General and Colorectal
CASE 9: DiFFerential DiagnoSiS oF loWer abDominal pain
history
A 22-year-old woman presents to the emergency department complaining of lower abdominal pain. This has steadily increased in severity over the previous 24 h and woke her from her sleep. The pain is constant, and simple analgesia has not helped. She has vomited once in the department. Her menses are regular and she is now on day 12 of her cycle. There is no history of vaginal discharge or urinary symptoms. She has no children. She has not undergone any previous surgery but has a history of sexually transmitted disease 2 years ago, treated with antibiotics. There is no other relevant medical history. She takes no current medication and has no allergies. She is a non-smoker.
examination
Her blood pressure is 110/72 mmHg and pulse rate is 110/min. Her temperature is 38.2°C and there is lower abdominal tenderness, more marked in the right iliac fossa, with some rebound tenderness. There are no palpable masses and the loins are not tender. Digital rectal examination is normal. Bimanual per vaginal examination reveals adnexal tenderness on the right.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
14.7 g/dl |
11.5–16.0 g/dl |
White cell count |
16.6 × 109/l |
4.0–11.0 × 109/l |
platelets |
367 × 109/l |
150–400 × 109/l |
Sodium |
139 mmol/l |
135–145 mmol/l |
potassium |
4.1 mmol/l |
3.5–5.0 mmol/l |
urea |
5.6 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
74 μmol/l |
44–80 μmol/l |
C-reactive protein (Crp) |
145 mg/l |
<5 mg/l |
urine dipstick: naD (nothing abnormal detected) urinary b human chorionic gonadotropin (hCg): negative
Questions
•What is the differential diagnosis?
•How should the patient be managed initially?
•If you are unsure of the diagnosis, how should you proceed?
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100 Cases in Surgery
ANSWER 9
The two main differential diagnoses are pelvic inflammatory disease and acute appendicitis. The young female with right iliac fossa pain is often difficult to diagnose. The other differential diagnoses of right iliac fossa pain mimicking appendicitis are shown below.
!Differential diagnoses
•Gynaecological
•pelvic inflammatory disease (salpingitis, salpingo-oophoritis, tubo-ovarian abscess, endometritis, Fitz-hugh–Curtis syndrome)
•ruptured ovarian cyst
•ovarian torsion
•haemorrhage/rupture of ovarian mass
•Surgical
•Crohn’s disease
•mesenteric adenitis
•gastroenteritis
•Diverticulitis (caecal or left sided with a floppy sigmoid lying centrally or on the right of the midline)
•meckel’s diverticulitis
•acute cholecystitis
•Urological
•acute pyelonephritis
•ureteric colic
The high white cell count, raised CRP and tenderness in the right iliac fossa make appendicitis the most likely diagnosis in this patient. In clear-cut cases of appendicitis, the patient is taken to theatre for appendicectomy. If the diagnosis is most likely gynaecological, the patient should be referred to the gynaecologists for a transvaginal ultrasound scan and high vaginal swabs. Where there is doubt, the patient can be taken for diagnostic laparoscopy. If the appendix is abnormal, it can then be removed laparoscopically.
KEY POINT
• a full gynaecological history should be taken in female patients.
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General and Colorectal
CASE 10: Small-boWel anomaly
history
A 14-year-old boy presented to the emergency department with a 24- h history of increasing abdominal pain. The pain localized to the right iliac fossa and a diagnosis of acute appendicitis was made. At operation, the appendix was found to be normal and the anomaly shown in Figure 10.1 was found in a loop of small bowel.
Figure 10.1 operative picture of the small bowel.
Questions
•What is the diagnosis?
•What are the characteristics of this anomaly?
•How can this present?
•How would you deal with this intraoperative finding?
19
100 Cases in Surgery
ANSWER 10
The photograph demonstrates a Meckel’s diverticulum located on the anti-mesenteric border of a segment of ileum. This is a remnant of the omphalomesenteric duct. The ‘rule of twos’ is associated with this condition, i.e. it is present in 2 per cent of the population, it is 2 inches long and located 2 feet from the ileocaecal valve. A Meckel’s diverticulum may be lined by small-intestinal, colonic or gastric mucosa, and it may contain aberrant pancreatic tissue.
The mode of presentation may be:
•Inflammation and perforation of the diverticulum presenting with abdominal pain and peritonitis, mimicking acute appendicitis
•Rectal bleeding from peptic ulceration caused by acid secretion from the ectopic gastric mucosa
•Intestinal obstruction from intussusception or entrapment of the bowel in a mesodiverticular band or a fibrous band that may connect the apex of the diverticulum to the umbilicus or anterior abdominal wall
Tumours may also develop inside a Meckel’s diverticulum.
The diverticulum should be removed by a segmental small-bowel resection. A symptomless diverticulum that is an incidental finding at laparotomy should not be excised, but the patient should be informed of its existence.
KEY POINT
•patients should be made aware if an asymptomatic meckel’s diverticulum is found at the time of surgery.
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