Match each patient's clinical presentation with the most appropriate next step in surgical or medical management.
- A -year-old male with a history of an open appendectomy presents with obstipation, bilious vomiting, and intermittent colicky abdominal pain. Vitals are normal. Examination reveals abdominal distension and high-pitched bowel sounds, but no guarding or rigidity. Upright radiograph shows multiple dilated small bowel loops and air-fluid levels.Nasogastric tube decompression, intravenous fluids, and serial examinations
- A -year-old female with a history of atrial fibrillation presents with the sudden onset of excruciating periumbilical pain. Her heart rate is /min and blood pressure is mm Hg. Abdominal examination is notably soft and non-tender. Initial laboratory studies show a normal serum lactate level.Computed tomography angiography (CTA) of the abdominal vessels
- A -year-old male presents with the abrupt onset of severe, diffuse abdominal pain. Vitals demonstrate a blood pressure of mm Hg and a heart rate of /min. Examination reveals a rigid, board-like abdomen with severe rebound tenderness. Upright chest radiograph demonstrates free air under the right hemidiaphragm.Immediate fluid resuscitation and emergent exploratory laparotomy
- A -year-old male presents with a -day history of worsening right lower quadrant pain and fever. Vitals are stable. Examination reveals a palpable, tender mass in the right lower quadrant. Computed tomography of the abdomen demonstrates a -cm periappendiceal fluid collection with a thick, enhancing rim.Percutaneous image-guided fluid drainage and intravenous antibiotics
Cevap
The correct management strategies match uncomplicated small bowel obstruction to conservative management, early mesenteric ischemia to CTA imaging, perforated viscus to emergent laparotomy, and a contained appendiceal abscess to percutaneous drainage.
Optimal surgical decision-making for the acute abdomen relies on risk stratification. Patients with peritonitis or hemodynamic instability (e.g., perforated viscus) require emergent laparotomy. Hemodynamically stable patients with a high suspicion of vascular compromise (e.g., early mesenteric ischemia) require rapid diagnostic imaging with CTA. Patients with mechanical obstruction but no signs of bowel compromise (uncomplicated small bowel obstruction) should undergo a trial of conservative management. Finally, stable patients with contained, walled-off infectious collections (e.g., large appendiceal abscesses) are best managed with percutaneous drainage to avoid the morbidity of operating in a highly inflamed field.
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Anahtar Kavram
The decision between conservative management, advanced imaging, and emergent surgery for the acute abdomen depends strictly on the presence of peritonitis, hemodynamic stability, and the specific underlying pathology.