Tricky cases - Intestinal perforation

An elderly man with a past history of knee joint osteoarthritis on long term analgesics from a GP presented with worsening abdominal pain for 1-day duration to the medical casualty ward. There was no fever or vomiting. He had not passed stools on the day of admission. There was no history of hematemesis or malena.

On examination, the patient was ill-looking. Epigastrium was tender. He was tachycardic, but the blood pressure was normal.

The house officer ordered IV omeprazole and IV fluids. He kept the patient nil by mouth. He ordered basic investigations including supine and erect Xrays of the abdomen and serum amylase.

About an hour later the Xrays were taken and as they were normal same management was continued.
Image result for xray supine abdomen


Image result for xray erect abdomen perforation

The senior registrar came for the ward round in the evening and he immediately called the colleague surgical senior registrar.
"Hey, I think we've got a patient for laparatomy. Please come and see!"
Tentative Diagnosis??

Perforated peptic ulcer due to long term NSAID use!!

Lesson

  • Not all patients admitted to medical wards have medical problems!
  • Are the Xrays normal?
Image result for xray erect abdomen perforation

AIR UNDER THE DIAPHRAGM !!

  • Unless you LOOK FOR something you will never pick it up!
  • What is the clinical feature missed by the house officer?
    • Absent liver dullness
  • What are the things that you should never miss in a patient with an acute abdomen?
    • Hernial orifices
    • Absent liver dullness
    • Flank dullness
    • Testicles - Torsion can present with abdominal pain
    • Digital rectal examination
    • Pulsatile abdominal mass - Aneurysm
      • The list goes on and on! Why don't you read about the rest?
(Photographs were taken from internet)

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