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Zorluk: OrtaSurgical and Procedural Interventions

A 45-year-old man presents to the emergency department with a 2-hour history of sudden-onset, severe, and diffuse abdominal pain. He has a history of chronic lower back pain managed with high-dose daily ibuprofen. He is in severe distress and lies completely still on the examination table. His temperature is 38.2°C (100.8°F), blood pressure is 92/58 mm Hg, pulse is 122/min, and respirations are 24/min. Abdominal examination demonstrates diffuse rigidity, involuntary guarding, and severe rebound tenderness. An upright chest radiograph reveals free air under the right hemidiaphragm. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

  1. Administration of intravenous crystalloid fluids and broad-spectrum antibioticsCevap
  2. Urgent surgical consultation for exploratory laparotomyCevap
  3. C
    Computed tomography of the abdomen and pelvis with oral contrast
  4. D
    Esophagogastroduodenoscopy (EGD) to localize the site of the lesion
  5. E
    Comprehensive transthoracic echocardiography to obtain cardiology clearance

Cevap

The correct steps are the administration of intravenous crystalloid fluids and broad-spectrum antibiotics, and an urgent surgical consultation for an exploratory laparotomy.
This patient presents with classic signs of a perforated hollow viscus, likely a peptic ulcer given his chronic NSAID use. The diagnosis is definitively established by the presence of a rigid, board-like abdomen and an upright chest radiograph demonstrating pneumoperitoneum (free air under the diaphragm). In the setting of an acute surgical abdomen with hemodynamic instability (tachycardia, hypotension, fever), the mandatory next steps are immediate medical stabilization with intravenous crystalloids and broad-spectrum antibiotics, followed immediately by an urgent surgical consultation for an exploratory laparotomy. Source control of the contamination is paramount to survival.

Adım Adım Çözüm

1
Analyze the clinical presentation and imaging findings.
The patient has a history of NSAID use, sudden severe abdominal pain, peritonitis (rigidity, guarding), and pneumoperitoneum (free air under the diaphragm) on x-ray.
Identifying these signs confirms the diagnosis of a perforated hollow viscus, likely a perforated peptic ulcer.
2
Assess the patient's hemodynamic status.
The patient is tachycardic, hypotensive, and febrile.
These vital signs indicate early septic shock secondary to intra-abdominal contamination.
3
Determine the necessary immediate medical and procedural interventions.
Immediate fluid resuscitation, broad-spectrum antibiotics, and urgent laparotomy are indicated.
Medical stabilization must occur concurrently with urgent surgical source control to prevent mortality.

Anahtar Kavram

Patients presenting with a perforated hollow viscus and peritonitis require immediate medical stabilization (IV fluids and broad-spectrum antibiotics) and concurrent emergent surgical repair (exploratory laparotomy); further diagnostic imaging or endoscopic procedures are strictly contraindicated.
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Surgical and Procedural Interventions

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