gastrointestinal disorders/peptic ulcer

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Question 1 / 3

683d163ec1b3f4bd827dace2

Surgery

gastrointestinal disorders

peptic ulcer

Case History

A 55-year-old woman is transferred to the hospital ward from the emergency department after initial evaluation. She has a history of chronic knee osteoarthritis, for which she has been taking high-dose naproxen for the past year. She reports a sudden onset of excruciating, diffuse abdominal pain that began 6 hours ago, distinct from her usual "heartburn" symptoms. She denies any prior gastrointestinal bleeding. Her vital signs on arrival to the ward are temperature 38.5 C (101.3 F), blood pressure 95/60 mm Hg, heart rate 120/min, respiratory rate 24/min, and oxygen saturation 96% on room air. She appears acutely ill, diaphoretic, and is protecting her abdomen. Abdominal examination reveals board-like rigidity, absent bowel sounds, and severe tenderness to light palpation across all quadrants. Upright chest X-ray performed in the emergency department showed significant free air under both hemidiaphragms. What is the most likely diagnosis, and what immediate definitive surgical intervention is warranted for this patient?

Lab Parameter	Value	Reference Range
Leukocyte count	19.5 x 10^9/L	3.5–10.5 x 10^9/L
Hemoglobin	13.2 g/dL	12-16 g/dL
Creatinine	1.8 mg/dL	0.6-1.2 mg/dL
Serum Lactate	3.8 mmol/L	0.5-2.2 mmol/L

A ) Acute Cholecystitis and Laparoscopic Cholecystectomy

B ) Diverticulitis with microperforation and IV antibiotics with bowel rest

C ) Bowel Obstruction and Nasogastric Tube placement with supportive care

D ) Perforated Peptic Ulcer and Emergent Exploratory Laparotomy with primary repair or omental patch

E ) Acute Pancreatitis and Endoscopic Retrograde Cholangiopancreatography (ERCP)

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Question 2 / 3

683d163ec1b3f4bd827dacc7

Surgery

gastrointestinal disorders

peptic ulcer

Case History

A 62-year-old male presents to the emergency department with sudden-onset, severe, generalized abdominal pain that began about three hours ago. He describes a prior history of recurrent burning epigastric discomfort, often relieved by antacids but worsened by spicy foods, for which he was advised to get tested for H. pylori but did not follow up. He also has a long-standing history of osteoarthritis, managing chronic pain with daily naproxen. On examination, he is diaphoretic, tachycardic (heart rate 118 bpm), and hypotensive (blood pressure 88/50 mmHg). His abdomen is scaphoid with board-like rigidity and diffuse rebound tenderness. Bowel sounds are absent. Considering these critical findings, what is the most likely diagnosis and the most critical immediate management step?

Lab Parameter	Value	Reference Range
White Blood Cell Count	18.5 x 10^9/L	4.0-11.0 x 10^9/L
Lactate	3.8 mmol/L	0.5-2.2 mmol/L

A ) Diagnosis: Acute gastritis; Management: Initiate proton pump inhibitor therapy and discharge with close outpatient follow-up.

B ) Diagnosis: Perforated peptic ulcer; Management: Immediately obtain an upright chest radiograph and consult general surgery for emergent exploratory laparotomy.

C ) Diagnosis: Acute cholecystitis; Management: Perform a transabdominal ultrasound and administer broad-spectrum antibiotics with pain control.

D ) Diagnosis: Acute pancreatitis; Management: Initiate aggressive intravenous fluid resuscitation and continuous pain management.

E ) Diagnosis: Small bowel obstruction; Management: Insert a nasogastric tube for decompression and arrange for a CT scan of the abdomen.

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Question 3 / 3

683d163ec1b3f4bd827dacce

Surgery

gastrointestinal disorders

peptic ulcer

Case History

A 45-year-old woman arrives at the emergency department, describing sudden-onset, severe, "knife-like" abdominal pain that began approximately 6 hours ago and has since become diffuse, radiating to her right shoulder. She has a history of rheumatoid arthritis, for which she regularly takes ibuprofen. On examination, she appears acutely ill, is tachycardic, and her abdomen is board-like with diffuse rigidity, guarding, and rebound tenderness; bowel sounds are absent. An upright abdominal X-ray reveals significant free air under both hemidiaphragms. Considering her acute presentation and imaging findings, what is the most probable diagnosis and the immediate, definitive management strategy?

Lab Parameter	Value	Reference Range
White Blood Cell Count (WBC)	18.5 x 10^9/L	4.5-11.0 x 10^9/L
Hemoglobin	12.8 g/dL	12.0-15.5 g/dL
Serum Creatinine	0.9 mg/dL	0.6-1.2 mg/dL
Serum Lactate	1.5 mmol/L	0.5-2.2 mmol/L

A ) Acute appendicitis with peritonitis; immediate surgical consultation for appendectomy

B ) Acute pancreatitis; administer aggressive intravenous fluids and broad-spectrum antibiotics, then perform an abdominal CT with contrast

C ) Acute gastrointestinal hemorrhage; initiate high-dose intravenous proton pump inhibitors and prepare for urgent upper endoscopy

D ) Perforated peptic ulcer; begin crystalloid resuscitation, broad-spectrum antibiotics, and prepare for emergent surgical exploration

E ) Acute cholecystitis with empyema; administer intravenous antibiotics and schedule elective laparoscopic cholecystectomy

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