A rapid response code is called for a 71-year-old man on his fourth day in the hospital af… — USMLE Step 2 CK

A rapid response code is called for a $71$ -year-old man on his fourth day in the hospital after an emergency bowel resection with primary anastomosis for acute mesenteric ischemia. The patient is suddenly experiencing severe, agonizing abdominal pain and difficulty breathing. Vital signs are temperature $39.0^\circ\text{C}$ ( $102.2^\circ\text{F}$ ), blood pressure $84/52\text{ mmHg}$ , pulse $138/\text{min}$ , and respirations $28/\text{min}$ . Oxygen saturation is $94\%$ on $4\text{ L/min}$ via nasal cannula. On physical examination, the patient appears ashen and diaphoretic. Lung auscultation reveals shallow breathing with bibasilar crackles. The abdomen is board-like with diffuse rigidity, severe tenderness to light palpation, and absent bowel sounds. Laboratory studies reveal a leukocyte count of $24,000/\text{mm}^3$ and a serum lactate level of $5.8\text{ mmol/L}$ . Which of the following is the most appropriate next step in the management of this patient?

A
Computed tomography of the abdomen and pelvis
B
Nasogastric tube insertion and serial abdominal examinations
Immediate exploratory laparotomyAnswer
D
Intravenous furosemide and noninvasive positive pressure ventilation
E
Obtain blood cultures and initiate broad-spectrum antibiotics as primary therapy

Answer

Immediate exploratory laparotomy

The correct answer is immediate exploratory laparotomy. This patient presents with an acute surgical abdomen on postoperative day 4, characterized by board-like rigidity, severe tenderness, absent bowel sounds, and profound septic shock (hypotension, tachycardia, fever, lactic acidosis). In the setting of a recent bowel resection, this clinical picture is highly suspicious for an anastomotic leak leading to massive intra-abdominal contamination and peritonitis. The definitive treatment for a perforated viscus or anastomotic leak with hemodynamic instability is emergent surgical exploration for source control, repair, or washout. While concurrent fluid resuscitation and broad-spectrum antibiotics should be initiated, any delay for advanced imaging is contraindicated.

Step-by-Step Solution

Assess the patient's hemodynamic status and physical examination findings.

The patient is in septic shock (blood pressure

84/52\text{ mmHg}

, pulse

138/\text{min}

, elevated lactate) and has an acute surgical abdomen (board-like rigidity, absent bowel sounds).

Identifying hemodynamic instability and peritonitis dictates whether the patient can undergo imaging or requires immediate surgery.

Determine the most likely etiology based on the surgical history.

Given the recent bowel resection with primary anastomosis, this acute presentation is highly suspicious for an anastomotic leak leading to severe intra-abdominal contamination.

Anastomotic leaks typically present between postoperative days 3 and 7 and can rapidly progress to fulminant sepsis.

Select the most appropriate definitive management.

Immediate exploratory laparotomy.

Patients with generalized peritonitis and hemodynamic instability require emergent surgical source control; delaying for imaging or relying solely on medical management increases mortality.

Key Concept

Patients presenting with generalized peritonitis and hemodynamic instability in the postoperative period require immediate exploratory laparotomy for source control, without delaying for diagnostic imaging.

Estimated Time:1m 15s

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