Theme: The acute abdomen

Theme: The acute abdomen
A. Acute appendicitis
B. Large bowel obstruction
C. Lower gastrointestinal haemorrhage
D. Mesenteric ischaemia
E. Perforated peptic ulcer
F. Peritonitis
G. Pseudo-obstruction
H. Sigmoid volvulus
I. Small bowel obstruction
J. Upper gastrointestinal haemorrhage

For each of the following patients, select from the given list the most likely cause of acute abdominal pain.

  1. A 58-y M with learning difficulties has been referred from his nursing home after the staff noted he was developing a distended abdomen. He has not opened his bowels for three days. On examination he is haemodynamically normal with a distended, tympanic and non-tender abdomen. There are no herniae or visible abdominal scars. A plain abdominal x ray shows a large ‘bean’ shaped loop of large bowel arising from pelvis.
  2. A 62-y F presents with acute onset of severe abdominal pain, diarrhoea and vomiting. On examination she appears unwell and agitated. She is in AF with a pulse of 110. Examination of her abdomen reveals only minor generalised tenderness. Bloods show a white cell count of 24, and ABG shows a pH of 7.14 and lactate of 7.5.
  3. A 62-y M presents with acute onset of abdominal pain and vomiting. He has not opened his bowels or passed flatus for three days. Two years ago he underwent an extended right hemicolectomy for a transverse colon tumour. On examination he has a distended, non-tender abdomen. On auscultation of the abdomen there are high pitched ‘tinkling’ bowels sounds. Plain abdominal x ray shows loops of small bowel centrally.

3 is large bowel obstruction: ? Recurrence of malignancy. That’s why I think the proximal small bowel is distended.

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