MEDizzy - A 38-year-old man is seen in the urgent care center with

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A 38-year-old man is seen in the urgent care center with several hours of severe abdominal pain. His symptoms began suddenly, but he reports several months of pain in the epigastrium after eating, with a resultant 10-lb weight loss. He takes no medications besides over-the-counter antacids and has no other medical problems or habits. On physical examination, temperature is 38.0°C (100.4°F), pulse is 130 bpm, respiratory rate is 24 breaths/min, and blood pressure is 110/50 mmHg. His abdomen has absent bowel sounds and is rigid with involuntary guarding diffusely. A plain film of the abdomen is obtained and shows free air under the diaphragm. Which of the following is most likely to be found in the operating room?

ExplanationThe patient presents with several months of epigastric abdominal pain that is worse after eating. His symptoms are highly suggestive of peptic ulcer disease, with the worsening pain after eating suggesting a duodenal ulcer. The current presentation with acute abdomen and free air under the diaphragm points to a diagnosis of perforated viscus. The perforated gallbladder is less likely in light of the duration of symptoms and the absence of the signifcant systemic symptoms that often accompany this condition. Because the patient is relatively young with no risk factors for mesenteric ischemia, necrotic bowel from infarction is highly unlikely. Pancreatitis can have a similar presentation, but a pancreas cannot perforate and liberate free air. Peritonitis is most commonly associated with bacterial infection, but it can be caused by the abnormal presence of physiologic fluids, for example, gastric contents, bile, pancreatic enzymes, blood, or urine, or by foreign bodies. In this case, peritonitis is most likely due to the presence of gastric juice in the peritoneal cavity after perforation of a duodenal ulcer has allowed these juices to leave the gut lumen.