Diffuse Peritonitis due to Hepar Abcess + Appendicitis

Nurul Najiha binti Noor Azhar 11 2011 141 dr. Johan Lucas, Surgoen Syrgery Department RSUD Ciawi

Identity

Name: Mr. M Age : 70 yo

Medical history

Chief complaint : pain at the whole of his abdomen

History of present illness

Patient came to emergency room with complaint of continuous pain at the whole of his abdomen since 2 days ago. The pain preceeded by discontinuous pain on right lower quadrant, after several days it spread to the whole abdomen. Nausea (+), vomiting (-), fever (-), he had defecate problem since 10 days ago but suddenly defecate in emergency room, fart (+), process to pee had no problem. Current complaint : Pain on right upper quadrant (+).

History of past illness

Bloody diarrhea sometimes present on past 3 month.

Physical examination

On examination patient alert Vitals :

Blood pressure: 150 / 80 mmHg

Pulse rate :
Respiration rate : temperature :

104 x / menit
40 x/ menit 38.8 C

Local examination of abdomen:

Inspection : lump on right upper quadrant Auscultation : bowel sounds (+) normal. Percussion : tympanic sound on all abdomen quadrant, liver dullness (+) Palpation : tenderness (+), abdominal guarding (+), liver is palpable, lump in soft consistency, size : 14cm

Differential diagnosis

Peritonitis due to rupture of amoebic hepar abcess Peritonitis due to rupture of pyogenis hepar abcess Peritonitis due to perforate appendicitis Empyema Infectious hepatitis

Additional workup
Laboratorium : fecal culture, LFTs X-ray : abdominal erect, abdominal supine, thorax xray. USG / scanning

Investigation (Laboratorium)
Tests Hemoglobin Hematocrit Leukocyte 35% 17 300/uL Result 12,0 mg/dL

Trombocyte Blood group

Rhesus AST ALT Ur Cr Na Potassium Cl Blood glucose level

569 000/uL B
+ 75 U/L 69 U/L 46 mg/dL 1,26 mg/dL 118 mEq/L 3,9 mEq/L 90 mg/dL 146 mg/dL

Working diagnosis

Diffuse peritonitis due to suspect rupture of hepar abcess + appendicitis + SIRS

Management
Non medical treatment :
NGT decompresion Urine catheter Aspiration abcess Pro Exploratory laparotomy

Medication :
IVFD RL 14 gtt/min Metronidazole 3x750 mg drip

Ceftriaxone 1x2 g iv
Ranitidin 3x1 amp iv Ketesse 3x1 amp iv

Prognosis

Ad Vitam Ad Fungsionam Ad Sanationam

: bonam : dubia : dubia

Thank you

Classic phase of Infectious Hepatitis

Phase 1 (viral replication phase) Patients are asymptomatic during this phase; laboratory studies demonstrate serologic and enzyme markers of hepatitis

Phase 2 (prodromal phase) Patients experience anorexia, nausea, vomiting, alterations in taste, arthralgias, malaise, fatigue, urticaria, and pruritus, and some develop an aversion to cigarette smoke; when seen by a health care provider during this phase, patients are often diagnosed as having gastroenteritis or a viral syndrome Phase 3 (icteric phase) Patients may note dark urine, followed by pale-colored stools; in addition to the predominant gastrointestinal (GI) symptoms and malaise, patients become icteric and may develop right upper quadrant pain with hepatomegaly
Phase 4 (convalescent phase) Symptoms and icterus resolve, and liver enzymes return to normal