33 Acute Abdomen Case Studies for Surgery

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Questions and Answers

What is the primary reason for performing Hartmann's procedure?

Unable to reverse an end-colostomy

Immediate need for bowel resection

Presence of sigmoid perforation and peritonitis (correct)

Patient preference for colostomy

Which incisions are generally used for laparotomy in emergency situations?

Right or left Paramedian incision (correct)

Pararectal incision

Bikini line incision

Rutherford Morrison incision

Which of the following is NOT a complication of diverticulitis?

Fistula formation

Diverticulosis resolution (correct)

Luminal obstruction

Abscess formation

What is a significant finding in the microbiological culture of abdominal fluid in diverticulitis?

Gram-negative bacilli Signup and view all the answers

What characterizes congenital diverticulosis compared to acquired diverticulosis?

Presence of all three layers of bowel wall Signup and view all the answers

What is the indicated empirical antibiotic regimen for a patient with mesenteric ischaemia requiring emergency surgery?

Cefuroxime, metronidazole, and gentamicin Signup and view all the answers

Which of the following findings was NOT reported in the management of the patient with mesenteric ischaemia?

Evidence of perforation Signup and view all the answers

What crucial observation was noted in the microbiology results of the peritoneal fluid sample?

No growth on peritoneal fluid sample Signup and view all the answers

What symptom did Susan NOT complain about when presenting to the ED?

Vomiting Signup and view all the answers

Which vital sign indicates that Susan was likely experiencing some level of distress?

Heart rate of 115 bpm Signup and view all the answers

What is the treatment of choice for difficult toxic megacolon?

Subtotal colectomy with end-ileostomy Signup and view all the answers

Which organism is primarily responsible for pseudomembranous colitis?

Clostridioides difficile Signup and view all the answers

What is the indicative imaging finding for appendicitis in Case 3?

Thickened appendix with surrounding fluid Signup and view all the answers

What is the recommended action if a patient is diagnosed with a perforated peptic ulcer?

Immediate exploratory surgery Signup and view all the answers

Which antibiotic is being used in Case 4 for empiric antifungal coverage?

Fluconazole Signup and view all the answers

In Case 5, what lab finding is the most concerning for possible sepsis?

Lactate 4.8 Signup and view all the answers

What type of bacteria was cultured from the peritoneal fluid in Case 4?

Gram-negative bacilli Signup and view all the answers

What does the presence of dark, smelly stools suggest in patient Roger's case?

GI bleeding Signup and view all the answers

What is a characteristic feature of pseudomembranous colitis?

Formation of an adherent inflammatory exudate Signup and view all the answers

In Case 4, what critical condition is suggested by the rigid abdomen and absent bowel sounds?

Perforated bowel Signup and view all the answers

What is the most likely cause of Jim's acute abdominal symptoms?

Diverticulitis Signup and view all the answers

Which vital sign finding indicates Jim may be experiencing sepsis?

High heart rate Signup and view all the answers

Which initial laboratory result is most concerning for Jim's condition?

Lactate of 3.6 mmol/L Signup and view all the answers

Which imaging study would be most beneficial in Jim's case to confirm bowel obstruction?

CT scan of the abdomen and pelvis Signup and view all the answers

What is the best empirical antibiotic treatment choice for potential diverticulitis in Jim's case?

Metronidazole plus a beta-lactam Signup and view all the answers

Which complication of diverticular disease should be monitored for in Jim's condition?

Bowel perforation Signup and view all the answers

What is the significance of rebound tenderness in Jim's examination?

Suggests possible peritoneal irritation Signup and view all the answers

To narrow down the differential diagnosis, which specialty would provide the most relevant information based on imaging findings?

Radiology Signup and view all the answers

If diverticulitis is confirmed, what should the immediate management plan include?

Fluid resuscitation and antibiotics Signup and view all the answers

What aspect of Jim's bloody results indicates inflammation?

WBC count of 22.1 x 10^9/L Signup and view all the answers

What is the primary reason for conducting a percutaneous cholecystostomy?

To drain an infected gallbladder Signup and view all the answers

Which antibiotic is NOT used empirically in the management of a perforated gallbladder?

Amoxicillin Signup and view all the answers

What symptom is most concerning in Malik's presentation for spontaneous bacterial peritonitis?

Acute onset of abdominal pain Signup and view all the answers

What is the appropriate initial management for a patient suspected of having spontaneous bacterial peritonitis?

Begin empiric ceftriaxone Signup and view all the answers

What significant laboratory finding indicates the need for SBP management in the patient?

Leukocyte count of 1500 with 95% polymorphs Signup and view all the answers

When is the decision to perform an emergency cholecystectomy made?

If the patient does not stabilize after the initial treatment Signup and view all the answers

What condition was Malik concerned to potentially have, given his presentation?

Spontaneous bacterial peritonitis Signup and view all the answers

What is the significance of sending specimens to histology after a cholecystectomy?

To identify any presence of malignancy Signup and view all the answers

What is the most likely diagnosis for Mary, considering her symptoms and examination findings?

Toxic megacolon Signup and view all the answers

Which management step is crucial for a patient exhibiting symptoms of toxic megacolon due to C. difficile?

Stop all antibiotics and initiate C. difficile therapy Signup and view all the answers

What imaging finding would most likely correlate with Mary’s diagnosis of toxic megacolon?

Dilated large bowel loops Signup and view all the answers

In managing a patient with suspected C. difficile infection, what level of precautions should be implemented?

Isolate with enhanced contact precautions Signup and view all the answers

What laboratory finding is most suggestive of severe colitis in Mary’s case?

Lactate level of 4.2 Signup and view all the answers

What are the first two steps in the management of a patient with sepsis?

Administer IV fluids and conduct blood cultures Signup and view all the answers

Which organism pair is most commonly associated with bowel commensal flora?

E.coli and Bacteroides fragilis Signup and view all the answers

What is the imperative focus of the empiric treatment for a patient with suspected perforated diverticulitis?

Address anaerobic and Gram-negative bacteria Signup and view all the answers

In cases of perforated diverticulitis, why is intravenous contrast important when performing a CT scan?

To identify inflammatory processes more effectively Signup and view all the answers

Which of the following statements about the likelihood of resistant organisms in this patient with sepsis is true?

He is not likely to have resistant organisms due to lack of healthcare exposure Signup and view all the answers

What can be deduced about the initial diagnostic imaging choice if free air is detected under the diaphragm?

CT is preferred to assess the etiology of free air Signup and view all the answers

Which lab value is of utmost importance for understanding a patient's abdominal CT findings related to diverticulitis?

Lactate levels Signup and view all the answers

Which initial management step for a patient with perforated diverticulitis requires the most urgent attention?

Ensure the patient is NPO Signup and view all the answers

What was the primary surgical intervention performed during the management of mesenteric ischaemia?

Emergency laparotomy with resection of the small bowel Signup and view all the answers

Which vital sign finding in Susan's case suggests a potential acute abdomen condition?

Heart rate of 115 beats per minute Signup and view all the answers

What was the outcome of the microbiological testing conducted on Susan's peritoneal fluid and blood cultures?

No growth in both peritoneal and blood cultures Signup and view all the answers

In the initial management of mesenteric ischaemia, which class of antibiotics was not included in the empirical treatment?

Vancomycin Signup and view all the answers

What key clinical finding points towards possible acute cholecystitis for Susan?

RUQ tenderness with guarding Signup and view all the answers

What is the purpose of sending peritoneal fluid for culture in a patient suspected of spontaneous bacterial peritonitis (SBP)?

To identify the micro-organisms causing infection Signup and view all the answers

Which antibiotic is used as an empiric treatment for managing spontaneous bacterial peritonitis?

Ceftriaxone Signup and view all the answers

If a patient does not show improvement after initial management, what is the next step recommended for a perforated gallbladder?

Emergency cholecystectomy Signup and view all the answers

What is the significance of leukocyte count in peritoneal fluid in the context of spontaneous bacterial peritonitis?

A high count confirms a bacterial infection Signup and view all the answers

What complication is associated with a history of non-alcoholic liver cirrhosis, particularly in the context of spontaneous bacterial peritonitis?

Development of ascites Signup and view all the answers

What immediate medical action should be taken for a patient presenting with signs of potential spontaneous bacterial peritonitis?

Administer IV fluids Signup and view all the answers

Why is blood culture essential in the management of a patient with suspected spontaneous bacterial peritonitis?

To determine antibiotic sensitivities Signup and view all the answers

What is the expected finding in a microbiological culture from peritoneal fluid in a case of spontaneous bacterial peritonitis?

Gram-negative bacilli like Klebsiella pneumoniae Signup and view all the answers

What is the main advantage of performing surgery earlier in cases of difficult toxic megacolon?

Improved surgical outcomes Signup and view all the answers

Which of the following best describes a pseudomembrane associated with pseudomembranous colitis?

A coagulum overlying sites of inflammation Signup and view all the answers

In Ciara's case, what finding is most indicative of appendicitis upon examination?

Tenderness at McBurney’s point Signup and view all the answers

Which antibiotic regimen is appropriate for Emily's management after an emergency surgery for a perforated peptic ulcer?

Cefuroxime, metronidazole, and fluconazole Signup and view all the answers

What does the presence of gram-negative bacilli in Roger's peritoneal fluid suggest?

Bacterial sepsis Signup and view all the answers

What is the primary characteristic of the pus sample obtained from Ciara's surgery?

It contained multiple types of bacteria Signup and view all the answers

In Emily's recovery post-surgery, what would be the most critical lab value to monitor for potential complications?

WBC count Signup and view all the answers

What could the rigid abdomen and absent bowel sounds in Emily's examination indicate?

Perforated viscus Signup and view all the answers

What finding was noted in Roger's examination that points towards possible atrial fibrillation?

Irregular, rapid heart rate Signup and view all the answers

What was the microbiological finding regarding E. coli from Emily's peritoneal fluid sample?

Resistant to co-amoxiclav and susceptible to gentamicin Signup and view all the answers

Study Notes

Acute Abdomen Case Studies

The cases are presented as junior surgical doctors on-call, needing to manage a range of acute abdomen presentations.
The specialties present to guide the management plan are Surgery, Pathology, Microbiology, and Radiology.

Case 1

A 68-year-old male presents with bloating, worsening abdominal pain for 3 days, and constipation for 1 week.
The patient has a history of hypertension, hypercholesterolemia, and a recent colonoscopy showing diverticulosis.
He is febrile, hypotensive, with tachycardia, elevated WBC, CRP, and Lactate.
He presents with tenderness, guarding, and rebound tenderness in the left iliac fossa, absent bowel sounds, and mild distension.
The most likely diagnosis is diverticulitis, but could be large bowel obstruction.

Case 1: Management

Surgery is consulted and performs a laparotomy. Findings are faecal contamination, sigmoid perforation, and peritonitis.
Samples are sent to Pathology and Microbiology.
A Hartmann’s procedure is performed, with a Robinson’s drain left in situ.

Case 1: Hartmann’s Procedure

Hartmann’s procedure involves a rectosigmoid resection and creating a colostomy.
This procedure is performed when an end-to-end anastomosis is not suitable.
The rectal stump remains, and the proximal colon is exteriorized as a colostomy, potentially to be reversed later.

Case 1: Pathology

The patient’s pathology results indicate diverticulitis with complications.

Diverticulosis

Diverticulosis is a condition where pouches form in the wall of the colon.
It can be congenital or acquired.
Congenital diverticulosis involves all three layers of the bowel wall and is often associated with Meckel’s diverticulum.
Acquired diverticulosis lacks or has an attenuated muscularis propria. It is common in western societies and affects over 50% of people older than 60 years.

Diverticular Disease: Aetiology

The primary cause of diverticulosis is increased intraluminal pressure.
This pressure can be caused by exaggerated contractility of the muscularis propria or constipation.
Herniation occurs at weak points in the bowel wall, particularly where blood vessels supply the colon and between the taenia coli, longitudinal muscle layers.
These herniations involve the mucosa prolapsing through the muscularis propria, forming outpouchings and thickening the muscularis propria layer.

Diverticulitis Complications

Common complications include abscess, luminal obstruction, peritonitis, perforation, bleeding, and fistulas.
Fistulas can occur between the colon and other structures, such as the enteric tract, bladder, vagina, or skin.

Case 1: Microbiology

Abdominal fluid shows Gram-negative bacilli on microscopy.
The culture indicates C. difficile toxic megacolon.

Case 1: Management (Continued)

Surgery is considered on a case-by-case basis, with early surgery associated with better outcomes.
The treatment of choice for C. difficile toxic megacolon is subtotal colectomy with an end ileostomy followed by subsequent re-anastomosis.

End and Loop Ileostomy

An ileostomy is a surgical procedure where a portion of the ileum is brought out to the surface of the abdomen creating a stoma.
An end ileostomy is where the end of the ileum is brought out to the surface of the abdomen.
A loop ileostomy is where a loop of the ileum is brought out to the surface of the abdomen

Case 2

A 42-year-old female presents with loss of appetite, nausea, vomiting, and intermittent lower abdominal pain for 5 days.
She has a past history of asthma, is on oral contraceptives, and has no known allergies.
She is febrile with tenderness, guarding, and rebound tenderness in the right iliac fossa, consistent with appendicitis.
She has elevated WBC, CRP, and Lactate.

Case 2: Management

The patient is diagnosed with appendicitis, blood cultures are taken, and IV fluids are administered.
Empiric antibiotics, including cefuroxime, metronidazole, and gentamicin, are prescribed.
The patient undergoes an emergency laparoscopic appendectomy.

Case 2: Microbiology

The pus sample from theatre shows Gram-negative bacilli and culture confirms E. coli.
The E. coli is resistant to co-amoxiclav but susceptible to cefuroxime and gentamicin.

Case 2: Management (Continued)

The patient is treated with antibiotics post-operatively for 5-7 days, with gentamicin discontinued after 48-72 hours once culture results are available.

Pseudomembranous Colitis

Pseudomembranous colitis is characterized by adherent plaques of yellow fibrin and inflammatory debris on reddened mucosa.
This is caused by the toxins produced by C. difficile.
These plaques are not true membranes because they are not epithelial layers.

Case 3

A 37-year-old female presents with severe constant upper abdominal pain 2 hours after undergoing open reduction internal fixation (ORIF) of her right ankle.
She had a fall 3 days prior resulting in the ankle injury and has no other significant injuries.
She has a past history of non-insulin dependent diabetes mellitus, currently diet-controlled.
She has low blood pressure, increased respiratory rate, and elevated WBC, CRP, and Lactate.
The clinical exam findings are consistent with a perforated peptic ulcer or small bowel obstruction.

Case 3: Radiology

The chest X-ray shows free air under the diaphragm.
The abdominal CT-scan confirms free air and evidence of ascites.

Case 3: Management

The patient has sepsis and requires emergency surgery.
She receives empiric antibiotics, including cefuroxime, metronidazole, gentamicin, and fluconazole for potential upper GI perforation and peritonitis.

Case 3: Surgery

Surgery confirms a perforated peptic ulcer and a laparoscopic or open laparotomy is performed to repair the bowel.
Peritoneal fluid is sent to microbiology.

Case 3: Microbiology (Continued)

The peritoneal fluid sample contains Gram-negative bacilli and yeast on microscopy.
Culture results show E. coli and Candida albicans.

Case 3: Management (Continued)

The patient's antibiotics are rationalized to amoxicillin, metronidazole, and fluconazole.
She is treated with antibiotics post-operatively for 5-7 days, with gentamicin discontinued after 48-72 hours once culture results are available.

Case 4

A 75-year-old male presents to the ED in acute distress with confusion, severe sudden abdominal pain, nausea, bloating, and bloody stools.
He has a history of poorly controlled hypertension, hypercholesterolemia, and occasional palpitations.
He is febrile, hypotensive, tachycardic, and has elevated WBC, CRP, and lactate.
The clinical exam findings suggest mesenteric ischemia or large bowel ischemia.

Case 4: Radiology

CT-scan of the abdomen shows evidence of bowel ischemia.

Case 4: Management

The patient has sepsis and requires emergency surgery.
He is given empiric antibiotics, including cefuroxime, metronidazole, and gentamicin.
Emergency laparotomy is performed with bowel resection and the formation of an end ileostomy.

Case 4: Microbiology

No growth is seen in the peritoneal fluid or blood cultures.
The patient’s antibiotics are discontinued after 48-72 hours with negative microbiology results.

Case 5

A 61-year-old female presents with progressively worsening upper abdominal pain for 2 days.
She has a past history of hypothyroidism, cholelithiasis, and a penicillin allergy.
She is febrile, tachycardic, and has elevated WBC, CRP, and liver enzymes.
The clinical exam findings suggest acute cholecystitis, ascending cholangitis, or a perforated gallbladder.

Case 5: Radiology

The CT-scan demonstrates gallstones, a thickened gallbladder wall, and pericholecystic fluid, consistent with acute cholecystitis.

Case 5: Management

The patient is managed with IV fluids, blood cultures, and empiric antibiotics, including ciprofloxacin, metronidazole, and gentamicin due to penicillin allergy.
She undergoes a percutaneous cholecystostomy, and a sample is sent for microbiology.
She is scheduled for a delayed laparoscopic cholecystectomy once stabilized.
If the patient’s condition doesn’t improve, emergency cholecystectomy is considered and tissue specimens are sent to histology.

Case 6

A 66-year-old male on the medical ward presents with new onset confusion, acute onset of abdominal pain, and an elevated temperature.
He has been admitted 2 days previously with community-acquired pneumonia and has a CURB-65 score of 2.
He has a past history of non-alcoholic liver cirrhosis, Child-Pugh Class A, previous laparoscopic cholecystectomy, and is a smoker.
He has elevated WBC and CRP.

Case 6: Management

The patient is suspected to have spontaneous bacterial peritonitis (SBP).
He is managed with a medical consultation for SBP, IV fluids, blood cultures, and a peritoneal fluid analysis for culture and white cell count.
Empirical ceftriaxone 2g OD IV is administered.

Case 6: Microbiology

The peritoneal fluid leukocyte count is 1500 with 95% polymorphs.
Klebsiella pneumoniae is identified in the culture and it is resistant to amoxicillin and co-amoxiclav.

Case 6: Long-term Management

The patient recovers and is treated with a liver transplant. The liver is sent for histopathology.

Perforated Diverticulitis

Erect chest x-ray reveals free air under the diaphragm, suggesting a perforation.
Rigler's sign is visualized on a plain abdominal film, indicating free air in the abdomen.
The preferred imaging modality for further assessment is CT scan with intravenous contrast.
Sepsis is a life-threatening condition characterized by infection, triggering a host response, leading to organ dysfunction.
The initial management of perforated diverticulitis includes sepsis management, intravenous fluids, and immediate surgical intervention.
Empirical antibiotics are typically administered, covering gram-negative bacteria and anaerobes.
Cefuroxime, metronidazole, and gentamicin are commonly used in perforated diverticulitis.
Gentamicin is advised to be discontinued after 48 hours, while cefuroxime and metronidazole are continued for 5-7 days postoperatively.

Toxic Megacolon due to C. difficile

Key exam/blood findings suggestive of toxic megacolon include elevated white blood cell count (WBC), C-reactive protein (CRP), and lactate, as well as altered mental status, fever, tachycardia, hypotension, and abdominal distention with tenderness.
Patients with suspected C. difficile should be isolated with enhanced contact precautions to prevent further transmission.
Management of toxic megacolon due to C. difficile involves urgent discussion with surgical and microbiology teams, discontinuing offending antibiotics, initiating C. difficile therapy with fidaxomicin and/or intravenous metronidazole, and stabilizing the patient.
Surgical intervention is considered on a case-by-case basis, with earlier surgery associated with better outcomes.
Subtotal colectomy with end-ileostomy is the treatment of choice.