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Difficulty: MediumGastrointestinal and Abdominal Surgery

Paramedics rush a 58-year-old male to the resuscitation bay after he experienced sudden, unbearable epigastric pain followed by a syncopal episode. His past medical history is notable for severe osteoarthritis managed with daily high-dose naproxen. On assessment, the patient is lethargic, diaphoretic, and lies completely motionless on the stretcher. Vital signs are significant for a heart rate of 122/min, blood pressure of 82/50 mmHg, and respiratory rate of 24/min. Abdominal examination reveals diffuse rigidity and exquisite rebound tenderness in all four quadrants. Following administration of 2 Liters of warmed isotonic crystalloid, his blood pressure remains 86/54 mmHg. An upright chest radiograph demonstrates a crescent-shaped radiolucency between the liver shadow and the right hemidiaphragm. Intravenous broad-spectrum antibiotics are initiated. What is the most appropriate next step in the care of this patient?

  1. A
    Cross-sectional abdominal imaging with contrast
  2. B
    Gastric decompression and close clinical observation
  3. Transfer to the operating room for laparotomyAnswer
  4. D
    Urgent upper gastrointestinal endoscopy
  5. E
    Intravenous proton pump inhibitor therapy and intensive care admission

Answer

Transfer to the operating room for laparotomy
The clinical presentation is highly indicative of a perforated peptic ulcer resulting in peritonitis and septic shock. The patient has a strong risk factor (daily high-dose NSAID use) and presents with sudden-onset severe epigastric pain, a rigid abdomen, and hemodynamic instability that is refractory to initial fluid resuscitation. Furthermore, the upright chest radiograph definitively confirms pneumoperitoneum (free air under the diaphragm). In a hemodynamically unstable patient with generalized peritonitis and a confirmed hollow viscus perforation, immediate surgical exploration is mandatory to irrigate the abdominal cavity and close the defect.

Step-by-Step Solution

1
Identify the primary pathological process based on the patient's history and physical examination.
The patient presents with sudden severe epigastric pain, chronic NSAID use, and a rigid, board-like abdomen.
Chronic naproxen use significantly increases the risk of gastric and duodenal ulcers, which can perforate and abruptly spill gastrointestinal contents into the peritoneal cavity, causing chemical and bacterial peritonitis.
2
Analyze the objective diagnostic and hemodynamic data.
The upright chest radiograph shows free air under the diaphragm (pneumoperitoneum), and the patient remains hypotensive despite aggressive fluid resuscitation.
Pneumoperitoneum confirms the presence of a perforated hollow viscus. The refractory hypotension and tachycardia indicate that the patient has progressed into septic shock.
3
Determine the definitive intervention required.
Urgent surgical exploration is mandatory.
In any hemodynamically unstable patient with generalized peritonitis and confirmed pneumoperitoneum, immediate surgical source control is necessary to prevent mortality.

Key Concept

Patients presenting with generalized peritonitis, hemodynamic instability, and radiographic evidence of pneumoperitoneum require emergent exploratory laparotomy.
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Topics

Gastrointestinal and Abdominal Surgery

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