A 45-year-old woman is brought to the emergency department due to severe abdominal pain, nausea, and 2 episodes of vomiting over the last 2 hours. After meals for the past several weeks, the patient has had episodic epigastric and right upper quadrant pain associated with nausea. Medical history is significant for mitral valve prolapse, obesity, and migraine headaches relieved by nonsteroidal anti-inflammatory drugs (NSAIDs). Temperature is 38.3 C (100.9 F), blood pressure is 140/92 mm Hg, and pulse is 102/min. Physical examination reveals diffuse abdominal tenderness and guarding over the upper abdomen. Stool guaiac test is positive. Which of the following is the best next step in management of this patient?

Question

A 45-year-old woman is brought to the emergency department due to severe abdominal pain, nausea, and 2 episodes of vomiting over the last 2 hours.  After meals for the past several weeks, the patient has had episodic epigastric and right upper quadrant pain associated with nausea.  Medical history is significant for mitral valve prolapse, obesity, and migraine headaches relieved by nonsteroidal anti-inflammatory drugs (NSAIDs).  Temperature is 38.3 C (100.9 F), blood pressure is 140/92 mm Hg, and pulse is 102/min.  Physical examination reveals diffuse abdominal tenderness and guarding over the upper abdomen.  Stool guaiac test is positive.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation is concerning for undiagnosed peptic ulcer disease (PUD) (eg, postprandial nausea/upper abdominal pain, nonsteroidal anti-inflammatory drug [NSAID] use, positive stool guaiac test) complicated by perforation. 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, quickly resulting in chemical peritonitis (eg, marked abdominal tenderness with guarding) and a systemic inflammatory response (eg, fever, tachycardia). Perforated viscus is primarily a clinical diagnosis; however, confirmation can often be made quickly via demonstration of subdiaphragmatic free air (pneumoperitoneum) on upright x-ray of the chest and abdomen. When perforation is suspected and plain radiographs are negative, CT scan of the abdomen with intravenous contrast can help detect smaller amounts of free air or free fluid. However, CT scan should not delay surgical consultation and intervention, especially when peritonitis is present. subdiaphragmatic free air (Choice A) Gallbladder ultrasonography can be used to evaluate for suspected cholecystitis, which may present with right upper quadrant (RUQ) and/or epigastric pain and a systemic inflammatory response. However, a positive stool guaiac test is not characteristic of cholecystitis. In addition, cholecystitis is more likely to cause isolated RUQ, rather than diffuse abdominal, tenderness. Although RUQ pain is classically associated with gallstone disease, it can also occur with PUD. (Choice B) Mesenteric angiography can be used to evaluate for mesenteric ischemia. Acute mesenteric ischemia typically causes acute-onset, severe abdominal pain with a relatively benign abdominal examination (rather than diffuse tenderness and guarding) and hematochezia (rather than fecal occult blood). (Choice C) NSAID avoidance and oral proton pump inhibitors are part of uncomplicated PUD management. In contrast, this patient has signs (eg, fever, peritonitis) concerning for complicated PUD (eg, perforation) and should remain NPO while awaiting radiologic confirmation of the diagnosis and/or definitive management. (Choice D) Upper and lower gastrointestinal endoscopy should be considered in patients with occult gastrointestinal bleeding (eg, positive stool guaiac test); however, endoscopy is contraindicated if acute gastrointestinal perforation is suspected because air insufflation and instrumentation may worsen the perforation. Educational objective: Peptic ulcer disease can be complicated by perforation, which typically causes acute-onset, severe pain; a systemic inflammatory response (eg, fever, tachycardia); and peritonitis. Upright x-ray of the chest and abdomen can confirm the diagnosis of perforation by revealing subdiaphragmatic free air. References: 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 45-Year-Old Woman Is Brought to the Emergency Department Due