Differential Diagnosis for Abdominal Pain and Perforation

The patient's symptoms and laparotomy findings suggest an inflammatory bowel disease or an infectious process. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • C. Crohn's disease: The presence of a perforation in the distal ileum, adherent ileum to the caecum, whitish plaques, fat stranding, and thickened bowels are highly suggestive of Crohn's disease. The disease often affects the terminal ileum and can cause complications like perforation, especially in cases of severe inflammation.

• Other Likely Diagnoses

  • D. TB: Tuberculosis can affect the gastrointestinal tract and cause similar symptoms, including abdominal pain, nausea, vomiting, and perforation. The presence of whitish plaques and thickened bowels could also be consistent with intestinal TB.
  • B. UC: While ulcerative colitis (UC) primarily affects the colon, it can extend to the terminal ileum (backwash ileitis) and cause similar symptoms. However, the presence of skip lesions and the specific location of the perforation make UC less likely than Crohn's disease.

• Do Not Miss Diagnoses

  • A. Actinomycosis: This rare bacterial infection can cause abdominal pain, nausea, vomiting, and perforation, especially in the context of bowel obstruction or previous surgery. Although less likely, actinomycosis can mimic other conditions and has a high mortality rate if left untreated.
  • Appendicitis or other causes of acute abdomen: Although the patient has undergone laparotomy, it's essential to consider other causes of acute abdomen, such as appendicitis, especially if the diagnosis is not yet confirmed.

• Rare Diagnoses

  • Other infectious causes: Rare infections like yersiniosis, salmonellosis, or campylobacteriosis can cause similar symptoms, although they are less likely to cause perforation.
  • Neoplastic causes: Although rare, neoplastic causes like lymphoma or adenocarcinoma can cause bowel obstruction, perforation, and similar symptoms. However, these conditions are less likely in a 29-year-old patient without a significant family history or other risk factors.