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Zorluk: OrtaSurgical and Procedural Interventions

A 76-year-old woman is brought to the emergency department due to the sudden onset of severe abdominal pain that started 3 hours ago. Her medical history includes hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. She stopped taking her prescribed apixaban one week ago prior to a dental extraction and did not resume it. Her temperature is 38.2°C (100.8°F), blood pressure is 82/50 mm Hg, pulse is 128/min and irregular, and respirations are 26/min. On physical examination, the abdomen is distended with board-like rigidity, diffuse tenderness to palpation, and marked rebound tenderness. Bowel sounds are absent.

Laboratory studies reveal:
TestResult
Leukocyte count22,000/mm³
Serum lactate6.1 mmol/L (Normal: 0.5–2.2 mmol/L)
pH7.28
pCO₂32 mm Hg
HCO₃⁻14 mEq/L

The patient is immediately started on aggressive intravenous fluid resuscitation, broad-spectrum antibiotics, and an intravenous heparin infusion. Which of the following is the most appropriate next step in the management of this patient?

  1. Emergent exploratory laparotomyCevap
  2. B
    Computed tomography angiography of the abdomen
  3. C
    Magnetic resonance angiography of the mesenteric vessels
  4. D
    Intravenous tissue plasminogen activator
  5. E
    Admission to the medical intensive care unit for serial abdominal examinations

Cevap

Emergent exploratory laparotomy
This patient presents with classic signs of acute mesenteric ischemia (AMI), likely secondary to a superior mesenteric artery embolism (given her paroxysmal atrial fibrillation and recent cessation of apixaban). The classic presentation of AMI is severe abdominal pain out of proportion to physical exam findings. However, this patient has progressed to develop fever, hemodynamic instability (hypotension, tachycardia), severe lactic acidosis, and a rigid abdomen with rebound tenderness. These findings indicate transmural bowel infarction and peritonitis. In any patient with suspected AMI who develops peritonitis or hemodynamic instability, the most appropriate next step is emergent exploratory laparotomy. Surgery is required to resect necrotic bowel segments, restore mesenteric perfusion (e.g., via surgical embolectomy or bypass), and prevent overwhelming sepsis and death. Proceeding to the operating room takes precedence over confirmatory imaging.

Adım Adım Çözüm

1
Identify the underlying diagnosis based on history and presentation.
The patient's history of atrial fibrillation off anticoagulation, sudden severe abdominal pain, and elevated lactate strongly suggest acute mesenteric ischemia due to arterial embolism.
Recognizing the primary pathology is essential for determining the specific treatment algorithm.
2
Assess the patient's clinical stability and abdominal exam findings.
The patient has hypotension, tachycardia, fever, and a rigid abdomen with rebound tenderness (peritonitis).
The presence of peritonitis indicates transmural bowel infarction and potential perforation, shifting the management from diagnostic to emergent therapeutic.
3
Select the appropriate intervention based on stability.
Emergent exploratory laparotomy is chosen over imaging.
Unstable patients with peritonitis require immediate surgery to resect necrotic tissue; delaying for imaging increases mortality.

Anahtar Kavram

Patients with suspected acute mesenteric ischemia who exhibit signs of peritonitis or hemodynamic instability require emergent exploratory laparotomy, bypassing diagnostic imaging.
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Surgical and Procedural Interventions

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