Question 1

Q: A 67-year-old woman with a history of atrial fibrillation on warfarin presents with sudden-onset severe periumbilical pain that is disproportionate to her abdominal tenderness on examination. She has nausea and one episode of vomiting. Vital signs: BP 110/72 mmHg, HR 108 bpm, RR 18/min, temperature 37.2°C. Abdominal examination reveals mild diffuse tenderness without rigidity or guarding. Bowel sounds are present. INR is 3.1. CT abdomen with contrast demonstrates occlusion of the superior mesenteric artery with segmental bowel wall thickening and pneumatosis intestinalis, consistent with established bowel infarction. Which of the following is the most appropriate next step in management?

Urgent surgical exploration for bowel ischemia. ***Urgent surgical exploration for bowel ischemia*** - The presence of **pneumatosis intestinalis** and **bowel wall thickening** on CT indicates established **intestinal infarction**, which is a surgical emergency. - **Urgent laparotomy** is required to resect necrotic bowel and attempt restoration of blood flow to viable segments to prevent sepsis and death. *Administer IV heparin infusion and admit for observation* - While heparin is used in early **acute mesenteric ischemia**, observation is contraindicated when there is radiographic evidence of **bowel necrosis**. - Delaying surgery in the setting of **pneumatosis** significantly increases the risk of perforation and multi-organ failure. *Perform colonoscopy to evaluate for ischemic colitis* - **Colonoscopy** is the investigation of choice for **ischemic colitis**, but it is not used for **acute mesenteric ischemia** involving the small bowel. - In the setting of suspected bowel infarction, colonoscopy carries a high risk of **iatrogenic perforation** and delays definitive treatment. *Reverse anticoagulation with vitamin K and fresh frozen plasma, then observe* - Reversal of anticoagulation may be necessary pre-operatively, but **observation** is inappropriate once **bowel infarction** is confirmed. - Managing the **INR** should happen concurrently with surgical preparation rather than being a reason to delay life-saving exploration. *Obtain mesenteric angiography for diagnostic confirmation before any intervention* - **Mesenteric angiography** was traditionally the gold standard, but it is time-consuming and unnecessary when CT already shows **occlusion** and **infarction**. - Diagnostic confirmation is already established; further imaging only delays the **surgical intervention** required to manage established gangrene.

Question

A 67-year-old woman with a history of atrial fibrillation on warfarin presents with sudden-onset severe periumbilical pain that is disproportionate to her abdominal tenderness on examination. She has nausea and one episode of vomiting. Vital signs: BP 110/72 mmHg, HR 108 bpm, RR 18/min, temperature 37.2°C. Abdominal examination reveals mild diffuse tenderness without rigidity or guarding. Bowel sounds are present. INR is 3.1. CT abdomen with contrast demonstrates occlusion of the superior mesenteric artery with segmental bowel wall thickening and pneumatosis intestinalis, consistent with established bowel infarction. Which of the following is the most appropriate next step in management?

Accepted Answer

Urgent surgical exploration for bowel ischemia

Answer

Administer IV heparin infusion and admit for observation

Answer

Perform colonoscopy to evaluate for ischemic colitis

Answer

Reverse anticoagulation with vitamin K and fresh frozen plasma, then observe

Answer

Obtain mesenteric angiography for diagnostic confirmation before any intervention

Trauma/Emergencies — MCQs

Trauma/Emergencies — MCQs

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