Case 190 -- Severe Abdominal Pain

Contributed by James Davie, MD PhD
Published on line in April 1999


The patient is a 16-year-old boy who was in his normal state of good health until presenting emergency department with a one-day history of severe abdominal pain localized to the periumbilical area. He had vomited twice with thick-yellow fluid, and could not tolerate oral intake. He was diagnosed with presumptive gastroenteritis and sent home.

He returned the next day complaining of unremitting severe sharp, crampy pain in the lower abdomen, with occasional radiation to the back. He reported an absence of bowel movements and no flatus for the prior 24 hour period.

Past medical or surgical history was non-contributory. The patient was on no medications.


On admission the patient was febrile to 38.2 degrees Celsius, with heart rate 160, blood pressure 110/68.

Physical examination of the skin and pharynx was unrevealing. The abdomen, on examination, showed distension, guarding, rebound tenderness, tenderness to percussion, and equivocal psoas sign.

A CBC with differential was remarkable for a white cell count of 14,600/cubic millimeter, with 35% bands. Serum chemistries were unremarkable. Chest x-ray demonstrated a distended bowel, with air/fluid levels, suggestive of small bowel ileus. An abdominal ultrasound was unremarkable.

The patient was admitted with the presumptive diagnosis of appendicitis.


The patient was taken to the operating room, where an open appendectomy was started, revealing purulent ascites, and a grossly normal appendix. Exploratory laparotomy via midline incision was performed.

In the mid-jejunum was a found a large, complex intussusception with markedly distended bowel approximately 10 cm in diameter in a closed loop. At the base of the intussusception, the twisted bowel was necrotic with microperforation. The bowel segment with the jejunal intussusception was completely excised and submitted to pathology as part #1.

In the mid-ileum was found a second intussusception. The point of intussusception origin contained a palpable intra-ileal polyp, 5 cm long. The ileum intussusception was reduced, and a polypectomy was performed with a 1 cm margin around the base of the polyp, by entering the antimesenteric border of the ileum and excising the polyp and its base with electrocautery. The ileal polyp was submitted to pathology as part #2.

The grossly normal appendix was removed and submitted as part #3.





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