Match each patient's clinical presentation with the most appropriate next step in diagnosis or surgical management. Assume initial standard resuscitation (e.g., intravenous access, basic labs) has been initiated for all patients.
- A 62-year-old man with a history of open appendectomy presents with crampy abdominal pain, nausea, and obstipation. Vital signs are normal. Abdomen is distended but lacks rebound tenderness. Radiographs show dilated small bowel loops.Nasogastric tube placement, intravenous fluid resuscitation, and serial abdominal examinations
- A 71-year-old woman taking daily NSAIDs for osteoarthritis presents with sudden-onset severe, diffuse abdominal pain. She is tachycardic. Examination reveals a rigid, board-like abdomen. Upright chest X-ray demonstrates subdiaphragmatic free air.Intravenous fluids, broad-spectrum antibiotics, and immediate exploratory laparotomy
- A 68-year-old man with severe coronary artery disease complains of postprandial periumbilical pain and a 12-kg (26-lb) weight loss over 4 months due to fear of eating. Abdominal examination is unremarkable.Computed tomography (CT) angiography of the abdomen and pelvis
- A 44-year-old woman presents with fever and persistent right upper quadrant pain. Examination reveals inspiratory arrest on deep palpation. Ultrasound shows a thick-walled gallbladder, pericholecystic fluid, and gallstones.Intravenous antibiotics and scheduling for early laparoscopic cholecystectomy
- A 28-year-old man presents with 5 days of progressively worsening right lower quadrant pain and fever. Examination reveals a palpable right lower quadrant mass. CT scan shows a 5.5-cm rim-enhancing fluid collection adjacent to the cecum.Intravenous antibiotics and CT-guided percutaneous drainage
Answer
Patients presenting with an acute abdomen require precise management based on clinical stability and pathology. Uncomplicated SBO is managed with nasogastric decompression. Perforated viscus requires immediate laparotomy. Chronic mesenteric ischemia is investigated via CT angiography. Acute cholecystitis is treated with early laparoscopic cholecystectomy. An appendiceal abscess is managed initially with percutaneous drainage.
The correct matches represent the current standard of care algorithms for gastrointestinal surgery. Uncomplicated SBO is managed conservatively; pneumoperitoneum demands immediate laparotomy; postprandial abdominal pain in vasculopaths necessitates CT angiography for chronic mesenteric ischemia; acute cholecystitis is treated with early cholecystectomy; and a contained appendiceal abscess is managed with percutaneous drainage rather than immediate appendectomy to significantly reduce surgical morbidity.
Step-by-Step Solution
Key Concept
Triage and step-wise management of acute and chronic abdominal surgical conditions based on hemodynamic stability, presence of peritonitis, and diagnostic imaging.