Case Presentation and Discussion
Abdominal Pain

Geraldine B. Remucal, MD
General Surgery Resident, Year V

Case Presentation:

Present Database
	
	Our patient is MC, a 25 year old male who presents at the emergency department for abdominal pain of one day duration.
	
	His present condition started one day prior to his consult at our institution as abdominal pain initially vague and tolerable, located in the epigastric area and later shifting to the right lower quadrant, becoming more intense.  He associates this pain with a sense of anorexia but he says he did not experience nausea nor did he vomit.  There were no associated fever, dysuria, changes in bowel movement, cough and colds.  
	
	MC claims he never underwent surgery before nor was he ever hospitalised for any medical condition.  He denies having any vices.

	Our patient was ambulatory at the emergency department.  He does not walk straight; his right hand seems to cradle his right lower abdomen as he gets on a gurney.  He is polite, cooperative, and coherent.  Vital signs are within normal limits;  there is no fever noted.  His sclerae are pink and anicteric.  His breath sounds are equal and clear.  Heart sounds are regular and distinct.  Pulses are full and regular.  Physical examination now centers upon his abdomen.  It is flat and warm, with normoactive bowel sounds being noted on auscultation.  Palpation elicits a grimace, revealing a tender right lower quadrant with minimal guarding.  Testing for Rovsing’s, psoas, and obturator signs comes up positive.  There are no masses palpated.

Case Discussion

	We are presented with a 25 year old male whose symptoms are persistent right lower quadrant pain shifting from the epigastric area and associated with anorexia.  No other symptoms such as fever, vomiting, dysuria, and diarrhea were present.  Right lower quadrant pain may be brought about by conditions affecting organ systems in this area.  In this patient, it may come from pathology in the following:
a] skin over the right lower quadrant;
b] subcutaneous tissue over the right lower quadrant; or 
c] internal organs usually situated in the right lower quadrant such as the terminal ileum, cecum, appendix, ascending colon, and right ureter.  

Anorexia is a nonspecific symptom which can be present in conditions involving inflammation of the peritoneal surfaces.  If we concentrate on this fact, we can easily rule out a condition involving the skin and subcutaneous tissue.	

Let us first go back to the physical examination.  Focusing upon the abdomen, we see a flat and warm abdomen with no distinct mass.  The skin overlying the right lower quadrant is lesion-free.  This clearly eliminates the possibility of a pathology in the skin.  Our patient came in with normal vital signs presenting unequivocally with a tender right lower quadrant.  The absence of a distinct mass also eliminates the possiblity of a subcutaneous tissue pathology, pain from which may be due to a carbuncle, an abscess, a rectus sheath hematoma, a bleeding soft tissue sarcoma, or an infected sebaceous cyst.  However there is no mass.  Hence the major consideration is a pathology in the internal organs usually situated in the right lower quadrant.

Since MC does not present with any symptom nor sign pertaining to the genitourinary system, there is a chance that the right ureter is not involved in our problem.  The fact that he has no dysuria, darkeining of urine, oliguria, frequency, hesitancy, lithuria, or hematuria allows us to now concentrate on the bowels:  terminal ileum, cecum, ascending colon, and appendix.  

Pain and tenderness in the intestinal tract are sensed by a patient when the sensory nerves of the gut are stimulated.  Pain may be caused  by distention of a hollow viscus, by inflammation causing stretching of the visceral peritoneum, or by peritonitis.

If pain is to originate from the terminal ileum, the more common etiology is an ileitis versus an inflamed Meckel’s diverticulum.  These entities present as right lower quadrant with no palpable mass as MC’s case.  However, ileitis is invariably associated with fever and constitutional signs which are clearly absent in our patient.  It is therefore unlikely.  What we may consider is an inflamed Meckel’s diverticulum.  This condition is almost always diagnosed intraoperatively.  Only the psychic surgeon can actually give this as his primary consideration.

Conditions of the colon (ascending colon and cecum) that bring about pain are various.  However, diseases that bring about pain but are not accompanied by the presence of a mass are fewer.  One distinct entity is diverticulitis.  Given the acuteness of the present condition and the age of the patient we may relegate this disease to the background.    
The last organ within the vicinity and belonging to the intestinal tract is the appendix.  The primary clinical diagnosis considered in MC’s case is acute appendicitis.  The history of abdominal pain beginning vaguely in the epigastric area and later becoming sharper and shifting to the right lower quadrant points to this.  Moreover, the presence of anorexia lends support to the diagnosis.  The physical examination only served to strengthen the diagnosis of acute appendicitis since direct tenderness was elicited over the right lower quadrant.  Additional signs usually present in acute appendicitis such as Rovsing’s sign, obturator sign, and psoas sign were all elicited on physical exam again reinforcing the  diagnosis.

Paraclinical Diagnostic Procedures

	Our primary clinical diagnosis is acute appendicitis.  A condition to rule out at this point is Meckel’s diverticulitis.  At this point, no paraclinical dignostic procedure will aid in the swift management of MC.  We are 90% certain that the primary clinical dignosis is indeed the condition with which he is inflicted.  This is solely based on the history and physical examination findings.  Acute appendicitis is a condition diagnosed clinically and usually requires no additional diagnostic work-up to ascertain its presence.  

Treatment

	The main consideration for MC’s condition is acute appendicitis.  At this point, Meckel’s diverticulitis is also considered a possibility but by no means should it be ruled out definitely before MC is managed according to the primary clinical diagnosis.  The goal is to treat his condition which we will now label with confidence as acute appendicitis.  This condition requires principally surgical intervention:  appendectomy.  It is prudent to allow MC nothing by mouth and to start an intravenous line for hydration.  Antibiotics in intravenous form are administered before the procedure.  Finally, once he is given his premedications, he will be brought to the operating room and an appendectomy wil be done.

	If right lower quadrant exploration reveals an appendicitis, appendectomy is done expeditiously.  If the appendix appears normal, the terminal ileum must be inspected to rule out a Meckel’s diverticulitis.