Ease Into Prep with a PANCE^® Question of the Day

The correct answer is D. The clinical picture is highly suggestive and the radiograph findings virtually pathognomonic for a perforated viscus. Alcoholics can easily get peptic ulcer disease (which can perforate), and perforated ulcers are well known for their propensity to produce elevations of the serum amylase. Patients who have a perforated viscus will classically lie motionless and have a rigid, quiet abdomen on physical examination. The next step in any patient with a perforated viscus is emergent surgery to close the perforation site.

Pancreatitis, whether edematous (choice A) or hemorrhagic (choice B) , could indeed account for abdominal pain, but it would have had gradual onset, be mostly in the upper abdomen with radiation straight through to the back, and be accompanied by rather modest physical findings. The high amylase would have fit, but not the free air under the diaphragms, because the pancreas is a solid organ that would not release air if perforated.

Gangrenous cholecystitis (choice C) is not correct. Although it is true that the gallbladder could have perforated and led to generalized peritonitis, it would have been far more likely to have findings confined to the right upper abdomen. Besides, a gangrenous gallbladder is full of pus and stones but not air, and this condition would therefore not produce the radiograph described.

The same is true of pancreatic pseudocyst (choice E) . It could produce severe generalized chemical peritonitis when it ruptures, but no air would have escaped from it.

PEARL: Suspect perforated viscus when there is sudden onset of abdominal pain and acute abdomen. Free air under the diaphragm seen on upright film makes the diagnosis. Immediate surgical intervention is required for treatment.