Acute Abdomen 1

A 61-year-old man presents to the emergency department with severe abdominal pain for 2 days.

Initially the pain was colicky; it is now continuous.

History

• Abdominal pain for 2 days
• Initially colicky, now continuous
• Nausea
• Loss of appetite
• No stool for 3 days
• Persistent sensation of incomplete bowel emptying
• No hematemesis
• No fever

Past medical history

• Depression, on medication (Amitriptyline 25 mg daily)

Previous operations

• Appendectomy many years ago

Vital signs

• Blood pressure: 132/78 mmHg
• Heart rate: 104/min
• Respiratory rate: 20/min
• Oxygen saturation: 98% (room air)
• Temperature: 37.3 °C

Physical examination

• Alert and oriented, appears to be in pain
• Abdomen markedly distended
• Old scar from appendectomy in the right lower quadrant
• Bowel sounds increased, tinkling
• Diffuse tenderness on palpation, accentuated periumbilically
• No guarding
• No rebound tenderness
• No palpable hernias
• Rectal examination:
  • Rectal ampulla largely empty
  • No blood
  • No palpable tumor

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Note

• Proximal to the obstruction: dilated small bowel loops
• Distal to the obstruction: absence of gas, including the rectosigmoid (physiologically gasless)

Quiz

• What is your most likely working diagnosis?
• Which findings support this?
• Which differential diagnoses should be considered?
• How would you proceed?
• Which investigations would you order?
• What further diagnostics would be useful?