Examkin

Question

Difficulty: MediumGastrointestinal and Abdominal Surgery

For each of the following acute gastrointestinal scenarios evaluated in the emergency department, identify the most appropriate next step in diagnosis or management.

  • 35-year-old man with 4 days of worsening left lower quadrant pain, fever of 38.9°C (102°F), and a CT scan revealing a 5.5-cm fluid collection adjacent to the descending colon.CT-guided percutaneous drainage
  • 78-year-old woman with a history of atrial fibrillation who develops severe, sudden-onset periumbilical pain; her abdomen is soft and non-tender on palpation.CT angiography of the abdomen and pelvis
  • 45-year-old woman presenting with jaundice, right upper quadrant pain, a temperature of 39.4°C (103°F), confusion, and a blood pressure of 80/50 mm Hg.Emergent endoscopic retrograde cholangiopancreatography
  • 65-year-old man with previous abdominal surgeries who complains of crampy diffuse abdominal pain, nausea, and failure to pass flatus for 24 hours; examination shows high-pitched bowel sounds without rebound tenderness.Nasogastric tube decompression and intravenous hydration
  • 50-year-old man who suddenly experiences excruciating, diffuse abdominal pain; his abdomen is rigid and board-like, and an upright chest radiograph shows free air under the right hemidiaphragm.Emergent exploratory laparotomy

Answer

The 35-year-old with a diverticular abscess requires CT-guided percutaneous drainage. The 78-year-old with suspected mesenteric ischemia requires CT angiography. The 45-year-old with acute suppurative cholangitis requires emergent ERCP. The 65-year-old with an uncomplicated small bowel obstruction requires nasogastric tube decompression. The 50-year-old with a perforated viscus requires an emergent exploratory laparotomy.
Each correct pairing directly applies surgical guidelines: percutaneous drainage for large diverticular abscesses, CT angiography for early mesenteric ischemia to map vascular anatomy, ERCP to relieve septic biliary obstruction, conservative NG decompression for stable adhesive bowel obstructions, and immediate laparotomy for viscus perforation with peritonitis.

Step-by-Step Solution

1
Analyze the first scenario (35-year-old man).
Identify complicated diverticulitis with a 5.5-cm abscess.
Abscesses larger than 3-4 cm require percutaneous drainage alongside antibiotics, whereas smaller ones may be managed with antibiotics alone.
2
Analyze the second scenario (78-year-old woman).
Identify acute mesenteric ischemia without peritonitis.
The classic presentation of pain out of proportion to exam in an atrial fibrillation patient dictates urgent vascular imaging (CT angiography) to confirm the occlusion prior to surgical or endovascular intervention.
3
Analyze the third scenario (45-year-old woman).
Identify acute suppurative cholangitis (Reynolds pentad).
The presence of fever, jaundice, RUQ pain, confusion, and shock indicates a life-threatening biliary infection that requires immediate mechanical decompression via ERCP.
4
Analyze the fourth scenario (65-year-old man).
Identify an uncomplicated small bowel obstruction.
Prior abdominal surgeries make adhesions the most likely cause. The lack of fever, tachycardia, or localized peritonitis means trial of non-operative management (NG tube, IV fluids) is indicated.
5
Analyze the fifth scenario (50-year-old man).
Identify a perforated hollow viscus.
Free subdiaphragmatic air on radiograph combined with a rigid abdomen is an absolute indication for emergency exploratory laparotomy.

Key Concept

Triage and definitive management selection for acute abdominal emergencies based on hemodynamic status, imaging findings, and peritoneal signs.
Rate this question

Topics

Gastrointestinal and Abdominal Surgery

More questions from this topic