Pandora's Box Final

7/31/2019 Pandora's Box Final

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PANDORAS BOX

Let us start with a story ..


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Greek mythology

Zeus, Greek God, took back firefrom humans

Prometheus stole fire from heaven

Zeus took vengeance by presenting

Pandora to Epimetheus,Prometheus' brother.

With her, Pandora was given a

beautiful container.


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WHY ABDOMENA

PANDORAS BOX?one never knows what will come

out of it when one opens it.

WE EXPECT ONE THING MANYTIMES UNEXPECTED THINGCOMES OUT

WE EXPECT ONE THING NOTHING COMES OUT


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Case 1

60 year old female

Pain lower abdomen 4 days

Generalised 3 daysAbdominal distension 3 days

Vomiting 3 days

Obstipation 3 days History of bleeding PR on and off

No previous pain abdomen or surgery


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On examination

Lower abdominal distension

Tenderness lower abdominal

No obliteration of liver dullnessBowel sounds sluggish


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X-ray abdomen


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Usg abdomen


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What we expected ?

Serial examination

Distension and pain persisted

No bowel movements bowel sounds

absentDecision taken to do laparotomy

Intestinal obstruction -Malignancy


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What we found?

Duodenal perforation with peritonitis


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Case 2

44 year old female

Pain abdomen 5 Days

Abdominal distension 5 days

Vomiting 2 Days

PREVIOUS LAPAROTOMY FORHYSTERECTOMY


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Examination

Generalised abdominal distension

Tenderness

Bowel sounds exaggerated


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X-ray abdomen


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USG abdomen


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What we expected ?

Failed conservative management

Planned for laparotomy

Intestinal obstruction adhesions


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Intra-operative findingsGrowth in ascending colon

Right hemicolectomy done


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Case 3

37 year old female

Complains of pain abdomen rightiliac fossa 5 days

Fever

Vomiting


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On examination

Obese female

Abdominal distension

Maximum Tenderness mainly inright iliac fossa


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Diagnosis

Perforated appendix with abscessformation


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Investigations

Xray no specific findings

Usg collection in RIF

S. amylase normal


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Per-op findings

Pus collection in RIF but appendixnormal

pus appearing to come from upper

abdomen

Necrotizing pancreatitis


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Postop CT scan


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Case 4 and 5

25 year old male

Fever 7 days

Pain abdomen 4 Days

Vomiting - 2 Days

12 Year old male

Pain abdomen 5 daysDistension

Vomiting


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Examination

Features of peritonitis

USG free fluid present

TLC raisedX-ray abdomen no positive

finding


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Intra-operative findings

Normal appearing contents

Straw colored peritoneal fluid nopus


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Case 6

6 yr old girl case of RTAdiagnosed to have grade II splenicinjury with hemoperitoneum

Hemodynamically stable

Persisting abdominal distensionand pain


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Examination ( serial )


No features of peritonitis

Bowel sounds absent

X-ray abdomen no free air under

diaphragmUSG free fluid in abdomen

Dilated bowel loops


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Intra-operative findings-

jejunal perforation ( Day 3 )


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Case 7

50 year old female

Deaf and mute

Brought with c/o abdominaldistension and vomiting 5 days


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On examination


No features of peritonitis

Per rectal impacted stools

Enema stool passeddistensionslightly reduced


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Investigation

X-ray abdomen air fluid levels insmall bowel

Usg no significant findings other

than dilated bowel loops


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Diagnosis

Intestinal obstruction

However passes still c/o painabdomen

Examination guarding in rightiliac fossa

USG repeat- Collection in RIF


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Gangrenous appendix with

pus


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Why diagnosis is difficult ?

History may not be forthcoming/not reliable

Delayed presentation

Atypical presentation

Peritonitis features masked


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Why diagnosis is difficult?

X-ray free air under diaphragm not in all perforation cases

X-ray evidence of obstruction,not the cause

CT abdomen cannot be done in

many acute abdomen cases

Diagnostic laparoscopy cannot be

done in all acute abdomen cases


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Does experience help?

For over 50 years that I have been

opening up patients abdomen, I am

constantly amazed at the variety of

pathology I have encountered.In spite of so many new

investigations at our disposal like

ultrasound, CT scan and MRI, thehuman belly defies them all andreveals its secret only when

confronted by a surgeons scalpel.


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Does experience help?

Surgery never runs out ofsuspenseful surprises.

The last operation that a surgeon

performs on the abdomen beforeretiring, he might see something he

has never seen before.


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At the end of all this .,

Decided whether it is abdomen witha surgical cause or not

Not necessary to make a exactdiagnosis though we should beaware of the possibilities


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Let me end with a story

A weekend party amongstudents, interns, GPs andsurgeons by the river side

A bird seen

A student says look at that

bird, it may be a kite or tern orhawk or even a sea-gull

Intern looks like a either a tern

bird or sea-gull, it cant be the

other two


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GPs bird came from the south ,wings are characteristic of seagull,it is most probably a sea-gull

At the end the surgeon shoots thebird

go and confirm which birdit is

D i h f


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Does it mean we have a free

hand?Remember the story of Pandoras

box

Negative laparotomy- known entity

But better to err on the wrong side

it doesnt matter if you

arent right , but never be

wrong


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Take home messages

No short cuts to detailed historyand examination

Decide whether it is a surgicalabdomen

Serial assessment of bowel sounds


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Take home messages

Rule out pancreatitis in all acuteupper abdomen

Rule out perforation in all acuteabdomen

Rule out cause outside abdomen


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Another Pandorasbox is perhaps a

girls mind

Thank you

Pandora's Box Final

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