Typical case of Acute Abdomen

1. Morning Meeting
3-5-2017
Unit III

2. 10 year old 20kg previously well child,
resident of Lyari presented to E.R with
C/O
• Severe Abdominal Pain since 10 days
• Constipation
• Fever

3. HOPC
• Severe pain since 10 days. Colicky in nature.
Not localized to a particular area.
• Absolute constipation since 8 days
• Fever undocumented

4. • PAST MEDICAL HISTORY: Not Significant
• BIRTH HISTORY: NVD at home. No complications. Stool and Urine
passed on 1stday of life
• FAMILY HISTORY: 8th issue of Non- Consaigunous marriage. All
other siblings healthy. No chronic illnesses like TB DM or HTN in
family.
• DRUG & ALLERGY HISTORY: Not significant.
• VACCINATION HISTORY: Only Polio drops
• SOCIOECONOMIC HISTORY: Poor family, father is a fisherman, live
in poorly ventilated house and drink unboiled water.

5. On Examination
Alert looking child in obvious pain, lying
uncomfortably on bed.
GCS 15/15. A- Cl- Cy- Ed- Dh- LN-
HR: 120. RR 28. Sat 99%
Abdomen: Tense, tender, tenderness not localized
to any particular area. Abdomen moving equally
with respiration, no visible scar marks or pulsations.
Umbilicus inverted. Visceromegally not appreciated
due to tenderness. Temperature of overlying skin
was normal. No palpable mass. No herniation on
cough. Gut sounds not audible. No prominent veins.
Chest: Clear B/L Equal air entry
CVS: S1 + S2 + 0

6. Differential Diagnosis
1. Intestinal Obstruction
2. Peritonitis secondary to perforation
3. Pancreatitis
4. Appendicitis

7. Investigations
• CBC: Hb 10.4. TLC 16,100 (N 74, L 20, Plt 651000)
• S.UCE: Urea 43, Cr. 0.6, Na 138, K 5, Cl 100, HCO3
21
• PT Test: 14
Control: 14
APTT Test: 34
Control: 34
• ESR: 40
• M.P -ve

8. Xray Abdomen

10. Ultrasound Abdomen
• Splenomegaly. A large irregular echogenic
area is seen at lower pole of spleen measuring
3.5*4.3 cm. The rest of spleen appears
hypoechoic. The splenic vessels could be
visualized properly.
• The pancreas appears heterogeneous.
Multiple enlarged peripancreatic lymphnodes
seen, one of them measuring 0.8*0.8cm
• Serum Amylase, Lipase, CT Abdomen adviced

11. Serum Amylase & Lipase
• Amylase 71 (28-100)
• Lipase 17 (<60)

12. CT Abdomen with Contrast
• Spleen appears enlarged measuring 13cm.
Spleen also appears displaced inferiomeidally.
Diffuse hypodensity seen in spleen without
evidence of enhancement of splenic
parenchyma. These findings are highly keeping
with wandering spleen which is most likely
twisted at its pedicle resulting in its ischemic
infarction. Splenic artery and splenic vein can
be traced up to hilum. Needs clinical
correlation and urgent surgical opinion.

15. Final Diagnosis
Wandering Spleen with splenic infarct
Treatment
Splenopexy, fixation of spleen, but if there is no
blood flow after unwinding the spleen through
detorsion then spleenectomy must be
performed.

16. Discussion
• Wandering spleen (also called Pelvic Spleen) is a
rare medical disease caused by loss or weakening
of the ligaments that help to hold the spleen
stationary.
• Most commonly diagnosed in young children.
• Very rare. Only 500 cases reported till 2005.
• Usually found at birth but it can occur in adults as
a result of injuries and other similar conditions
that cause ligaments to weaken such as
connective tissue disease or pregnancy.
• Wandering spleen predisposes the spleen to
complications such as torsion, splenic infarct,
pancreatic necrosis and rarely pseudocyst
formation

17. Thankyou