A 66-year-old woman with a past medical history of atrial fibrillation, chronic hypertension, diabetes, and hypercholesterolemia presents to the University Hospital emergency room complaining of severe diffuse abdominal pain with associated vomiting and diarrhea. She denies any prior abdominal symptoms prior to this episode. Her temperature is 37.8 degrees Celsius, blood pressure of 178/90, and she has an irregular pulse at 120/minute. Physical exam is significant for extreme diffuse tenderness with rebound and rigidity on abdominal exam. A rectal exam reveals occult blood. What is the next step in management?
- HIDA scan
- Right Upper Quadrant Ultrasound
- Emergent Laparotomy
- Administration of Tissue Plasminogen Activator
- Cardiac Catheterization
explanation
The patient is presenting with signs and symptoms most consistent with acute mesenteric ischemia with associated peritonitis. This is a surgical emergency which requires immediate laparotomy.
Signs and symptoms of acute mesenteric ischemia include extreme pain, vomiting, diarrhea, and heme positive stools. Additionally, patients often have risk factors for embolization including atrial fibrillation, heart disease, and hyperlipidemia. Patients are treated with a Fogarty catheter embolectomy as well as a resection of obviously necrotic intestine. A second look laparotomy is often performed 24-72 hours postoperatively to remove further necrosing bowel.
Illustration A is a gross depiction of necrotic areas of small intestine that can be seen in a patient with acute mesenteric ischemia.