A 71-year-old male is admitted directly to the resuscitation bay following an episode of p… — USMLE Step 2 CK

A $71$ -year-old male is admitted directly to the resuscitation bay following an episode of profuse hematemesis at his residence. For the preceding $2$ weeks, he noted intermittent melena, subjective fevers, and a deep, gnawing lumbar ache. His surgical history is significant for a synthetic graft repair of an infrarenal abdominal aortic aneurysm $4$ years ago. On arrival, he is confused and diaphoretic. Vital signs include a temperature of $38.4^\circ\text{C}$ ( $101.1^\circ\text{F}$ ), heart rate of $134/\text{min}$ , blood pressure of $72/40\text{ mmHg}$ , and respiratory rate of $22/\text{min}$ . Abdominal examination reveals a well-healed midline scar and mild epigastric tenderness without guarding. Intravenous access is established, and aggressive fluid resuscitation is initiated, but his blood pressure remains $76/44\text{ mmHg}$ . Which of the following is the most appropriate next step in management?

A
Contrast-enhanced cross-sectional imaging of the abdomen and pelvis
Immediate exploratory laparotomy with proximal vascular controlAnswer
C
Deferral of procedural intervention until the designated healthcare proxy arrives
D
Targeted antimicrobial therapy and supportive care in the intensive care unit
E
Intravenous loop diuretic administration and noninvasive respiratory support

Answer

Immediate exploratory laparotomy with proximal vascular control

The correct intervention for a hemodynamically unstable patient with a suspected secondary aortoenteric fistula is immediate surgical exploration. This patient's history of a synthetic aortic graft repair combined with back pain, fever, and massive hematemesis is the classic presentation of a secondary aortoenteric fistula. The initial, smaller episodes of melena represent a 'herald bleed', which typically precedes catastrophic, life-threatening hemorrhage. Because the patient is in decompensated hemorrhagic shock that is unresponsive to initial fluid resuscitation, transporting him to the radiology suite is strictly contraindicated. Proximal aortic control and graft excision must be performed emergently in the operating room to prevent death from exsanguination.

Step-by-Step Solution

Analyze the patient's presenting symptoms and surgical history.

The combination of massive hematemesis, prior synthetic abdominal aortic aneurysm repair, and preceding melena indicates a secondary aortoenteric fistula.

Synthetic aortic grafts can erode into the overlying third portion of the duodenum over time, often presenting initially with a smaller 'herald bleed' before a massive rupture.

Evaluate the patient's hemodynamic status.

The patient is in profound hypovolemic shock (blood pressure

72/40\text{ mmHg}

) that is unresponsive to initial fluid resuscitation.

Massive, uncontained gastrointestinal hemorrhage is occurring directly from the aorta.

Determine the most appropriate management step based on stability.

Immediate operative intervention is required.

Unstable patients with suspected exsanguinating hemorrhage cannot safely undergo cross-sectional imaging and require emergent surgical vascular control to prevent death.

Key Concept

Secondary aortoenteric fistula typically presents with a 'herald bleed' followed by massive hemorrhage; hemodynamically unstable patients require immediate surgical exploration, whereas stable patients may undergo computed tomography angiography.

Estimated Time:1m 30s

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