Tuesday, November 4, 2014

A 58-year-old man has a long history of dyspepsia for which he frequently takes over the counter antacids.

A 58-year-old man has a long history of dyspepsia for which he frequently takes over the counter antacids.

For the past 2 days his epigastric pain is worse and is constant.

 Vital signs:
oral temperature 99.0◦F,
 heart rate 110/min,
blood pressure 158/90 mmHg.

His abdomen is rigid and you note decreased bowel sounds.
The x-ray showed in Figure  was obtained.

Your next step would be to

a. Perform an immediate paracentesis.
b. Consult surgery for perforated hollow viscus.
c. Give oral contrast and take to CT scan for further evaluation.
d. Start a proton pump inhibitor and refer to a gastroenterologist.
e. Begin high-dose somatostatin therapy and consult gastroenterology.:

The answer is b: This upright chest x-ray shows free air under the diaphragms, consistent with perforated peptic ulcer. PUD is common in the United States but only 7% experience perforation. Ninety-five percent of these patients will require emergent operative intervention. The upright chest x-ray is approximately 70% sensitive for detecting perforation from peptic ulcer disease. Although, instillation of 500 mL of air, or lateral decubitus films may help improve the sensitivity, CT abdomen (either no contrast or with oral contrast) is the next best test if perforation is suspected and the initial x-ray is negative 

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