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Zorluk: KolayGastrointestinal and Abdominal Surgery

A 61-year-old man is evaluated in the emergency department for sudden, severe, and generalized abdominal pain that started 3 hours ago. He has a past medical history of chronic knee osteoarthritis, for which he takes naproxen regularly. His temperature is 38.4°C (101.1°F), blood pressure is 92/58 mm Hg, and heart rate is 118/min. On physical examination, the patient is visibly uncomfortable and lying rigidly still on the stretcher. The abdomen is distended, diffusely rigid, and exhibits profound rebound tenderness in all quadrants. An upright chest radiograph reveals a crescent of radiolucency beneath the right hemidiaphragm. Intravenous fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

  1. Immediate surgical explorationCevap
  2. B
    Abdominal computed tomography scan
  3. C
    Placement of a nasogastric decompression tube
  4. D
    Intravenous broad-spectrum antibiotic therapy alone
  5. E
    Esophagogastroduodenoscopy

Cevap

Immediate surgical exploration
The correct answer is immediate surgical exploration. This patient presents with a classic perforated peptic ulcer, supported by a history of chronic naproxen use, sudden severe abdominal pain, signs of diffuse peritonitis (rigidity, rebound tenderness), and hemodynamic instability. The upright chest radiograph reveals pneumoperitoneum (free air under the diaphragm), which unequivocally confirms a hollow viscus perforation. In a patient with generalized peritonitis and free air, urgent laparotomy is required for source control, washout, and repair of the perforation. Delaying surgery for further diagnostics or attempting non-operative management would drastically increase mortality.

Adım Adım Çözüm

1
Analyze the patient's presentation and history.
The patient has sudden, severe abdominal pain and a history of chronic NSAID use.
NSAID use is a major risk factor for complicated peptic ulcer disease.
2
Evaluate the physical examination and vital signs.
The patient has hypotension, tachycardia, and a rigid, board-like abdomen with rebound tenderness.
These findings indicate diffuse peritonitis and early septic shock.
3
Interpret the diagnostic imaging.
An upright chest X-ray shows free air under the right hemidiaphragm (pneumoperitoneum).
Pneumoperitoneum confirms the diagnosis of a perforated hollow viscus.
4
Determine the next best step in management.
The patient requires immediate surgical exploration.
A perforated viscus with peritonitis and hemodynamic instability is an absolute indication for an emergent laparotomy to achieve source control.

Anahtar Kavram

Patients with peritonitis, hemodynamic instability, and radiographic evidence of a perforated viscus require emergent surgical exploration.
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Gastrointestinal and Abdominal Surgery

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