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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 56-year-old man is brought to the emergency department due to the sudden onset of severe, diffuse abdominal pain that began 2 hours ago. He has a history of osteoarthritis for which he takes naproxen daily. His temperature is 38.2∘C38.2^\circ\text{C} (100.8∘F100.8^\circ\text{F}), pulse is 122/min122/\text{min}, respirations are 24/min24/\text{min}, and blood pressure is 88/56 mmHg88/56\text{ mmHg}. On physical examination, the patient is lying completely still on the stretcher. The abdomen is diffusely tender to palpation with board-like rigidity and pronounced rebound tenderness. Bowel sounds are absent. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. An upright chest radiograph reveals a crescent of radiolucency between the liver and the right hemidiaphragm. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen with intravenous contrast
  3. C
    Nasogastric tube placement and serial abdominal examinations
  4. D
    Upper gastrointestinal endoscopy
  5. E
    Right upper quadrant abdominal ultrasound

Answer

Exploratory laparotomy
The correct answer is exploratory laparotomy. This patient presents with a classic perforated viscus, likely a peptic ulcer secondary to chronic NSAID (naproxen) use. The diagnosis is strongly supported by the sudden onset of severe abdominal pain, generalized peritonitis (board-like rigidity, rebound tenderness, lying still), and systemic toxicity (fever, tachycardia, hypotension). The upright chest radiograph confirms the diagnosis by showing free subdiaphragmatic air (pneumoperitoneum). In a hemodynamically unstable patient with an acute surgical abdomen and confirmed perforation, emergent surgical exploration is required to repair the defect, control contamination, and perform thorough peritoneal lavage. Further imaging or conservative therapy is inappropriate and dangerous.

Step-by-Step Solution

1
Evaluate the patient's clinical presentation and vital signs.
The patient has sudden, severe abdominal pain, a history of NSAID use, tachycardia (122/min122/\text{min}), and hypotension (88/56 mmHg88/56\text{ mmHg}).
Identifying hemodynamic instability is critical for determining whether the patient can tolerate delayed interventions or requires immediate life-saving therapy.
2
Interpret the physical examination findings.
The patient lies completely still and has board-like rigidity with rebound tenderness.
These are classic signs of generalized peritonitis, indicating severe intra-abdominal pathology that typically requires urgent surgical intervention.
3
Analyze the diagnostic imaging.
An upright chest radiograph shows radiolucency between the liver and right hemidiaphragm (free air under the diaphragm).
Free air confirms the diagnosis of a perforated hollow viscus (likely a perforated peptic ulcer given the NSAID use).
4
Determine the next best step in management.
The appropriate step is emergent exploratory laparotomy.
A perforated viscus with peritonitis and hemodynamic instability is an absolute indication for immediate surgical exploration.

Key Concept

Patients presenting with a perforated hollow viscus (evidenced by pneumoperitoneum), generalized peritonitis, and hemodynamic instability require emergent exploratory laparotomy.
Estimated Time:1m 0s
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Topics

Gastrointestinal and Abdominal Surgery

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