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A 76-year-old woman is brought to the emergency department after being found unresponsive in her room at her nursing facility. Past medical history is significant for Alzheimer's disease, hypertension, and diabetes. Surgical history is notable for an open cholecystectomy at age 38 and multiple cesarean sections. On arrival, she is non-responsive but breathing by herself, and her vital signs are T 102.9 F, HR 123 bpm, BP 95/64, RR 26/min, and SaO2 97% on 6L nasal cannula. On physical exam the patient has marked abdominal distension and is tympanic to percussion. Laboratory studies are notable for a lactic acidosis. An upright abdominal radiograph and CT abdomen/pelvis with contrast are shown in Figures A and B respectively. She is started on IV fluids and a nasogastric tube is placed to suction which returns green bilious fluid. Repeat vitals 1 hour later are T 101F, HR 140 bpm, BP 75/44, RR 30/min, and SaO2 is 100% on the ventilator after she is intubated for airway concerns. What is the next best step in management?
Therapy with levofloxacin and metronidazole
Immediate laparotomy and surgical management
Continue IV fluid hydration, nasogastric suction, NPO
Sigmoidoscopy, attempted derotation and rectal tube placement
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A 69-year-old female presents to the emergency department with crampy abdominal pain. She has a past medical history of hypertension, dyslipidemia, and cholelithiasis status post cholecystectomy. The patient states she has not passed stool or gas for 48 hrs. On physical exam vitals are T 98.4 F HR 105 bpm BP 155/101 mmHg RR 16 SpO2 96%, abdominal exam is notable for distension, tympany to percussion, and tenderness to palpation without rebound or guarding. Which of the following findings are most likely on radiograph?
Free air under the diaphragm on upright abdominal radiograph
Apple core defect after lower GI series
Multiple punctate mucosal outpouchings through the serosa on lower GI series
Ladder-like series of distended bowel loops with air-fluid levels on abdominal radiograph
Loss of haustral markings and "lead pipe" appearance to the descending colon on lower GI series
A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he underwent as a child, and he takes no daily medications. His temperature is 38.5°C (101.3°F), blood pressure is 92/60 mmHg, pulse is 138/min, and respirations are 25/min. His pulse oximetry is 99% on room air.There are no cardiopulmonary abnormalities on auscultation. His abdomen is distended and tender in all quadrants, with guarding and rebound present. He also has increased bowel sounds throughout. Laboratory results are as follows:Hemoglobin: 11 g/dLLeukocyte count: 16,500/mm^3 with normal differentialPlatelets: 250,000/mm^3Serum:Creatinine: 1.0 mg/dLGlucose: 95 mg/dLLipase: 45 U/LTotal bilirubin: 0.8 mg/dLAlkaline phosphatase: 74 U/LAspartate aminotransferase (AST, GOT): 32 U/LAlanine aminotransferase (ALT, GPT): 45 U/LLactate: 7.0 mmol/LWhich of the following is the most appropriate next step in management?
Broad-spectrum antibiotics and serial abdominal radiographs
CT angiography of the abdomen and pelvis
Nasogastric tube placement
Supportive care, NPO, and intravenous fluids
Urgent surgical intervention