WBR0003

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Author Anonymous (Edited by Will Gibson and Alison Leibowitz)
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Gastrointestinal
Prompt A 56-year-old man presents to the urgent care clinic for constant epigastric pain. He reports a history of gastrointestinal ulcers, which felt similar to the patient's current presentation. He recalls taking one week of a 2-week course of medication several years ago after which his ulcers resolved. While waiting for preliminary laboratory results, the patient's condition rapidly deteriorates. He suddenly complains of severe pain in his upper abdomen and turns pale. His blood pressure acutely rises to 150/110 mmHg and his heart rate increases to 120 bpm. What is the optimal imaging study for diagnosing the most likely condition?
Answer A Lateral decubitus chest x-ray.
Answer A Explanation [[AnswerAExp::In a decubitus X-ray, the patient lays down on her side while films are taken. A lateral decubitus X-ray is useful for determining whether a patient is suffering from a pneumonia or a pleural effusion. If an effusion is present, the fluid will form a freely mobile layer on the dependent side of the chest wall.]]
Answer B Plain upright chest x-ray.
Answer B Explanation As a general rule, chest X-ray is the best initial radiographic test for any pulmonary complaint. In the case of gastric perforation, upright chest x-ray is a rapid diagnostic tool that will show free air under the diaphragm.
Answer C Abdominal CT scan
Answer C Explanation While abdominal CT scan is the most accurate test for gastric perforation, it is not the best initial test due to the urgent nature of the disease. Abdominal CT is the most accurate test to diagnose intrabdominal inflammatory diseases such as diverticulitis and pancreatitis. Oral contrast is critical when performing abdominal CTs, as it helps to outline the bowel against other organs that may become pressed against it.
Answer D Abdominal X-ray
Answer D Explanation Abdominal X-ray is not the best initial radiographic test for suspected perforation of the stomach or bowel. Instead, a plain upright X-ray is more appropriate. Abdominal X-ray will often fail to detect free air under the diaphragm generated by a perforation, especially in tall people. Abdominal X-ray is the appropriate imaging test for suspected cases of bowel obstruction or ileus.
Answer E Emergency esophagogastroduodenoscopy
Answer E Explanation While the perforated ulcer may require surgical or endoscopic treatment, emergency gastroduodenoscopy is not the best initial diagnostic test in this patient.
Right Answer B
Explanation [[Explanation::This patient exhibits signs of acute gastric ulcer perforation. As this is a surgical emergency, fast and accurate testing is very important, making plain upright chest x-ray the preferred diagnostic test. Upright chest x-ray will commonly show free air concentrated under the diaphragm. Peptic ulcer disease is often caused by Helicobacter pylori infection. In this case, the patient underwent antibiotic treatment, but did not complete the full course, suggesting possible survival of resistant organisms. The risk of perforated peptic ulcers can be reduced by the prompt use of antibiotic regimens against H. pylori. The perforation in this patient may require surgical intervention or may spontaneously seal.

Educational Objective: In the case of gastric perforation, upright chest x-ray is a rapid diagnostic tool that will show free air under the diaphragm.
References: Master the Boards 2013 page 389-492]]

Approved Yes
Keyword Gastric, Ulcer, Gastic Ulcer, Perforation, Xray, X-ray, Imaging, Stomach, Gastrointestinal
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