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SU28.{1-4,18} | Abdominal Wall and Peritoneal Conditions — PBL Case
CLINICAL SETTING
You are the surgical team on call at a district hospital. Over a single night shift you are asked to assess three different patients who have presented to the emergency department, each with an abdominal problem that will test your understanding of the abdominal wall and peritoneal cavity. Work through each trigger as a group, in order, before revealing the next.
Trigger 1: The young man with the rigid abdomen
A 28-year-old man is brought in with sudden, severe pain that began in the upper abdomen four hours ago. He lies perfectly still on the trolley and winces when the trolley is bumped. He gives a history of months of epigastric pain relieved by food and antacids. On examination he is tachycardic, the abdomen is board-rigid with generalised guarding and rebound tenderness, and bowel sounds are absent. An erect chest X-ray is requested.
DISCUSSION POINTS
- What is your clinical diagnosis, and what does 'lying still' tell you compared with a patient who writhes?
- What single finding on the erect chest X-ray would confirm a perforated viscus, and why?
- Classify this peritonitis and outline the three pillars of management you would begin in parallel.
Click to reveal Trigger 2: The elderly woman with the painful groin lump (discuss previous trigger first!)
Trigger 2: The elderly woman with the painful groin lump
A 74-year-old woman presents with 10 hours of central colicky abdominal pain, vomiting and a small, tender lump in the right groin that she had never noticed before. The lump lies below and lateral to the pubic tubercle, is irreducible and has no cough impulse. Her abdomen is distended with tinkling bowel sounds. She is dehydrated.
DISCUSSION POINTS
- What type of hernia is this, and which anatomical features make it the groin hernia most likely to strangulate?
- How do the abdominal findings indicate that bowel is involved, and what complication has occurred?
- Why must you resuscitate before operating, and how would you assess bowel viability at surgery?
Click to reveal Trigger 3: The post-operative swinging fever (discuss previous trigger first!)
Trigger 3: The post-operative swinging fever
A 35-year-old man returns three weeks after an appendicectomy for perforated appendicitis. He has felt unwell with a swinging fever, malaise and a deep, dragging ache in the pelvis. He reports passing mucus with his stools and a feeling of incomplete emptying. His abdomen is soft, but a vague fullness is felt on rectal examination. Inflammatory markers are high.
DISCUSSION POINTS
- What is the most likely diagnosis, and which features point to a walled-off collection rather than diffuse peritonitis?
- Why will antibiotics alone usually fail, and what is the definitive principle of management?
- What imaging would you request, and how does it guide both diagnosis and treatment?
Group Task Assignments
- Construct a one-page comparison table of primary, secondary and tertiary peritonitis (cause, organisms, surgical source, principle of management).
- Draw the relationships of the inguinal and femoral hernias to the pubic tubercle and inferior epigastric vessels, and annotate which is most likely to strangulate and why.
- List the criteria you would use intra-operatively to decide that bowel is non-viable and must be resected.
Learning Issues
Research these questions and bring your findings to the discussion.
- [SU28.3] What distinguishes primary, secondary and tertiary peritonitis, and how does the management differ for each?
- [SU28.1] How are groin hernias classified by their relationship to the inferior epigastric vessels and the pubic tubercle, and which complications threaten bowel viability?
- [SU28.4] How does an intra-abdominal abscess present after abdominal sepsis, and why is drainage rather than antibiotics alone the definitive treatment?
- [SU28.18] Which bedside signs (rigidity, rebound, shifting dullness) and investigations (erect chest X-ray, CT) drive the work-up of the acute abdomen?