Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Stomach
Question 3#

A 65-year-old man with a history of hypertension, GERD, and chronic low back pain presents with vague chest pain. He takes oxycodone, gabapentin, and ibuprofen daily. He is admitted for observation and cardiac workup. EKG shows nonspecific T-wave changes and laboratory test results are unremarkable. On hospital day 2 he has:

His abdomen is distended with tap tenderness and guarding on mild palpation in all four quadrants. Upright chest X-ray demonstrates free air under the diaphragm.

Which of the following is the MOST appropriate next step in management?

A. Repeat EKG and troponins
B. Obtain CT abdomen with IV and PO contrast
C. Place NGT and perform serial abdominal examinations
D. Consult gastroenterology for endoscopic evaluation
E. Consult surgery for exploratory laparotomy

Correct Answer is E

Comment:

Correct Answer: E

This patient’s chronic NSAID use puts him at risk of developing PUD. Patients with PUD may be asymptomatic or have a history of dyspepsia. Nearly half of patients with PUD also experience acid regurgitation symptoms. This patient’s presenting complaint was chest pain, but his cardiac workup is unremarkable. Acid reflux and epigastric pain are frequently confused with chest pain, as was likely in this case. When the patient subsequently developed acute abdominal pain with hypotension, peritoneal signs, and evidence of free air, a perforated ulcer should be high on the differential. Repeating the cardiac workup would delay care and potentially have distracting findings related to cardiac demand. With free air on upright chest X-ray, taking a hemodynamically unstable patient to the CT scanner is an unnecessary delay. Similarly, monitoring him with serial abdominal examinations would be unsafe. Although upper endoscopy is the most accurate diagnostic test for PUD with up to 90% sensitivity in detecting a lesion, in this unstable patient, it would not allow for definitive management of his perforated ulcer. This patient needs a surgical consultation for identification and repair of his perforated peptic ulcer. 

References:

  1. Barkun A, Leontiadis G. Systematic review of the symptom burden, quality of life impairment and costs associated with peptic ulcer disease. Am J Med. 2010;123:358-366.
  2. Solis CV, Chang Y, DeMoya MA, Velmahos GC, Fagenholz PJ. Free air on plain film: do we need a computed tomography too? J Emerg Trauma Shock. 2014;7(1):3-8.