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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 48-year-old male is evaluated in the emergency department after experiencing an abrupt onset of agonizing, diffuse abdominal pain that started two hours ago. He reports that the discomfort is continuous and severely worsens with any physical movement. His medical history is significant for chronic osteoarthritis, which is managed with high-dose daily naproxen, and he is a current tobacco user. He recently noted a gnawing upper abdominal ache that would temporarily improve after meals. Currently, he is lying motionless on the examination table and taking shallow breaths. Vital signs indicate a temperature of 37.9°C (100.2°F), a pulse of 118/min, and a blood pressure of 105/65 mm Hg. Abdominal assessment is notable for board-like rigidity, generalized rebound tenderness, and absent bowel sounds. An upright chest radiograph reveals a distinct crescent of free air below the right hemidiaphragm. Following initial fluid resuscitation, which of the following is the most appropriate next step in management?

  1. Urgent surgical exploration and defect closureAnswer
  2. B
    Diagnostic esophagogastroduodenoscopy
  3. C
    Intravenous proton pump inhibitor therapy and observation
  4. D
    Abdominal cross-sectional imaging with oral contrast
  5. E
    Image-guided percutaneous peritoneal drainage

Answer

Urgent surgical exploration and defect closure
The patient presents with an acute surgical abdomen secondary to a perforated peptic ulcer. This is indicated by his history of NSAID use, sudden-onset severe pain, generalized peritonitis (board-like rigidity, rebound tenderness), and pneumoperitoneum (free air under the right hemidiaphragm). The definitive treatment for a perforated hollow viscus with generalized peritonitis is urgent surgical exploration to close the defect (e.g., Graham patch) and perform peritoneal lavage.

Step-by-Step Solution

1
Analyze the patient's risk factors and clinical presentation.
The patient uses NSAIDs and tobacco and has a history of dyspepsia, placing him at high risk for peptic ulcer disease. He now presents with sudden, severe abdominal pain and peritonitis.
Identifying specific risk factors and characterizing the abdominal pain helps narrow the differential diagnosis for an acute abdomen.
2
Interpret the radiographic findings in the context of the physical examination.
The upright chest radiograph shows free air under the diaphragm (pneumoperitoneum), confirming a perforated hollow viscus.
Radiographic evidence of free air combined with a rigid abdomen is the hallmark of a surgical emergency.
3
Determine the definitive treatment for the identified condition.
The patient requires urgent surgical intervention to close the perforation (often via an omental patch) and wash out the peritoneal cavity.
Conservative or delayed management in the setting of generalized peritonitis and pneumoperitoneum inevitably leads to worsening sepsis and high mortality.

Key Concept

Patients presenting with a perforated peptic ulcer (characterized by sudden, severe pain, peritonitis, and pneumoperitoneum on imaging) require immediate fluid resuscitation and urgent surgical exploration.
Estimated Time:1m 0s
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Topics

Gastrointestinal and Abdominal Surgery

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