gangrenous with microperforation at the tip. Purulent fluid present in the pelvis. Appendix removed with stapled base. Peritoneal lavage performed. No drain placed.

### Postoperative Course
- Antibiotics continued for 5 days (transitioned to oral amoxicillin-clavulanate)
- Diet advanced on POD 1
- Discharged POD 2 in good condition
- Pathology confirmed acute gangrenous appendicitis with perforation

### Teaching Points
1. Classic migration of pain from periumbilical to RLQ occurs in only 50-60% of cases
2. CT scan is the gold standard for diagnosis with sensitivity >95%
3. Early surgical intervention reduces perforation risk
4. Laparoscopic approach preferred when expertise available
5. Perforated appendicitis requires extended antibiotic course

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

**Image Description:** Contrast-enhanced CT scan of the abdomen demonstrating an enlarged, inflamed appendix with periappendiceal fat stranding characteristic of acute appendicitis. The appendix diameter exceeds 6 mm with wall thickening and enhancement.

**Attribution:** Image from Wikimedia Commons, Category:CT images of appendicitis. Source: https://commons.wikimedia.org/wiki/Category:CT_images_of_appendicitis

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## Case 2: Perforated Peptic Ulcer

### Patient Demographics
- **Age:** 52 years
- **Sex:** Male
- **Occupation:** Construction foreman

### Chief Complaint
"I have sudden, severe pain in my upper abdomen that started 4 hours ago."

### History of Present Illness
The patient presents to the ED with acute onset of severe epigastric pain that began suddenly while at work 4 hours ago. He describes the pain as "like a knife stabbing me" with radiation to both shoulders. He has been unable to move without severe pain and has not had any bowel movements or passed gas since symptom onset. He reports a history of epigastric burning and discomfort over the past several months, which he self-treated with over-the-counter antacids. He admits to taking ibuprofen daily for chronic back pain for the past 3 years.

### Past Medical History
- Chronic low back pain
- Hypertension
- No prior surgeries

### Medications
- Ibuprofen 800 mg three times daily
- Lisinopril 10 mg daily

### Social History
- Smokes 1 pack per day for 30 years
- Drinks 4-5 beers daily
- Divorced, lives alone

### Physical Examination
- **Vitals:** BP 98/62 mmHg, HR 118 bpm, RR 24/min, Temp 37.2°C, SpO2 96% on room air
- **General:** Middle-aged male in severe distress, lying motionless, appears diaphoretic
- **Cardiovascular:** Tachycardic, regular rhythm
- **Abdomen:**
  - Inspection: Scaphoid, not moving with respiration
  - Auscultation: Absent bowel sounds
  - Palpation: Board-like rigidity, diffuse tenderness, severe guarding
  - Percussion: Loss of liver dullness (suggests free air)
- **Extremities:** Cool, mottled

### Laboratory Results
- WBC: 14,200/μL
- Hemoglobin: 15.8 g/dL (hemoconcentrated)
- Platelets: 198,000/μL
- Creatinine: 1.6 mg/dL
- BUN: 32 mg/dL
- Lactate: 3.8 mmol/L
- Lipase: 45 U/L (normal)
- pH: 7.32, pCO2: 32, HCO3: 18 (metabolic acidosis)

### Imaging
**Upright Chest X-ray:** Free air under both hemidiaphragms (pneumoperitoneum)

**CT Abdomen/Pelvis (performed rapidly):**
- Large pneumoperitoneum
- Free fluid in the peritoneal cavity
- Anterior perforation of the prepyloric antrum
- No evidence of malignancy

### Diagnosis
Perforated peptic ulcer with generalized peritonitis

### Resuscitation
1. Two large-bore IV access
2. Aggressive crystalloid resuscitation (2L bolus)
3. Nasogastric tube placement
4. Foley catheter
5. Broad-spectrum antibiotics (piperacillin-tazobactam)
6. IV PPI (pantoprazole 80 mg bolus then infusion)
7. Blood type and crossmatch

### Management Decision
Given hemodynamic instability, diffuse peritonitis, and large pneumoperitoneum, emergent surgical exploration is indicated. The patient is taken to the OR within 90 minutes of presentation.

### Operative Findings and Procedure
- Exploratory laparotomy via upper midline incision
- 1.5 cm perforation in the anterior prepyloric region
- 2 liters of purulent, bilious peritoneal contamination
- Graham patch repair with omental plug
- Thorough peritoneal lavage (10L warm saline)
- Placement of 2 abdominal drains

### Postoperative Course
- ICU admission for hemodynamic monitoring
- Mechanical ventilation for 24 hours
- Vasopressor requirement resolved by POD 1
- NGT removed POD 3
- Diet advanced slowly
- Triple therapy for H. pylori initiated
- Discharged POD 8

### Teaching Points
1. Sudden onset severe abdominal pain with rigidity = surgical emergency
2. NSAID use is a major risk factor for peptic ulcer disease
3. Free air on imaging indicates hollow viscus perforation
4. Resuscitation should not delay definitive surgical management in unstable patients
5. H. pylori testing and treatment essential post-repair

### Clinical Image
![Pneumoperitoneum on Chest X-ray](case_02_image.jpg)

**Image Description:** Upright chest X-ray demonstrating free air under the right hemidiaphragm (pneumoperitoneum), a classic finding in hollow viscus perforation. The crescent of air between the liver and diaphragm is clearly visible.

**Attribution:** Image from Wikimedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/Category:Pneumoperitoneum

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## Case 3: Large Bowel Obstruction from Sigmoid Volvulus

### Patient Demographics
- **Age:** 78 years
- **Sex:** Male
- **Occupation:** Retired, nursing home resident

### Chief Complaint
"He hasn't had a bowel movement in 4 days and his belly is getting bigger."

### History of Present Illness
The patient is brought from his nursing facility by EMS. According to nursing staff, he has had progressively worsening abdominal distension over the past 4 days with absence of bowel movements and minimal flatus. He has had several episodes of non-bilious vomiting today. He has become increasingly confused and lethargic. His baseline mental status includes mild dementia, but he is usually conversant and ambulatory with assistance. He has a history of chronic constipation requiring regular laxatives.

### Past Medical History
- Chronic constipation
- Dementia (mild)
- Parkinson's disease
- Previous episode of sigmoid volvulus (decompressed endoscopically 2 years ago)
- Hypertension
- Type 2 diabetes

### Medications
- Carbidopa-levodopa
- Metformin 500 mg twice daily
- Lisinopril 20 mg daily
- Polyethylene glycol daily
- Senna as needed

### Physical Examination
- **Vitals:** BP 105/68 mmHg, HR 104 bpm, RR 22/min, Temp 37.8°C, SpO2 94% on room air
- **General:** Elderly male, confused, uncomfortable
- **Abdomen:**
  - Inspection: Massively distended, tympanitic
  - Auscultation: High-pitched, tinkling bowel sounds
  - Palpation: Diffuse tenderness, no peritoneal signs
  - No hernias palpable
- **Rectal exam:** Empty rectal vault, no masses, guaiac negative

### Laboratory Results
- WBC: 11,800/μL
- Hemoglobin: 12.4 g/dL
- Creatinine: 1.8 mg/dL (baseline 1.2)
- BUN: 48 mg/dL
- Potassium: 3.2 mEq/L
- Sodium: 131 mEq/L
- Lactate: 2.1 mmol/L

### Imaging
**Abdominal X-ray:**
- Markedly dilated loop of large bowel in an inverted "U" shape
- Classic "coffee bean" sign
- Apex of the loop points toward the right upper quadrant
- Small bowel dilation proximal to obstruction

**CT Abdomen/Pelvis:**
- Sigmoid volvulus with "whirl sign" at the point of torsion
- Massively dilated sigmoid colon (15 cm diameter)
- No evidence of bowel wall ischemia or perforation
- Transition point at the rectosigmoid junction

### Diagnosis
Sigmoid volvulus without evidence of ischemia

### Initial Management
1. NPO status
2. IV fluid resuscitation
3. Nasogastric tube decompression
4. Electrolyte replacement (potassium)
5. Foley catheter
6. Gastroenterology consultation for attempted endoscopic decompression

### Endoscopic Decompression
Flexible sigmoidoscopy performed at bedside. Twisted sigmoid colon encountered at 25 cm. Gentle manipulation with scope achieved detorsion. Large volume of gas and liquid stool expelled. A rectal tube placed for continued decompression.

### Post-Decompression Course
- Abdominal distension improved significantly
- Repeat abdominal X-ray showed resolution of volvulus
- Bowel function returned POD 2
- Diet advanced slowly
- Surgical consultation for definitive management

### Surgical Discussion
Given this is his second episode of sigmoid volvulus, elective sigmoid colectomy recommended after medical optimization to prevent recurrence (recurrence rate 40-60% without surgery). Patient and family counseled on risks and benefits. Decision made to proceed with surgery during this admission after nutritional optimization.

### Definitive Surgery
Laparoscopic sigmoid colectomy with primary anastomosis performed on hospital day 7 after bowel preparation and nutritional support. Uneventful procedure with estimated blood loss of 75 mL.

### Teaching Points
1. Sigmoid volvulus is most common in elderly, institutionalized, and psychiatric patients
2. "Coffee bean" sign on X-ray is pathognomonic
3. Endoscopic decompression is first-line treatment if no signs of ischemia/perforation
4. Definitive surgery (sigmoid resection) recommended after successful decompression to prevent recurrence
5. Emergency surgery required if endoscopic decompression fails or signs of ischemia present

### Clinical Image
![Sigmoid Volvulus X-ray](case_03_image.jpg)

**Image Description:** Abdominal radiograph demonstrating the classic "coffee bean" sign of sigmoid volvulus. The massively dilated sigmoid colon forms an inverted U-shape with the apex pointing toward the right upper quadrant. Air-fluid levels and proximal small bowel dilation are also visible.

**Attribution:** Image from Wikimedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/Category:Volvulus