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?
- Emergent surgical consultationCevap
- BComputed tomography scan of the abdomen and pelvis
- CRight upper quadrant abdominal ultrasonography
- DAdministration of intravenous fluids and serial abdominal examinations
- EInitiation of intravenous pantoprazole and admission for observation
Cevap
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.
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Anahtar Kavram
Identification of pneumoperitoneum on an upright radiograph mandates emergent surgical intervention for a perforated viscus.