A 52-year-old man is brought to the emergency department complaining of sudden-onset, excruciating epigastric pain that started 2 hours ago. He has a history of chronic knee osteoarthritis for which he takes high-dose ibuprofen daily. His temperature is 38.2°C (100.8°F), pulse is 118/min, and blood pressure is 92/58 mmHg. The patient is lying completely still on the stretcher. Physical examination reveals a rigid, board-like abdomen with severe diffuse rebound tenderness. An upright chest radiograph demonstrates a crescent of radiolucency under the right hemidiaphragm. Which of the following is the most appropriate next step in management?
- Emergent exploratory laparotomyCevap
- BComputed tomography of the abdomen and pelvis
- CEsophagogastroduodenoscopy
- DNasogastric tube placement and intravenous proton pump inhibitors
- EAdministration of broad-spectrum intravenous antibiotics and observation in the intensive care unit
Cevap
Emergent exploratory laparotomy is the appropriate next step for a patient presenting with an acute abdomen, hemodynamic instability, and pneumoperitoneum due to a perforated viscus.
The correct answer is emergent exploratory laparotomy. This patient presents with a classic perforated peptic ulcer, supported by his history of NSAID use, sudden-onset severe pain, and rigid, board-like abdomen. The upright chest radiograph showing free air under the diaphragm confirms pneumoperitoneum. In the setting of a perforated viscus, generalized peritonitis, and hemodynamic instability (tachycardia and hypotension), the absolute next best step is immediate surgical exploration for washout and repair of the defect. Any delay increases the risk of severe sepsis and death.
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Anahtar Kavram
Patients presenting with signs of a perforated hollow viscus (e.g., rigid abdomen, pneumoperitoneum) and hemodynamic instability require emergent exploratory laparotomy.