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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 4848-year-old man is brought to the emergency department by his wife due to sudden-onset, agonizing abdominal pain that began 22 hours ago. He reports no prior episodes of similar pain but has a history of chronic knee osteoarthritis, for which he takes high-dose naproxen daily. His temperature is 38.3∘C38.3^\circ\text{C} (100.9∘F100.9^\circ\text{F}), pulse is 118/min118/\text{min}, blood pressure is 90/58 mm Hg90/58\text{ mm Hg}, and respirations are 22/min22/\text{min}. The patient appears distressed and lies completely still on the examination table, refusing to move. Physical examination reveals a rigid, board-like abdomen with diffuse guarding and rebound tenderness. Bowel sounds are absent. An upright chest radiograph demonstrates a crescent of free air under the right hemidiaphragm. Which of the following is the most appropriate next step in management?

  1. A
    Upper gastrointestinal endoscopy
  2. B
    Computed tomography of the abdomen and pelvis with oral contrast
  3. Urgent exploratory laparotomyAnswer
  4. D
    Placement of a nasogastric tube, intravenous antibiotics, and observation
  5. E
    Upper gastrointestinal series with barium contrast

Answer

Urgent exploratory laparotomy is the required immediate intervention for a patient with a perforated viscus, peritonitis, and hemodynamic instability.
This patient's presentation of sudden-onset, severe abdominal pain, a rigid abdomen, and pneumoperitoneum (free air under the diaphragm) on an upright chest radiograph is highly characteristic of a perforated viscus, most likely a perforated peptic ulcer given his chronic NSAID use. The presence of hemodynamic instability (hypotension, tachycardia) and diffuse peritonitis dictates that the patient requires immediate fluid resuscitation followed by urgent exploratory laparotomy for definitive surgical repair and peritoneal washout.

Step-by-Step Solution

1
Identify the primary diagnosis from the clinical and radiographic findings.
The patient's sudden-onset pain, chronic NSAID use, rigid abdomen, and free air under the diaphragm strongly point to a perforated peptic ulcer.
NSAIDs impair gastric mucosal protection, predisposing to ulceration and eventual full-thickness perforation, which releases air and gastric contents into the peritoneum.
2
Assess the severity of the patient's condition and hemodynamic status.
The patient exhibits signs of systemic toxicity and hemodynamic instability (tachycardia, hypotension, fever) along with diffuse peritonitis (rigid, board-like abdomen).
These findings indicate an acute surgical emergency where the peritoneal cavity is heavily contaminated, leading to third-spacing and early septic shock.
3
Determine the most appropriate definitive intervention based on surgical guidelines.
Immediate surgical exploration (laparotomy) is indicated to seal the leak and wash out the abdominal cavity.
A perforated viscus with peritonitis and instability cannot be managed conservatively or delayed for further imaging; emergent operative source control is life-saving.

Key Concept

A perforated viscus presenting with pneumoperitoneum, diffuse peritonitis, and hemodynamic instability is an absolute surgical emergency that requires immediate exploratory laparotomy without delay for advanced imaging.
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Topics

Gastrointestinal and Abdominal Surgery

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