A 65-year-old man is brought to the emergency department by his wife due to severe upper-abdominal pain. The pain began suddenly 4 hours ago while he was watching television; it radiates to the back and is exacerbated by any movement. The patient has had gastroesophageal reflux disease for many years and has been taking over-the-counter antacids for symptom control. He also has hypertension, which is controlled with a thiazide diuretic. He walks 5 miles daily. The patient has been consuming large amounts of milk and other dairy products to relieve "burning" symptoms in his stomach. His temperature is 37.8 C (100 F), blood pressure is 110/62 mm Hg, pulse is 110/min, and respirations are 22/min. He lies flat and motionless on the bed. His mucous membranes are dry. Abdominal examination shows marked tenderness on superficial palpation. The patient does not allow any further palpation of the abdomen. Electrocardiogram shows sinus tachycardia. Further evaluation shows pneumoperitoneum on the upright chest x-ray. The patient's white blood cell count is 11,300/μL, creatinine is 1.1 mg/dL, and lactic acid level is 2.1 mg/dL. Which of the following is the most appropriate next step in management of this patient?

Question

A 65-year-old man is brought to the emergency department by his wife due to severe upper-abdominal pain.  The pain began suddenly 4 hours ago while he was watching television; it radiates to the back and is exacerbated by any movement.  The patient has had gastroesophageal reflux disease for many years and has been taking over-the-counter antacids for symptom control.  He also has hypertension, which is controlled with a thiazide diuretic.  He walks 5 miles daily.  The patient has been consuming large amounts of milk and other dairy products to relieve "burning" symptoms in his stomach.  His temperature is 37.8 C (100 F), blood pressure is 110/62 mm Hg, pulse is 110/min, and respirations are 22/min.  He lies flat and motionless on the bed.  His mucous membranes are dry.  Abdominal examination shows marked tenderness on superficial palpation.  The patient does not allow any further palpation of the abdomen.  Electrocardiogram shows sinus tachycardia. Further evaluation shows pneumoperitoneum on the upright chest x-ray.  The patient's white blood cell count is 11,300/μL, creatinine is 1.1 mg/dL, and lactic acid level is 2.1 mg/dL.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Peptic ulcer perforation is a potentially fatal complication of peptic ulcer disease. If left untreated, the patient can have a rapid clinical deterioration leading to death within 12-24 hours. However, early diagnosis and treatment generally lead to excellent prognosis and most patients recover fully. Emergency surgery (open or laparoscopic) is indicated in all patients with perforated peptic ulcer. In preparation for surgery, patients with a perforated viscus should receive fluid resuscitation and broad-spectrum intravenous antibiotics with good coverage for Gram-negative organisms. Intravenous proton-pump inhibitor therapy is also suggested for patients with perforated peptic ulcer. (Choice A) Barium esophagram is indicated for the evaluation of dysphagia (eg, patients with suspected hiatal hernia, achalasia, esophageal webs). It is contraindicated in patients with suspected perforation. (Choice C) Non-contrast chest CT is useful for evaluating disorders of the pulmonary parenchyma or traumatic chest injuries. It would not be recommended in a patient with a known perforated viscus. (Choice D) Octreotide infusion is most commonly used for bleeding esophageal varices. It would not be helpful in the setting of perforation. (Choice E) Upper gastrointestinal endoscopy is used in the evaluation of gastritis and peptic ulcer disease. However, surgery is needed in the setting of perforation. Educational objective: In preparation for expedited surgical intervention, patients with suspected or confirmed peptic ulcer perforation should receive intravenous fluid resuscitation, broad-spectrum intravenous antibiotics, and intravenous proton-pump inhibitor therapy. References: Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. (http://www.ncbi.nlm.nih.gov/pubmed/24338777)

A 65-Year-Old Man Is Brought to the Emergency Department by His