fongch
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A 34-year-old man presents to the clinic, 24 hours after he was hit in the abdomen. He has constant abdominal pain since the altercation. He denies nause or vomiting. His abdomen is soft, painful to palpation mostly around the umbilicus. Rebound tenderness is also present. Bowel sound is diminished. Rectal exam is normal. Abdominal X-ray, USG and CT are unremarkable. Vitals: BP 120/70mmHg, PR 90/min, Hct 40%, serum amylase 53U/L. The most appropriate management is
A Observation
B Angiography
C Contrast studies of the GI tract
D Diagnostic peritoneal lavage
E Laparotomy
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| vradojc1
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A - no signs of any major organ injured. Both bowel and pancreas would present with increased amylase, no bleeding...US/CT negative...
He is malingering!
Oops sorry, I just saw rebound tenderness - I'd do DPL, since minor bleed could irritate peritoneum and cause tenderness. If that is negative, just relax dude!
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| fongch
Forum Elite
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But I believe signs of peritoneal irritation (i.e rebound tenderness) are clear indications for exploratory laparotomy, right?
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| ManuNastai
Transilvanian..
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I also think is A. I guess he'd experience pain on the site of a powerfull previous blow in the belly if some overzelous doctor will try to check the damn Blumberg sign again and again.. 
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| Akeen
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Agree with A.
The negative investigation results and stable vital signs .......
but the rebound tenderness makes observation necessary.
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| usmle12
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i would go for dpl.....there can still be small perforation and not dtected with ct and us and also it was in usmle wolrd that if ct and us negative go for dpl....its quick n reliable way to detect small perforations...
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| ram3
Forum Guru
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This is laparotomy big time
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| dncosta
Licensed, finally
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| radonc
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Well... I have seen this question from uw. The answer is DPL.
I answered observation in the qbank, which was wrong. I think this is because, as well-explained by vradojc1, he has significant abdo tenderness. Rebound tenderness is also present and bowel sounds reduced. These make you worry about peritoneal irritation due to blood.
Immediate laparotomy is indicated if he is clearly bleeding from his abdomen (as suggested by unstable haemodynamics) AND there are clear abdominal signs (eg tenderness, distension, etc.).
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| arlete
Intern in 2009!!!!!
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radonc 
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| DrVirgo
Forum Hero
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Can we please discuss WHEN we must do DPL and WHEN we must do an Exp. Lap?
I think that would help in answering this question.
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| gr8doc
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I think tghe answer should be Contrast studies of the GI Tact & I have following points to support that.
1. His vitals are stable after 24 hrs of injury so definitely he is not actively bleeding.
2. His Abdomen is soft which rules out any lifethreatening peritonitis, thus ruling out immediate exploratory laparotomy.
Please post your views & also, if anyone knows the right answer along with the explanation,please post it.
Ciao.
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| lena02
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hello
im new here and read this question posted.. so since this patient is haemodynamically stable with minimum abdominal signs ill opt to oral or iv contrast CT scan of the abdomen because DPL is no longer widely used and coz its non specific and less sensitive plus it can alter CT results
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| elitoki
Forum Guru
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This pt already has CT scan and also USG. Everything is unremarkable.
I think due to this pt is stable and has periumbilical pain we should observe and recheck for serum amylase, serum lipase and repeat CT scan. Peritoneal lavage can not diagnose retroperitoneal bleeding and laparotomy without indication(?)??? is unnecessary.
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| lena02
Forum Newbie
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yep but whats confusing me is do they mean by ct scan that is unremarkable that its contrast ct or not coz one of the answers include contrast studies ???? then if what they have done is contrast ct scan observation will be right
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| gr8doc
Forum Senior
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Hi Lena,
As I had mentioned earlier, I think contrast study is a more appropriate answer here. When they mention just the CT it means CT without contrast.
Hope this helps.
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| lena02
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the pt is stable but after reviewing kaplan its dpl
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| lena02
Forum Newbie
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kaplan says labrotomy is indicated in gun shot wounds and penetration wounds or if their is obvious signs of abdominal irritation...
dpl is diagnosis of choice for unstable pts with intraabdominal bleeding coz its fast and can be done in theatre and if its positive then do labarotomy
ct scan is only done in stable patients as a rule which is already done here..
think this pt is stable and has abdominal irritation but was around for 24 hours now so its safer to choose dpl and if its positive then the second best option is exploration
any suggestions
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| gr8doc
Forum Senior
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You are missing the point. You are right , Kaplan says that do DPL / USG in unstable patients. But mind you, this patient is not unstable. Also, He's come after 24 hrs & is still pretty much stable. The intra abdominal bleed if any is not torrential to lead you to do a Laparotomy. Your aim is just to see what's going on & then If you find any gross abnormality then you go ahead & do a laparotimy.
Differences are pretty much appreciated.
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| cirus
Forum Guru
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The ans of this Qs on UW is observation & not DPL
they explained it by saying that it is most probably ms pain from the trauma..
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| lena02
Forum Newbie
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His abdomen is soft, painful to palpation mostly around the umbilicus. Rebound tenderness is also present. Bowel sound is diminished....ct is done why not do dpl..
there is something going on
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| gr8doc
Forum Senior
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Posts: 210
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Let me answer both your concerns.
First of all, the explanation of MS trauma is wrong because it would not give rise to rebound Tenderness.
Secondly, Lena, What are you going to achieve by doing DPL at this stage after 24 hrs of stable vitals? The indication for DPL is only in an unstable patient where you can't do CT scan before exploring in a case of Blunt abdominal trauma.
Will be happy to clarify it further.
PS : UW has many wrong explanations.
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| lena02
Forum Newbie
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thanks i agree
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| lena02
Forum Newbie
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but what are you looking for by contrast studies....i got your point about the stability of the patient...ok why not just observe
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| gr8doc
Forum Senior
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The reason for subjecting him to one more investigation is that he is still having Rebound Tenderness. If he had not had this, we would have probably just observed the patient.
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