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Difficulty: HardGastrointestinal and Abdominal Surgery

Match each clinical presentation of an acute abdominal emergency with the most appropriate definitive next step in management.

  • A 78-year-old man with atrial fibrillation develops sudden-onset abdominal pain out of proportion to physical findings; serum lactate is 6.5 mmol/L, and CT shows pneumatosis intestinalis and portal venous gas.Exploratory laparotomy with resection of necrotic bowel and temporary abdominal closure (damage control)
  • A 59-year-old woman with a history of hysterectomy presents with obstipation, intractable vomiting, and tachycardia; CT reveals a transition point, a 'whirl sign', and diminished enhancement of the affected bowel segment.Urgent exploratory laparotomy with detorsion, lysis of adhesions, and likely bowel resection
  • A 52-year-old man presents with fever, right upper quadrant pain, jaundice, confusion, and a blood pressure of 85/50 mm Hg; ultrasound demonstrates severe common bile duct dilation.Emergent endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression
  • A 64-year-old woman taking chronic diclofenac presents with a sudden, rigid, board-like abdomen; erect chest radiograph reveals free air under the right hemidiaphragm.Immediate exploratory laparotomy with omental (Graham) patch closure

Answer

The correct matching aligns acute mesenteric ischemia with infarction to damage control laparotomy, closed-loop small bowel obstruction with strangulation to urgent laparotomy and resection, severe acute ascending cholangitis to emergent ERCP, and a perforated peptic ulcer to omental (Graham) patch closure.
Each clinical presentation represents a distinct, life-threatening abdominal emergency that requires a highly specific intervention. Recognizing the underlying pathophysiology—ischemic necrotic bowel, strangulated closed-loop obstruction, suppurative biliary infection, or viscus perforation—directly dictates whether the patient needs damage-control surgery, standard resection, endoscopic decompression, or an omental patch.

Step-by-Step Solution

1
Diagnose the patient with atrial fibrillation, disproportionate pain, and pneumatosis intestinalis.
Identified as acute mesenteric ischemia with late-stage bowel infarction.
Pneumatosis and portal venous gas confirm dead gut, which dictates a damage control laparotomy approach rather than just revascularization or primary anastomosis.
2
Diagnose the patient with obstipation, a 'whirl sign', and decreased bowel enhancement.
Identified as a strangulated closed-loop small bowel obstruction.
The diminished enhancement indicates ischemia, meaning non-operative management with a nasogastric tube is contraindicated; urgent exploratory laparotomy is required.
3
Diagnose the patient with fever, jaundice, RUQ pain, hypotension, and confusion.
Identified as severe acute cholangitis (Reynolds pentad).
The presence of septic shock from an infected, obstructed biliary tree mandates urgent minimally invasive decompression via ERCP to stabilize the patient.
4
Diagnose the patient on diclofenac with a rigid abdomen and subdiaphragmatic free air.
Identified as a perforated viscus, most likely a perforated peptic ulcer.
Pneumoperitoneum in this clinical context requires immediate surgical exploration and repair using an omental patch to seal the leak.

Key Concept

Triage and precise procedural selection for acute abdominal emergencies based on hemodynamics and underlying etiology.
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Topics

Gastrointestinal and Abdominal Surgery

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