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  #1  
Old 03-05-2012
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Surgery Peritonitis; X ray or Laparotomy?

A 35-year-old man with a long history of dyspepsia experiences sudden onset of severe epigastric distress with associated pain in the right shoulder. Physical examination reveals a patient who appears ill and who has a rigid, quiet abdomen with rebound tenderness.
Which of the following is the most appropriate first step in the management of this patient?
(A) Order a barium study of the upper gastrointestinal system.
(B) Order upright and supine abdominal films.
(C) Perform a peritoneal lavage.
(D) Administer antacids.
(E) Do an exploratory laparotomy.

pls give reason
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  #2  
Old 03-05-2012
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I THINK THE pERITONITIS IS QUITE OBVIOUS, A MUST GO FOR "EXPLORATORY LAP "...a surgical emergency

the xray wont change the line of management
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Old 03-05-2012
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Abdominal Xray required before Exp Laparotomy.
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Old 03-05-2012
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http://emedicine.medscape.com/articl...erview#showall

Ok it says- you can directly go for Ex-Lap!!!!!
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  #5  
Old 03-05-2012
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i think in USMLE ... nothing is absolutely true or false... when it comes to two close ans...

i mean if this case wasnt obvious n requiring a Lap anyways...

then Xray wud def be correct...

but here since Xray wont affect the lkine of management... and neither will it help much in further plan of action....direct ExLap is the ans...isnt it?


Now mr.tyagee

plz giv the correct ans...

itna tadpao mat !!
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  #6  
Old 03-05-2012
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I think the ans is B. this patient with long history of dyspepsia probably now has perforation leading to peritoneal peritoinits. so she needs ans xray to confirm diagnosis before exploratory laboratomy.
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  #7  
Old 03-05-2012
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xray is the answer not lapro. cant find any clear expln in qbank
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  #8  
Old 03-05-2012
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now i m confused... its a gud quetn.

can cm up in d exam...

anyone with more substantial explanation or source ?
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  #9  
Old 03-07-2012
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its perforation ,
so best next step is abdominal x-ray.
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  #10  
Old 03-07-2012
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this pt has long history of dyspepsia means now pt has perforated stomach or duodenal ulcer, now presentation is guarding, regidity and tenderness, when ever these findings u seen in pt (guarding, regidity and tenderness) ALWAYS GO FOR EXP LAPROTOMY, ITS TRICK
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  #11  
Old 03-07-2012
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are u sure?

can u atleast quote the source where this info is from ?
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  #12  
Old 03-07-2012
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Correct Answer

Quote:
Originally Posted by drnrpatel View Post
http://emedicine.medscape.com/articl...erview#showall

Ok it says- you can directly go for Ex-Lap!!!!!
Acute-onset abdominal pain and clinical findings suggestive of intra-abdominal pathology requiring emergency surgery
In these conditions, exploratory laparotomy is carried out both to diagnose the condition and to perform the necessary therapeutic procedure.

Peritonitis

Patients with clinical features of peritonitis may have pneumoperitoneum on erect chest and abdominal radiographs. They usually have a perforated viscus, most commonly the duodenum, stomach, small intestine, cecum, or sigmoid colon. Exploratory laparotomy is done first to determine the exact cause of pneumoperitoneum, followed by the therapeutic procedure. In the absence of pneumoperitoneum, appendicular perforation and intestinal ischemia are possible diagnoses; a high index of suspicion for possible intestinal ischemia should be maintained.
(In this taken from the link you have posted,it never says that Xray are not done first)
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  #13  
Old 03-07-2012
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Correct Answer

In severe abdominal sepsis, however, delays in operative management may lead to a significantly higher need for reoperations and to worse outcomes overall; early exploration (ie, prior to completion of diagnostic studies) may be indicated. Surgical intervention may include resection of a perforated viscus with re-anastomosis or the creation of a fistula. To reduce the bacterial load, a lavage of the abdominal cavity is performed, with particular attention to areas prone to abscess formation (eg, paracolic gutters, subphrenic area)
this is from link-
http://emedicine.medscape.com/article/1952823-overview
Here though they have mentioned prior to completion of diagnostic studies but have not mentioned prior to initiation of diagnostic studies.
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  #14  
Old 03-09-2012
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sholder pain indicate gallbladder involvement ,so xray may be for perforation &stone??
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