Case 3

The history of pain in his left foot raises the possibility that he has been using NSAIDs. These drugs increase the risk of peptic ulcer disease or perforation.

His pain has now become severe, suggesting that the abdominal pathology is worsening.

Pain radiating to back is suggestive of AAA, aortic dissection or perforation.

He is pale and diaphoretic. While this may be secondary to pain, it can indicate significant pathology.

He is tachycardiac. This could be due to pain but may also suggest he is septic or hypovolaemic.

His respiratory rate is elevated. Again this may be due to pain, but is often a sign that the patient is acidotic due to sepsis or hypovolaemia.  This is often an early sign that is missed.

True guarding is a sign of peritonism.

NSAIDS (which can be obtained without prescription) are frequently used for pain control. These increase the risk of peptic ulcer disease, GI bleeding and/or perforation.

Not infrequently, patients with gout can also be treated with prednisone. Steroids also increase the risk of GI bleeding and perforation.

The most likely diagnosis if gastric or duodenal ulceration with perforation, giving rise to his peritonism.

Upper GI bleeding on its own from peptic ulcer disease does not usually produce true peritonism.

Other differential diagnoses to consider are:

• Pancreatitis
• Cholecystitis
• ACS such as STEMI/NSTEMI (does not produce peritonism but can cause abdominal pain and tenderness)
• Lower lobe pneumonia (does not produce peritonism but can cause abdominal pain and tenderness)
• AAA (35 years of age is still fairly young for this diagnosis)
• Diverticular disease
• Pyelonephritis
• Renal colic

IV fluids – usually boluses of 500-1000mL 0.9% NaCL

Analgesia – will need IV morphine

Antiemetics such as metoclopromide, cyclizine or ondansetron

IDC to monitor urine output

Antibiotics such as amoxycillin, gentamicin and metronidazole

Urgent surgical review for laparotomy