Case Presentation and
Discussion on
Abdominal Pain

 

Janix M. De Guzman, MD

Department of Surgery

Ospital ng Maynila Medical Center

General Data:
            B.G., 46 y/o Male, from Intramuros, Manila

Chief Complaint:

                        “abdominal pain”

History of the Present Illness:

            2 years PTA – Patient started to experience a bulging mass on the inguino-scrotal area, easily reduced. No other symptoms noted. No consult done.

            1 year PTA – with recurrent bulging of inguino-scrotal mass, patient noted mass became non-reducible.

            1 day PTA -    patient suddenly experienced crampy epigastric pain, associated with nausea.

            Few hours PTA – patient noted       right lower quadrant pain becoming generalized. This prompted consult to our institution.

Past Medical History:

            unremarkable

Family History:

            unremarkable

Personal and Social History:

            smoker 5 pack years

Physical Examination:

            > conscious, coherent

            > BP=120/80mmHg,            PR=82bpm

                        RR=20cpm,   Temp=37.1oC

            > pink palpebral conjunctivae, anicteric sclerae

            > supple neck, no cervical lymphadenopathy

            > symmetrical chest expansion, clear breath sounds

            > adynamic precordium, no murmur

            > extremities no edema with good and equal distal pulses

            > Globular abdomen, hypoactive bowel sounds, (+) muscle guarding,

            (+) tenderness on all quadrants more         pronounced on RLQ area

            > Rectal Examination:

                        no mass, no fissures, good sphincteric tone, full rectal vault,                               (+) brown stool, (-) blood on tactating finger

            20 x 15 x 10 cm , bulging

            mass, inguino-scrotal area, right

            Non-reducible

            Distended

            Tender

Salient Features

                        46y/o, Male

                        long standing inguinoscrotal bulging mass, right

                        abdominal pain

                        P.E.

                                    Globular abdomen, hypoactive bowel sounds,

                                    (+) muscle guarding, (+) tenderness on all quadrants

Clinical Diagnosis

Primary Diagnosis:

                         Indirect Inguinal Hernia, Right, incarcerated

                                    with bowel strangulation

Secondary Diagnosis:

                        Acute Appendicitis, ruptured

Pathophysiology: Primary Diagnosis

•         Long standing hernia

•         Non-reducible

•         Mesentery to the intestines may be compromised – strangulation – perforation - peritonitis

•         Abdominal pain

Pathophysiology: Secondary Diagnosis

•         Abdominal pain

                        - epigastric     -Luminal obstruction

                        - RLQ  - suppuration

                        - Generalized - perforation

•         Generalized tenderness more pronounced RLQ

            area

Paraclinical Diagnostic Procedure

Do I need a paraclinical diagnostic procedure?

                        No.

                        Treatment plan for Primary and Secondary diagnosis     is the same.

Pretreatment diagnosis:

Acute abdomen secondary to Indirect Inguinal Hernia, Right, Incarcerated

With probable strangulation

Goals of treatment:

•         To reduce the incarcerated organ

•         Assess viability of incarcerated organ

•         To repair the defect

Surgical Approach

Treatment:

1. Pre-op Preparation

•         Informed consent

•         Psychosocial support

•         Optimize patient’s health

•         Screen for any condition that will interfere with treatment

•         Prepare materials

2. Intra-operatively

·        Patient placed supine

·        Area prepared

·        Sterile drapes placed

·        Incision done

                  Abdominal MIDLINE

Intra-operative Findings

            Yellowish thick purulent, non-foul-smelling material noted whole quadrant         of abdomen, with concentration at RLQ area.

            Incarcerated omentum and large intestines, from cecum to proximal     transverse colon, including appendix.

•         Incarcerated omentum and large intestines were markedly adherent to the scrotal sac.

•         Difficulty in pulling up incarcerated organs.

• Inguino-scrotal incision made.

•         Upon adhesiolysis, and reduction of herniated organs to the abdominal cavity; the following were noted:

                        Appendix was grossly normal. Incarcerated omentum and large intestines were viable.

2mm perforation noted at anterior aspect of first part of duodenum, covered with fibrin material. 2cm from pylorus

Intra-op Diagnosis

•         Perforated duodenal ulcer with generalized peritonitis

•         Indirect Inguinal Hernia, Right

            Incarcerated

Goals of Treatment

• Perforated Duodenal Ulcer with Generalized Peritonitis

–        Close/remove the perforation

–        Irrigate the abdomen to decrease / minimize the peritonitis

–        Prevent recurrent ulceration

OPERATION FOR REMOVAL OF ULCER

*Recommended Surgical Procedures for Duodenal Ulcer

*Yeo,C.J.,Zinner,M.J.,Duodenal Ulcer,Shackleford’s Surgery of the

Alimentary Tract,4th Edition,1996

Consequences of Duodenal-Ulcer Operations

*Yeo,C.J.,Zinner,M.J.,Duodenal Ulcer,Surgery of the Alimentary Tract,

4th Edition,1996

Other Supporting Reasons why we opted for excision of ulcer with simple closure coupled with medical management.

“…Due to recognition of H. pylori as a causative agent in duodenal ulcer disease many western surgeons are questioning the need for definitive ulcer surgery in the acute mgt of perforated duodenal ulceration.

Hill,A.G.,Management of perforated duodenal ulcer in a resource poor environment.Journal of East African Medicine.July 2001

“…It is suggested that selected patients,without preoperative risk factors are offered definitive surgery but those at risk of postoperative mortality maybe treated with conservative surgery and treatment for HP.”

-Hill,A.G.,Management of perforated duodenal ulcer in a resource poor environment.Journal of East African Medicine.July 2001

Most surgeons would then perform some form of definitive ulcer operation,
although there is some evidence now that, with appropriate medical therapy,
there is no need for such a procedure.

In the past vagotomy and antrectomy were performed in patients with a good risk profile. This is probably not indicated today because of the long-term side effects and the lower recurrence rates after treatment of H. pylori.

“…A major limitation in recommending highly selective vagotomy is the few numbers of procedures performed in the United States.Consequently,few surgeons are trained in the technique.”

-Livingston,EH.,Stomach and Duodenum,Surgery:Basic Science and Clinical Evidence,2000.

Operative Technique:

•         Ulcer margins were excised

•         Simple closure done and buttressing with a pedicle of omentum.

Surgical Options; repair of the floor

Operative Management: Bassini Repair

INTRA-OPERATIVE MANAGEMENT

•         Other maneuvers

•         Minimize further contamination

•         Gentle handling of tissues

•         Peritoneal lavage

•         Hemostasis check

•         Complete sponge and instrument  count

Closure Incisions

•         Midline

–        Continuous sutures using vicryl 0 with interrupted external bolsters

•         Inguino-scrotal incision

–        External oblique fascia closed continuously using vicryl 0 sutures

–        Subcutaneous and skin - open

Post-operative Diagnosis

            Perforated Duodenal Ulcer, Generalized Peritonitis

            Indirect Inguinal Hernia, Right, incarcerated

POST-OPERATIVE MANAGEMENT:

•         Basic needs supplied

–        Analgesia

–        Comfort

•         Support of organ function

–        NG tube decompression è GI

–        Hydration è Renal

•         Wound care

•         Monitoring of complications

•         Pulmonary

•         Wound infection

•         Advise

Anti-Helicobacter pylori regimens

•         two different regimens are used:

–        based triple therapy

•         bismuth is combined with tetracycline and metronidazole; it
is highly effective and inexpensive

•         given orally for 2 weeks

•         Bismuth subcitrate 120 mg qid, metronidazole 250mg tid, tetracycline 500mg qid

–        proton pump inhibitor—based antibiotic therapy.

–         

REFERENCES

1. Seymour Schwartz. PRINCIPLES OF SURGERY 7th ed. Vol I.
2. Wallace Ritchie Jr. SHACKLEFORD’S SURGERY OF THE ALIMENTARY TRACT Vol.2 and Vol 5
3. Michael Zinner. MAINGOT’S ABDOMINAL OPERATIONS 10th ed. Vol I
4. Norton JA, Bollinger RR, Chang AE, Lowry SF. BASIC SCIENCE AND CLINICAL EVIDENCE
5. MD consult – journals