Ward Round-An acute abdominalemergency

Abstract

A 32 year old unemployed male was brought into the Accidents and Emergency Department of the University College Hospital, Ibadan, with a 2-day history of severe generalized abdominal pain, fever, vomiting and abdominal distension. He had been previously well until 2 days prior to presentation when he had abdominal pain with loose stools. He went to a general practitioner and anti-ulcer drugs plus metronidazole tablets were prescribed. His condition did not improve and he developed a fever, became constipated and his abdominal girth started increasing with worsening of the pain. Examination at the emergency department showed a young adult male who looked acutely ill, he was febrile but not pale or jaundiced. His tongue was dry and coated with brownish material. The main findings were on abdominal examination; his abdomen was distended, tense and generally tender. There was a vague mass in the left iliac fossa which was tender. Auscultation revealed a silent abdomen. Rectal examination only yielded some mucus but not blood. The diagnosis entertained was of a perforated left-sided colon cancer with differentials of typhoid perforation or perforated amoebic colitis. Plain abdominal x-rays ordered showed dilated small bowel with multiple air/fluid levels with an isolated loop of gas-filled bowel on the left side. A consideration of small bowel volvulus was also entertained at that juncture. He was resuscitated and had an emergency exploratory laparotomy. Findings at surgery showed a 20cm length of jejunum that was a dusky red colour with a clear-cut demarcation between the affected part and a less erythematous but still rather hyperaemic part of the jejunum (Figure 1). The involvement of the mesentery of the affected part was also evident as a triangular thickened segment was also dusky-red. There were no enlarged mesenteric lymph nodes and there was about 500ml of serous peritoneal fluid. He had jejunal resection with end to end anastomosis using 3-0 Vicryl suture in 2 layers. He had an uneventful post-operative course and recovered bowel functions on the 4th post-operative day. He was discharged on the 9th post-operative day. The histopathology report of the resected small bowel stated 'acute on chronic jejunitis with peritonitis'. He has been seen for follow-up several times at the surgical outpatient clinic and he remains in good health.