Surgery Case Write

Up
A 22 Year old female with a lump in
her abdomen

Vikkineshwaran SM

Contents

Pag

Content

e
3 History
6 Physical Examination
7 Differential Diagnosis
7 Investigation
12 Diagnosis
13 Management, progress and
follow-up
14 Discussion
15 Summary and Conclusion
21 References
22 Appendix

Patient History
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Vikkineshwaran SM

Source: The patient gave her own history and appeared to be a reliable
source.
Personal Details: Mrs. X is a 22 year old married Indonesian female.
She is currently working as a factory worker and is staying in Damansara
Perdana with her husband.
Chief Complaint: Patient came to the emergency department with a
complaint of localized pain at the right lower abdomen with swelling at
the same site present for the past two weeks.
History of Present Illness: Patient has been having pain on her right
lower abdomen for about three months now. It started as a mild irritation
but slowly progressed to a painful sensation within a few months. Two
weeks back the pain got very severe until patient was not able to carry out
her daily routine and had to be bed bound. It was of a sudden onset,
starting at about daytime when patient was at work. The pain is localized
at a spot about two fingers above the right anterior suprior iliac spine.
Patient describes the pain as a stabbing sensation present at only the
specific spot with no spread or radiation.

Theres no aggaravating or

relieving factors identified. Typically the pain lasts about 15 minutes.

In addition to this, patient also had associated symptoms of fever for
2months, significant weight loss in one month, loss of appetite and nausea
feeling for about a month and constipation for about a week.
Patient has visited a few clinics where she was prescribed some pain
relievers but it was not helpful. She was also confirmed as not pregnant
Current

treatment

regime:

Patient

is

currently

not

under

any

medication.
Past Medical History: In 2010, patient was admitted due to stillbirth
preterm labor. Patient did not have any complications from or during the
delivery. It was a normal delivery.

Vikkineshwaran SM

Patient

does

not

suffer

from

diabetes,

hypertension

or

hypercholestremia.
Allergies: Patient is allergic to paracetamol. She gets epilepsy-like
shaking episodes once consuming paracetamol.
Family history: Patient originated from Indonesia. She is the eldest
among 5 siblings. Her mother has passed away while her father is still
alive. Patient has 4 siblings all currently residing in Indonesia. In addition
to this, patient is married and her husband is an Indonesian man, currently
working in Malaysia as a construction worker. Patient has been married for
about 5 years now.
Family medical history: Patients mother had passed away in indonesia
six years ago due to tuberculosis. Patient has been the primary caregiver
to her mother at that time. Patient does not know the cause of her
mothers death but knows that her mother was diagnosed with tuberculosis
and that she passed away about a month after starting treatment.
Patients father has hypertension and is on medication. Patients
sublings are all apparently healthy.
Social History: Patient has been residing in Malaysia for about 5 year
now. She is working as a factory worker and part time promoter in a mall.
Patient stays in Damansara Perdana in a 5 storey low cost apartment with
her husband. Patient claims that she used to smoke when shes under
stress. She smoked about three sticks a time but not regularly. Patient
claims to have quit smoking for about a year now. Patient claims of no
alcohol or drug intake.
Dietary history: Patient claims that she always takes her meals at
regular intervals. She has had previous experience of gastric pain when
she skips meals, thus patient always claims of taking small amounts of
food at about every 4 hours. She takes normal Malay style meal, rice or
bread for breakfast, rice with meat and vegetable for lunch, tea with

Vikkineshwaran SM

biscuits or kuih at teatime and dinner of rice or noodles usually about

9pm.

Systems Review:
1. Constitutional: Patient has been feeling well until three months back.
She complains of feeling sick and uncomfortable and recently has
lost about 5kg in a month . She has a general feeling of weakness.
Patient has been having low grade fever for two months.
2. HEENT:
a. No headaches ,
b. Eyes: No blurring of vision, diplopia or cataracts
c. Ears: normal hearing
d. Nose: no epistaxis or obstruction
e. No history of tonsillitis or tonsillectomy
3. Respiratory: History of TB exposure. No history of pleurisy, cough,
wheezing, asthma, haemoptysis, pulmonary emboli, or pneumonia
4. Cardiac: No chest pain, syncope, dizziness or radiating pain.
5. Vascular: No history of claudication, gangrene, deep vein
thrombosis, aneurysm
6. Gastrointestinal: History of gastritis since young. Loss of appetite,
weight loss, nausea, constipation and swelling in right iliac fossa.
Refer to History Of Presenting Illness.
7. Genitourinary: Normal mensturation. Last period on 18th December
2013. Bleeding usually lasts for about 5 days. Patient uses 6/7 pads
usually and the flow is quite scanty. Patient had preterm still birth on
2010. Refer to Past Medical History
8. Neuromuscular: not known
9. Emotional: denies history of anxiety or depression
10.
Haematological: patient appreas pale,

palmar

pallor,

conjunctival pallor and history of generalized weakness

11.
Rheumatic: no history of gout, rheumatic arthritis, or lupus.
12.
Endocrine: not known
13.
Dermatology: no new rashes of pruritus
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Vikkineshwaran SM

Physical Examination
Vital Signs: Temperature: 37oC; Pulse rate: 72/min; Blood pressure:
110/70mmHg regular rate and rhythm, no collapsing pulse;Respiratory
rate: 21/min
General inspection: On inspection, patient was a middle aged female
who was lying propped up on bed with a pillow. She did not apprear to be
in any obvious pain or respiratory distress. Patient had an intravenous line
attached to her right hand at the brachial region with dextrose infusion.
Patient has a mantoux test spot drawn on her lest arm. Patients built was
underweight and she appeared dehydrated.
Abdominal Examination: On inspection, the abdomen was rising with
inspiration. The central portion of the abdomen appreared slightly
distended. No obvious swellings noticed. Peristaltic waves were seen on
close inspection. No visible pulses or thrills seen. On palpation, the right
lower quadrant had guarding and felt full. Hardness was felt in the right
lower quadrant region in comparison to the other quadrants which felt
soft. Dullness was heard on the right lower quadrant while the other
quadrants were resonant. Normal bowel sound was heard in auscultation.
On cough reflex, no any hernia seen. When patient raised her head, the
swelling on right lower quadrant dissapeared. The contours of the swelling
could not be fully indentified.
Liver span was approximatedly 8cm and the spleen could not be
palpated. Fluid shift and fluid thrill was negative. The kidneys were not felt
on flank balloting. The pubic region was not examined.
Other Systems
Eyes: extra ocular motions full, gross visual fields full to confrontation,
conjunctiva pallor. Sclera was non-icteric, pupils equal round and reactive
to light and accommodation, fundi was well visualized.
Ears: Normal hearing. Tympanic membrane was present and intact
Nose: No discharge, no obstruction, septum not deviated.

Vikkineshwaran SM

Mouth: No angular stomatitis seen around the lips and the lips appeared
dry. The tongue was pale pink in color and fissures were seen on the
anterior portion of the tongue. No macroglossia seen. Uvula moves up in
midline. Normal gag reflex. On examination of the teeth, patient had one
of her right bottom incisor missing. Teeth was white in color and the gums
were intact. No gingival hyperplasia or gingical bleeding seen.
Neck: jugular venous pressure 7cm, normal and not raised. Thyroid gland
not palpable. No masses.
Lymph nodes: No lymphadenopathy, Trosseau sign negative
Spine: normal position, mobile, nontender, no costovertebral tenderness
Chest: Pectus carinatum, rises with inspiration, chest expansion was equal
and symmetrical, vocal fremitus was resonant, normal vesicular breathing
sounds heard on auscultation. Reduced air entry noted.
Extremities: skin warm and smooth No pitting oedema or clubbing nor
cyanosis on both hands and legs
Neurological: Awake, alert and fully oriented. Cranial nerves III-XII intact
Motor: Strength not tested, patient moves all extremities.
Sensory: Grossly normal to touch and pin prick. Cerebellar: no
tremors. Reflexes all present and symmetrical
Pelvic: not done
Pervaginal: not done

Differential Diagnosis
1.
2.
3.
4.
5.

Appendicular Mass
Abdominal tuberculosis
Gastrointestinal malignancy (intestinal tumor or lymphoma)
Hepatomegaly
Ovarian or uterine malignancy

Investigations and Results

Full Blood Count

Liver Function Test
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Vikkineshwaran SM

Urinalysis
Renal Function test
Mantoux Test
CT Scan

Full Blood Count

Test Name

Result

Fla
g

Units

Reference
Range

COMPLETE BLOOD COUNT W/ DIFF

WBC

11.16

RBC

4.02

x109/L

4.0 - 11.0

x1012/L

3.80 - 4.8

8.8

g/dL

12.0 - 15.0

HCT (HEMATOCRIT)

26.4

37.0-47.0

MCV

65.7

fl

83.0 - 101.0

MCH

21.9

pg

24.0-33.0

MCHC

33.3

31.0-37.0

RDW

18.2

11.5-14.5

x109/L

110-450

40.0-80.0

HGB (HEMOGLOBIN)

PLATELET COUNT

255

DIFFERENTIAL
TOTAL NEUTROPHILS, %

76.5

TOTAL LYMPHOCYTES, %

11.9

20.0-40.0

MONOCYTES, %

11.4

2.0-10.0

EOSINOPHILS, %

0.1

1.0-6.0

BASOPHILS, %

0.1

0.0-2.0

x109/L

1.90-8.0

x109/L

0.90-5.20

x109/L

0.16-1.0

TOTAL NEUTROPHILS,
ABSOLUTE

8.54

TOTAL LYMPHOCYTES,
ABSOLUTE

1.33

MONOCYTES, ABSOLUTE

1.27

EOSINOPHILS, ABSOLUTE

0.01

x109/L

0.0-0.8

BASOPHILS, ABSOLUTE

0.01

x109/L

0.0-0.2

Vikkineshwaran SM

Intertpretation:

Decreased hemoglobin, hematocrit, MCV and MCH suggests anemia.

Increased WBC, neutrophil and monocyte count suggests possibility
of infection.

Liver Function Test

Test

Result

Flag

Units

Name

Reference
Range

ALT

14

U/l

10-50

Albumin

55

g/l

35-50

ALP

68

U/l

40-125

Bilirubin

12.4

mol/l

2-17

Interpretation: Raised albumin indicates increased protein in blood. This

can be suggestive of a liver pathology which had lead to ascites
accumulation causing distension of abdomen. Increased protein can also
indicate poor renal function or increased production of albumin.

Urinalysis
Test

Result Flag

Name

Reference
Range

Protein

Trace

Nil

Nitrite

Nil

Neg

Leucocyt

Nil

Neg

Blood

Nil

Neg

pH

6.5

4.6-8.0

Vikkineshwaran SM

Interpretation: From this urinalysis, as there is no leucocyte present, it

indicates theres no urinary tract infection. Urine pH is slightly acidic but
within normal range.

Renal Function Test

Test

Resul

Flag Units

Reference

Name

Sodium

129

mmol/l

125-135

Potassiu

3.40

mmol/l

3.3-4.7

97.0

mmol/l

95-107

mol/l

50-110

Range

m
Chloride

Creatinin 55.8
e

Interpretation: No abnormalities in renal function test suggests that there

is no renal possible renal pathology in this patient.

Mantoux Test

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Vikkineshwaran SM

Interpretation: After 72 hours, the induration in patients arm has risen

more than 10mm. This is indicative of tuberculin exposure in patient.

CT Scan

Interpretation: CT abdomen is taken with contrast. There is presence of a

mass within the gut lumen. The mass is also causing uterus displacement
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Vikkineshwaran SM

and there is presence of gas in the bowel. In addition to this, thickening of

the small bowel is seen and theres also presence of some enlarged lymph
nodes. Based on this imaging, it is possible to rule out appendicular mass,
hepatomegaly and uterine or ovarian malignancy(4).

Diagnosis
Based on the history and physical examination, the patient was
suspected to have either an appendicular mass, abdominal tuberculosis,
hepatomegaly, intestinal tumor, or ovarian malignancy. Based on the
investigations done, it is possible to rule out hepatomegaly, appendicular
mass and ovarian malignancy. Thus the provisional diagnosis made is
patient is either suffering form abdominal tuberculosis or intestinal tumor.
In order to diagnose a patient as suffering from abdominal
tuberculosis, the following clinical features should be present:

Age group 20-40 most often affected

Female preponderance
Symptoms of abdominal pain, abdominal distention, weight loss,
anorexia, fever, diarrhoea or constipation, borborygmi, and perrectal
bleeding

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Vikkineshwaran SM

Signs of anemia, malnutrition, abdominal tenderness, ascites, mass

in the right iliac foss and features of intestinal obstruction

Doughy abdomen on palpation

The patient has all the clinical features described above and with her
history of prior exposure to tuberculosis from her mother, it is highly
suspected that patient might be suffering from abdominal tuberculosis.
Biopsy was obtained and sent for culture to confirm diagnosis.

Management, progress and Follow-up plan

Patient was identified as a TB suspect and was started on treatment
with isoniazid (INH), rifampin (RIF), pyrazinamide (PZA) and ethambutol
(EMB). She was subsequently discharged home to directly observed
therapy (DOT). Her fever improved over the initial weeks of therapy and
the ascites resolved. Two months later, the lab reported PZA resistance
and identified her isolate as Mycobacterium bovis. Treatment with INH and
RIF for 9 12 months was planned (2,3).
At the end of therapy, a repeat CT scan will be taken. Lab tests for
CEA antigen, CA 125, ESR, and hemoglobin needs to be taken to monitor
patients current status. She will be followed because of the extensive
initial disease and the persistent abnormal CT findings. Repeat scans and
laboratory tests will be done at 3 and 6 months post therapy.

13

Vikkineshwaran SM

Discussion
Tuberculosis

(Mycobacterium

tuberculosis and bovis)

can

infect

the

gastrointestinal tract after ingested organisms penetrate normal mucosa.

This can occur in one of four ways:
1. Swallowing of infected sputum coughed up from active pulmonary disease
2. Hematogenous or lymphatic spread from a distant foci
3. Direct extension from a contiguous site
4. Ingestion of M. bovis infected milk products
Few patients present with intestinal TB and concurrent active
pulmonary disease (20-30%) but almost 50% of smear-positive cavitating
pulmonary TB patients have TB enteritis with a correlation between the
severity of lung disease and intestinal involvement.
The most common region to be infected in the gastrointestinal tract is
the ileocecal (80-90%) demonstrating wall thickening, ulcers, and stricture
formation. The second site is the colon with segmental involvement,

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Vikkineshwaran SM

especially on the right side with ulcerative colitis and pseudo polyps
usually seen. Rarely, the esophagus and stomach are infected.
Most patients are young adults. The peak incidence is between the
ages of 20 and 40. Females are somewhat more commonly affected than
males. Diagnosis may be very difficult and less than 50% of cases are
correctly diagnosed. Treatment, if started early enough, is usually
successful; immunocompromised patients or misdiagnosed end-stage
disseminated infections have a poor prognosis. Follow-up issues or risks
for successfully treated patients include adhesions, obstructions and
blockages. Female patients may suffer infertility. M. bovis infected
patients are always resistant to PZA and must receive at least 9 months of
therapy(1).

Conclusion and Summary

Mrs. X is a 22 year old Indonesian female who was admitted to
the ward with a complaint of right iliac fossa pain and swelling. She has
had previous exposure to tuberculosis from her mother and did not get
proper vaccination. Patient has been suspected of abdominal tuberculosis
and started on 9 month regime of antitubercular drugs.
Patient will be under compined care of physicial and surgeon.
Vigirous supportive and full drug treatment is mandatory. Symptomatic
strictures are treated by appropriate resection as an elective procedure
once the disease is completely under control. Acute intestinal obstruction
from distal ileal stricture is treated by thorough resuscitation followed by
side-by-side ileotranscerse bypass. Once the patient has recovered with
medical treatment, then the second-stage definite procedure of right
hemicolectomy is done. One- stage resection and anastomosis can be
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Vikkineshwaran SM

considered if the patients general condition permitts. Perforation is treated

by appropriate local resection and anastomosis or exteriorisation if the
condition of the patient is very poor; this is later followed by restoration of
bowel continuity after the patient has fully recovered with anti-tuberculous
chemotherapy(1,4,5).

References

1. Williams, Norman. Bailey & Love's Short Practice of Surgery. 25.

Tuberculosis of small intestine: Great Britain, 2008. 65. EBook.
2. Anand, Mahesh K. N., Reddy, Jinna J. M. and Khan, Ali N.
"Tuberculosis, Gastrointestinal." Emedicine (2005): December 15,
2005www.Emedicine.com/radio/topic885.htm
3. Chow, Kai M., et al. "Tuberculous Peritonitis-Associated Mortality
is High Among Patients Waiting for the Results of Mycobacterial
Cultures

of

Ascitic

Fluid

Samples." Clinical

Disease August 15, 2002, Volume 35, p. 409-413.

16

Infectious

Vikkineshwaran SM

4. Collado, Caroline, et al. "Gastrointestinal tuberculosis: 17 cases

collected

in

hospitals

Paris." Gastroenterologie

in

the

Clinique

north
et

eastern

suburb

Biologique April

of

2005,

Volume 29, Number 4, p. 419-425.

5. Coyle, Walter J. and Sheer, Todd A. "Gastrointestinal Tuberculosis"
in Tuberculosis & Nontuberculous Mycobacterial Infections. New
York: McGraw Hill, Medical Publishing Division, 2006

Appendix

1. Cornell Medical Index (Systems

review)
2. Patient CT Scans
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Vikkineshwaran SM

18