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Difficulty: MediumSurgical and Procedural Interventions

While at work, a 4848-year-old construction worker experiences an abrupt onset of excruciating abdominal pain. He arrives at the emergency department shortly after via emergency medical services. His past medical history is significant for chronic knee osteoarthritis managed with frequent use of over-the-counter naproxen. Current vital signs show a temperature of 38.2∘C38.2^\circ\text{C} (100.8∘F100.8^\circ\text{F}), blood pressure of 96/58 mm Hg96/58\text{ mm Hg}, pulse of 118/min118/\text{min}, and respiratory rate of 24/min24/\text{min}. The patient appears diaphoretic and refuses to change position on the stretcher. Abdominal examination demonstrates diffuse, involuntary muscle spasm, marked rebound tenderness, and absent bowel sounds. An upright portable chest radiograph displays free subdiaphragmatic radiolucency. Fluid resuscitation and intravenous broad-spectrum antibiotics are immediately started.

Which of the following is the most appropriate next step in management?

  1. A
    Perform diagnostic paracentesis to evaluate the peritoneal fluid
  2. B
    Computed tomography of the abdomen with intravenous contrast
  3. C
    Diagnostic esophagogastroduodenoscopy
  4. Urgent exploratory laparotomyAnswer
  5. E
    Admission to the intensive care unit for nonoperative management

Answer

Urgent exploratory laparotomy
The correct answer is urgent exploratory laparotomy. This patient's presentation of abrupt, severe abdominal pain, a rigid abdomen with diffuse rebound tenderness, and hemodynamic instability strongly suggests a perforated hollow viscus. The history of chronic NSAID use makes a perforated peptic ulcer the most likely etiology. The upright portable chest radiograph demonstrating free subdiaphragmatic radiolucency (pneumoperitoneum) definitively confirms this diagnosis. In the presence of generalized peritonitis and systemic toxicity, emergency exploratory laparotomy is the required intervention to obtain definitive source control, repair the perforation, and irrigate the peritoneal cavity. Initial medical stabilization (intravenous fluids and broad-spectrum antibiotics) should be executed simultaneously, but it must not delay transport to the operating room.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient has sudden-onset, severe abdominal pain with hemodynamic instability (hypotension, tachycardia) and a rigid, board-like abdomen (diffuse peritonitis).
Identifying systemic toxicity and peritonitis establishes the presence of a surgical emergency.
2
Interpret the diagnostic findings provided in the vignette.
The upright chest radiograph shows 'free subdiaphragmatic radiolucency', confirming pneumoperitoneum.
Pneumoperitoneum in the setting of acute abdominal pain indicates a perforated hollow viscus, likely a peptic ulcer given the patient's history of heavy NSAID use.
3
Determine the definitive intervention.
Immediate transport to the operating room for an urgent exploratory laparotomy.
A perforated hollow viscus accompanied by generalized peritonitis and signs of sepsis is an absolute indication for emergency surgical source control to repair the defect and washout the peritoneal cavity.

Key Concept

Surgical management of a perforated hollow viscus with peritonitis.
Estimated Time:1m 0s
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Topics

Surgical and Procedural Interventions

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