Match each clinical presentation of an acute abdominal condition with the most appropriate next step in management.
- A 74-year-old man with a history of myocardial infarction presents with sudden, agonizing abdominal pain. Examination shows generalized guarding, rigidity, and rebound tenderness. Lactate is 5.2 mmol/L.Emergent exploratory laparotomy
- An 82-year-old bedbound man presents with massive abdominal distension and obstipation. Abdominal radiograph demonstrates a markedly dilated colonic loop forming a U-shape extending toward the right upper quadrant. There is no abdominal rigidity.Endoscopic detorsion via flexible sigmoidoscopy
- A 60-year-old woman presents with left lower quadrant pain, chills, and a temperature of 38.9°C (102.0°F). CT of the abdomen reveals sigmoid diverticular wall thickening and an adjacent 5.5-cm rim-enhancing peridiverticular fluid collection.Image-guided percutaneous drainage
- A 48-year-old man with a prior open appendectomy presents with crampy abdominal pain and bilious emesis. CT shows dilated small bowel loops up to 4 cm and a decompressed colon, with normal bowel wall enhancement and no free fluid.Nasogastric tube decompression and intravenous fluids
Answer
The correct matches align each distinct abdominal emergency with its standard-of-care intervention: mesenteric ischemia with peritonitis requires emergent laparotomy; uncomplicated sigmoid volvulus requires endoscopic detorsion; complicated diverticulitis with a large abscess requires percutaneous drainage; and uncomplicated adhesive small bowel obstruction requires nasogastric tube decompression.
Each clinical scenario represents a classic presentation of a gastrointestinal emergency with a distinct optimal next step in management. The 74-year-old man has acute mesenteric ischemia with overt peritonitis, which mandates immediate exploratory laparotomy to resect necrotic bowel. The 82-year-old man presents with an uncomplicated sigmoid volvulus, which is treated first-line with endoscopic detorsion. The 60-year-old woman has complicated diverticulitis with a 5.5-cm macroabscess, for which image-guided percutaneous drainage is the standard of care to achieve source control prior to any potential elective resection. The 48-year-old man has an uncomplicated adhesive small bowel obstruction, which is appropriately managed with conservative measures including nasogastric tube decompression and fluid resuscitation.
Step-by-Step Solution
Key Concept
Appropriate triage and selection of surgical, endoscopic, interventional, or conservative management for acute abdominal emergencies based on clinical stability and imaging findings.