Case 1: A 16-year-old female with left lower-quadrant abdominal pain

Abstract

A previously healthy 16-year-old female presented to the emergency department with a four-day history of vomiting, diarrhea and left lower-quadrant abdominal pain. Clinically, the patient exhibited signs of abdominal distention, with a fluid shift suggestive of ascites. Bowel sounds were diminished, her leukocyte count was elevated and radiographs of the abdomen showed dilated small-bowel loops compatible with a bowel obstruction. An ultrasound showed a large volume of peritoneal fluid without a visualized appendix. An urgent computed tomography scan suggested small-bowel obstruction. The patient underwent an exploratory laparoscopy, which revealed a large volume of purulent fluid in the pelvis, right and left lower colic gutters, as well as above the liver. The small bowel was tethered together with interloop abscesses. The small bowel was examined twice, distally to proximally, with no evidence of adhesive bowel obstruction. The appendix appeared normal. The uterus, fallopian tubes and ovaries all appeared inflamed but no tubo-ovarian abscess was present. The abdomen was irrigated copiously with 4 L of saline. Postoperatively, the patient was started on ampicillin, gentamicin and metronidazole. The preliminary blood culture identified Gram-positive clusters, and the antibiotics were switched to meropenem and vancomycin while awaiting identification of the organism.