A 68-year-old man comes to the emergency department due to sudden onset of severe epigastric pain 2 hours ago, accompanied by nausea and an episode of vomiting. The patient has had intermittent abdominal discomfort over the past several months, and an abdominal ultrasound performed 2 weeks ago revealed several small gallstones. Other medical conditions include hypertension, type 2 diabetes mellitus, coronary artery disease, and heart failure with reduced ejection fraction. The patient has a 30-pack-year smoking history and drinks 1 or 2 beers occasionally. Temperature is 38 C (100.4 F), blood pressure is 150/92 mm Hg, pulse is 112/min, and respirations are 26/min. Auscultation reveals normal lung and heart sounds. There is marked upper abdominal tenderness with guarding. ECG reveals no acute ST-segment or T-wave changes. Chest x-ray is shown in the image below: Which of the following is the most likely cause of this patient's current symptoms?

Question

A 68-year-old man comes to the emergency department due to sudden onset of severe epigastric pain 2 hours ago, accompanied by nausea and an episode of vomiting.  The patient has had intermittent abdominal discomfort over the past several months, and an abdominal ultrasound performed 2 weeks ago revealed several small gallstones.  Other medical conditions include hypertension, type 2 diabetes mellitus, coronary artery disease, and heart failure with reduced ejection fraction.  The patient has a 30-pack-year smoking history and drinks 1 or 2 beers occasionally.  Temperature is 38 C (100.4 F), blood pressure is 150/92 mm Hg, pulse is 112/min, and respirations are 26/min.  Auscultation reveals normal lung and heart sounds.  There is marked upper abdominal tenderness with guarding.  ECG reveals no acute ST-segment or T-wave changes.  Chest x-ray is shown in the image below:  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d1a8_f367_bc81_7d786e9cd6a0_MD0003_00 This patient with clinical manifestations (eg, months of intermittent abdominal pain) and risk factors (eg, likely aspirin use) for peptic ulcer disease (PUD) now has sudden-onset, severe abdominal pain with a chest x-ray showing subdiaphragmatic free air (ie, pneumoperitoneum). This presentation is highly concerning for perforated viscus due to PUD. Full-thickness erosion of a peptic ulcer through the stomach or duodenal wall releases both air and caustic (ie, pH ~1-2) gastric secretions/contents into the peritoneal cavity. This quickly results in chemical peritonitis (eg, marked abdominal tenderness with guarding) and an early systemic inflammatory response (eg, fever, tachycardia) that can progress to sepsis and shock if left untreated. Patients with free perforation causing gross spillage of gastrointestinal contents (vs microperforation with little to no spillage) can often note the precise time the perforation occurred. Sudden, severe pain is typical. Demonstration of intraperitoneal free air (eg, on upright x-ray) confirms the diagnosis and should prompt immediate surgical consultation, since many patients require surgical intervention and delay increases mortality (which is up to 30%, even with treatment). (Choice A) Acute cholecystitis can cause epigastric pain, fever, nausea/vomiting, and focal peritonitis. However, pain onset is not typically as sudden, and peritoneal inflammation is usually isolated to the right upper quadrant. Gallbladder perforation can cause upper abdominal pain but typically only after several days of symptoms (vs 2 hours in this patient) and would not cause pneumoperitoneum because the gallbladder does not contain significant air. This patient likely has asymptomatic gallstones, which are common in the general population. (Choice B) Acute gallstone pancreatitis can cause a sudden onset of severe epigastric pain, fever, and nausea/vomiting; however, pancreatitis does not cause subdiaphragmatic free air. Abdominal x-ray is often normal but may show gallstones or paralytic ileus due to surrounding inflammation. gallstones paralytic ileus (Choice C) Aortic dissection can present with sudden-onset abdominal pain but more commonly produces chest/back pain. Rather than pneumoperitoneum, it typically causes mediastinal widening. mediastinal widening (Choice D) Biliary colic can cause epigastric pain, but the pain is typically postprandial when the gallbladder contracts against a blocked (ie, gallstone) cystic duct in response to a fatty meal. In addition, biliary colic is typically associated with a benign abdominal examination and does not cause fever or pneumoperitoneum. Educational objective: Sudden-onset, severe abdominal pain with peritonitis and subdiaphragmatic free air on upright chest x-ray is a classic presentation of perforated viscus (eg, perforated peptic ulcer). References: Pneumoperitoneum. (http://www.ncbi.nlm.nih.gov/pubmed/30243453) Perforated peptic ulcer. (http://www.ncbi.nlm.nih.gov/pubmed/26460663) Perforated peptic ulcer-an update. (http://www.ncbi.nlm.nih.gov/pubmed/28138363)

A 68-Year-Old Man Comes to the Emergency Department Due to Sudden