PANDORAS BOX

Let us start with a story ..

Greek mythology
Zeus, Greek God, took back fire from humans Prometheus stole fire from heaven Zeus took vengeance by presenting Pandora to Epimetheus, Prometheus' brother. With her, Pandora was given a beautiful container.

WHY ABDOMEN A PANDORAS BOX?

one never knows what will come out of it when one opens it. WE EXPECT ONE THING MANY TIMES UNEXPECTED THING COMES OUT WE EXPECT ONE THING NOTHING COMES OUT

Case 1
60 year old female Pain lower abdomen 4 days Generalised 3 days Abdominal distension 3 days Vomiting 3 days Obstipation 3 days
History of bleeding PR on and off No previous pain abdomen or surgery

On examination
Lower abdominal distension Tenderness lower abdominal No obliteration of liver dullness Bowel sounds sluggish

X-ray abdomen

Usg abdomen

Serial examination
Distension and pain persisted No bowel movements bowel sounds absent

Decision taken to do laparotomy

What we expected ?
Intestinal obstruction Malignancy

What we found?
Duodenal perforation with peritonitis

Case 2
44 year old female Pain abdomen 5 Days Abdominal distension 5 days Vomiting 2 Days PREVIOUS LAPAROTOMY FOR HYSTERECTOMY

Examination
Generalised abdominal distension Tenderness Bowel sounds exaggerated

X-ray abdomen

USG abdomen

 Failed conservative management Planned for laparotomy

What we expected ?
Intestinal obstruction adhesions

Intra-operative findings
Growth in ascending colon Right hemicolectomy done

Case 3
37 year old female Complains of pain abdomen right iliac fossa 5 days Fever Vomiting

On examination
Obese female Abdominal distension Maximum Tenderness mainly in right iliac fossa

Diagnosis
Perforated appendix with abscess formation

Investigations
Xray no specific findings Usg collection in RIF S. amylase normal

Per-op findings
Pus collection in RIF but appendix normal pus appearing to come from upper abdomen Necrotizing pancreatitis

Post op CT scan

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 days Distension Vomiting

Examination
Features of peritonitis USG free fluid present

TLC raised X-ray abdomen no positive finding

Intra-operative findings
Normal appearing contents Straw colored peritoneal fluid no pus

Case 6
6 yr old girl case of RTA diagnosed to have grade II splenic injury with hemoperitoneum Hemodynamically stable Persisting abdominal distension and pain

Examination ( serial )
Abdominal distension No features of peritonitis Bowel sounds absent X-ray abdomen no free air under diaphragm USG free fluid in abdomen
Dilated bowel loops

Intra-operative findingsjejunal perforation ( Day 3 )

Case 7
50 year old female Deaf and mute Brought with c/o abdominal distension and vomiting 5 days

On examination
Abdominal distension No features of peritonitis

Per rectal impacted stools

Enema stool passed distension slightly reduced

Investigation
X-ray abdomen air fluid levels in small bowel Usg no significant findings other than dilated bowel loops

Diagnosis
Intestinal obstruction However passes still c/o pain abdomen Examination guarding in right iliac fossa USG repeat- Collection in RIF

Gangrenous appendix with pus

Why diagnosis is difficult ?

History may not be forthcoming/ not reliable Delayed presentation Atypical presentation Peritonitis features masked

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

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, the human belly defies them all and reveals its secret only when confronted by a surgeons scalpel.

Does experience help?

Surgery never runs out of suspenseful surprises. The last operation that a surgeon performs on the abdomen before retiring, he might see something he has never seen before.

At the end of all this .,

Decided whether it is abdomen with a surgical cause or not Not necessary to make a exact diagnosis though we should be aware of the possibilities

Let me end with a story

A weekend party among students, interns, GPs and surgeons by the river side A bird seen A student says look at that bird, it may be a kite or tern or hawk or even a sea-gull Intern looks like a either a tern bird or sea-gull, it cant be the other two

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

go and confirm which bird it is

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

Take home messages

No short cuts to detailed history and examination Decide whether it is a surgical abdomen

Serial assessment of bowel sounds

Take home messages

Rule out pancreatitis in all acute upper abdomen Rule out perforation in all acute abdomen

Rule out cause outside abdomen

Another Pandoras box is perhaps a girls mind

Thank you