A 78-year-old man is brought to the emergency department with abdominal pain. According to his wife, he has had epigastric discomfort for the past 2 days; this morning he refused to get out of bed and appeared confused. Past medical history is significant for diet-controlled diabetes mellitus, coronary artery disease with stable angina, hypertension, and gastroesophageal reflux disease.
On examination, the patient is lethargic. His temperature is 38 C (100.4 F), blood pressure is 144/90 mm Hg, pulse is 112/min and irregular, and respirations are 20/min. Chest is clear on auscultation. There are no heart murmurs. The abdomen is tender to palpation in the epigastric and right upper quadrant areas. His skin is warm and there are no rashes.
Laboratory results are as follows:

ECG reveals atrial fibrillation with no significant ST segment or T wave changes. Abdominal ultrasound shows several small gallstones without wall thickening or edema around the gallbladder. Common bile duct size is normal.
Which of the following is the best next step in managing this patient?

Question

A 78-year-old man is brought to the emergency department with abdominal pain.  According to his wife, he has had epigastric discomfort for the past 2 days; this morning he refused to get out of bed and appeared confused.  Past medical history is significant for diet-controlled diabetes mellitus, coronary artery disease with stable angina, hypertension, and gastroesophageal reflux disease.
On examination, the patient is lethargic.  His temperature is 38 C (100.4 F), blood pressure is 144/90 mm Hg, pulse is 112/min and irregular, and respirations are 20/min.  Chest is clear on auscultation.  There are no heart murmurs.  The abdomen is tender to palpation in the epigastric and right upper quadrant areas.  His skin is warm and there are no rashes.
Laboratory results are as follows:

ECG reveals atrial fibrillation with no significant ST segment or T wave changes.  Abdominal ultrasound shows several small gallstones without wall thickening or edema around the gallbladder.  Common bile duct size is normal.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_9612_e14a_853d_f3443944026f_MD0002_00 Fever, lethargy, abdominal pain, and epigastric tenderness in the setting of previously undiagnosed and untreated atrial fibrillation (AF) are most suggestive of acute mesenteric ischemia. Ischemia occurs due to abrupt occlusion of arterial flow from embolus or thrombus in the setting of atherosclerotic disease and/or AF without adequate anticoagulation. This patient's high CHA₂DS₂-VASc score places him at increased risk of systemic thromboembolism. CHA₂DS₂-VASc score Patients typically present with sudden onset of severe periumbilical pain that appears to be out of proportion to examination findings. Laboratory studies typically show leukocytosis, elevated amylase levels, and metabolic acidosis due to increased serum lactate levels. CT or MR angiography of the abdomen is typically used for diagnosis in stable patients. Conventional arteriography may be required when the diagnosis remains uncertain. (Choices A and B) Percutaneous cholecystostomy is usually reserved for high-risk patients with acute cholecystitis who are too ill to undergo cholecystectomy. This patient's ultrasound does not show gallbladder wall thickening or edema, making acute cholecystitis a less likely diagnosis. Similarly, cholescintigraphy (HIDA scan) is occasionally performed in patients with suspected cholecystitis if the diagnosis remains uncertain following abdominal ultrasound. (Choice D) Urgent direct current cardioversion for AF is indicated only in patients with active chest pain, severe acute heart failure, or hemodynamic instability. Moreover, cardioversion in patients with AF of unknown duration will increase the risk of systemic thromboembolism. (Choice E) Transesophageal echocardiogram can reveal an intracardiac source of embolus (left atrium or left atrial appendage); however, it will not change the immediate management of this patient. Therefore, CT angiography of the abdomen should be performed as an initial diagnostic test in this setting. Educational objective: The diagnosis of acute mesenteric ischemia depends on a high index of clinical suspicion in patients with known risk factors for thromboembolic disease (eg, atrial fibrillation, atherosclerosis). CT or MR angiography of the abdomen is typically used for diagnosis in stable patients. __________ References: Ischemic bowel syndromes. (http://www.ncbi.nlm.nih.gov/pubmed/23402466) The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24238311)

A 78-Year-Old Man Is Brought to the Emergency Department with Abdominal