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Difficulty: MediumGastrointestinal and Abdominal Surgery

Match each clinical presentation of an acute surgical abdomen with its most appropriate specific intervention or definitive surgical management.

  • A 45-year-old woman with a history of Roux-en-Y gastric bypass presenting with severe, intermittent abdominal pain and a normal computed tomography scan.Surgical exploration with closure of mesenteric defects
  • A 70-year-old man with chronic atrial fibrillation presenting with acute, severe abdominal pain out of proportion to exam and an elevated serum lactate.Emergent laparotomy with superior mesenteric artery embolectomy
  • A 75-year-old man presenting with marked abdominal distension, obstipation, and an abdominal radiograph showing a large U-shaped distended bowel loop.Endoscopic detorsion via flexible sigmoidoscopy
  • A 40-year-old man presenting with sudden-onset rigid abdomen, tachycardia, and free air under the diaphragm on an upright chest radiograph.Exploratory laparotomy with omental (Graham) patch repair

Answer

The correct matches align the internal hernia presentation with surgical exploration and defect closure, acute mesenteric ischemia with embolectomy, sigmoid volvulus with endoscopic detorsion, and a perforated viscus with omental patch repair.
Each clinical scenario describes a classic presentation of a distinct acute abdominal emergency. The correct pairings appropriately link the diagnosis to its standard-of-care initial or definitive intervention.

Step-by-Step Solution

1
Diagnose the patient in the first presentation.
History of gastric bypass with severe pain and a normal CT scan points to an internal hernia.
Internal hernias can intermittently reduce, resulting in normal imaging, but require a high index of clinical suspicion to prevent bowel strangulation.
2
Diagnose the patient in the second presentation.
Atrial fibrillation and abdominal pain out of proportion to the physical exam indicate acute mesenteric ischemia.
Emboli from the heart frequently lodge in the superior mesenteric artery, leading to acute ischemia.
3
Diagnose the patient in the third presentation.
Obstipation with a U-shaped bowel loop on an abdominal radiograph indicates a sigmoid volvulus.
The 'coffee bean' sign is a classic radiographic finding for sigmoid volvulus in elderly patients.
4
Diagnose the patient in the fourth presentation.
A rigid abdomen with free subdiaphragmatic air indicates a perforated viscus (e.g., peptic ulcer).
Pneumoperitoneum confirms a full-thickness gastrointestinal perforation requiring immediate surgery.
5
Match each diagnosis with the definitive surgical or interventional management.
Internal hernia matches with defect closure; Mesenteric ischemia matches with embolectomy; Sigmoid volvulus matches with flexible sigmoidoscopy; Perforated viscus matches with Graham patch repair.
These represent the gold-standard initial or definitive treatments for these respective abdominal emergencies.

Key Concept

Triage and specific interventional management of acute surgical abdominal emergencies.
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Topics

Gastrointestinal and Abdominal Surgery

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