Case 187: Severe abdominal pain
A 42 year old man presents with sudden onset of severe, constant central abdominal pain. On examination his abdomen is distended but soft and only mildly tender.
1. What are the xray findings?
There are several loops of small bowel seen within the central abdomen. They are distended and there is loss of the normal folds of plicae circulares. Adjacent loops of small bowel are separated by several millimetres indicating thickening of the bowel wall likely due to oedema. The colon contains gas throughout its length but is not distended and there are no diagnostic features in the colon.
There is loss of the normal psoas shadow on the right possibly indicating retroperitoneal oedema but there are no other obvious soft tissue or boney abnormalities seen.
The clinical picture of pain out of proportion to examination findings and abnormal small bowel on imaging raises the possibility of ischaemic small bowel.
2. What are the principles of management?
Rapid fluid resuscitiation followed by urgent transfer to the operating theatre for exploratory laparotomy.