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Difficulty: EasyInterpreting Imaging Results

A 62-year-old man comes to the emergency department complaining of sudden, severe abdominal pain that began 2 hours ago. His past medical history is significant for osteoarthritis, for which he takes ibuprofen daily. His temperature is 37.8°C (100.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination shows a rigid, board-like abdomen with diffuse guarding and rebound tenderness. An upright chest radiograph reveals a thin crescent of radiolucent gas between the right hemidiaphragm and the liver. Based on the interpretation of this imaging finding, which of the following is the most appropriate next step in management?

  1. Emergent surgical consultationAnswer
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Right upper quadrant abdominal ultrasonography
  4. D
    Administration of intravenous fluids and serial abdominal examinations
  5. E
    Initiation of intravenous pantoprazole and admission for observation

Answer

Emergent surgical consultation
The correct answer is emergent surgical consultation. The patient's upright chest radiograph demonstrates a thin crescent of radiolucent gas under the right hemidiaphragm. This finding represents pneumoperitoneum (free air in the peritoneal cavity). In the context of chronic NSAID use and a rigid, board-like abdomen (peritonitis), this imaging finding unequivocally points to a perforated viscus, most likely a perforated peptic ulcer. A perforated viscus is a surgical emergency that requires prompt fluid resuscitation, broad-spectrum antibiotics, and an emergent exploratory laparotomy to repair the defect and wash out the abdominal cavity.

Step-by-Step Solution

1
Evaluate the clinical presentation and physical exam.
The patient has acute-onset severe abdominal pain, tachycardia, and a rigid abdomen with rebound tenderness in the setting of chronic NSAID use.
These findings are classic for an acute surgical abdomen, highly suspicious for a perforated peptic ulcer.
2
Interpret the radiographic findings.
The upright chest radiograph shows a 'crescent of radiolucent gas between the right hemidiaphragm and the liver'.
This is the classic radiologic description of subdiaphragmatic free air (pneumoperitoneum).
3
Determine the appropriate management based on the interpretation.
Immediate surgical consultation for exploratory laparotomy is indicated.
Pneumoperitoneum in a patient with peritonitis confirms a perforated hollow viscus, which is a surgical emergency.

Key Concept

Identification of pneumoperitoneum on an upright radiograph mandates emergent surgical intervention for a perforated viscus.
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Interpreting Imaging Results

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