A patient with Periumbilical pain

If a patient presents with periumblical pain, one should consider following differential diagnoses considering site such as   

Early appendicitis

Gastroenteritis

Bowel obstruction

Ruptured aortic aneurysm

 

A patient with Periumbilical pain and vomiting

A 50 years gentle man presents with pain around umbilicus, vomiting and constipation for 6 hours.

What are the diagnoses striking in your mind?

  • Intestinal obstruction
  • Early appendicitis

What key questions would you ask?

Pain–

  • periumblical colicky pain with each peristalsis and audible borborigmi– intestinal obstruction.
  • Vague, often colicky periumbilical or epigastric pain which shifts to the right lower quadrant (right iliac fossa) within 12 hours – acute appendicitis.

Vomiting–

  • Vomiting is almost invariable and more profuse. The vomitus initially contains bile and mucus and later feculent- intestinal obstruction.
  • Nausea with one or two episodes of vomiting- acute appendicitis.

Constipation-

  • Absolute constipation (no passage of flutus and faeces)- intestinal obstruction.

Abdominal distention– diffuse abdominal distension in intestinal obstruction.

Temperature– raised in appendicitis but may be raised in intestinal obstruction if peritonitis develops.

H/O previous operation, hernia

What would you examine?

General examination– distressed during pain, dehydrated.

Abdominal examination–

  • Abdominal distention is the hallmark of all forms of intestinal obstruction. Visible peristalsis and auscultation may reveal loud, high-pitched borborygmi coincident with colicky pain in intestinal obstruction.
  • Localized tenderness with guarding in the right iliac fossa (McBurney’s point tender) – acute appendicitis.

Clinical diagnosis–

History of periumblical pain, absolute constipation, persistent vomiting, diffuse abdominal distension and tenderness and increased borborigmi and visible peristalsis   suggest the diagnosis of intestinal obstruction.

Investigation-

Plain X-ray abdomen in erect posture including both dome of diaphragm- multiple air fluid level (normal up to 3) is diagnostic of intestinal obstruction. It also excludes perforation of hollow viscus (free gas under both domes of diaphragm).

CBC- leucocytosis

Treatment-

   Resuscitation–

  • Nothing by mouth.
    • Decompression instituted by means of a nasogastric tube and aspiration.
  • Fluid and electrolyte balance should be restored by ringer’s lactate. (Replacement of potassium is especially important because intake is nil and losses in vomitus are large.)
  • Antibiotic- parentral ceftriaxone or ciprofloxacin

Definitive treatment– operative management, so referral for surgical consultation.