Question 158 · LEK · Gastrointestinal perforation

A 48-year-old gentleman with sudden severe epigastric pain was referred to the ER. Severe tenderness with a guarding and rebound sign over the upper, middle and lower abdominal regions was found on physical exam. Pulse rate was 120/min and blood pressure 100/60 mmHg. Blood testing revealed WBC 18.3 K/µL; serum amylase 85 U/L; serum lipase 42 U/L; CRP 183 mg/dL; total bilirubin 0.56 mg/dL. On abdominal imaging the empty gall bladder, CBD of 5mm in diameter and normal sized heterogenous pancreas with free fluid in the upper part of the peritoneal cavity. The results of the plain chest x-ray are shown in the picture. Which management would you recommend to this patient?

1. AA. a discharge with prescribed pain killers, proton pump inhibitors and antibiotics and a follow-up visit the next day.
2. BB. in-hospital intensive conservative treatment with pain killers, proton pump inhibitors and antibiotics.
3. CC. in-hospital intensive conservative treatment with pain killers, proton pump inhibitors and antibiotics and performing upper endoscopy if clinical worsening occurs.
4. DD. in-hospital intensive conservative treatment with pain killers, proton pump inhibitors 54 z 117 29.06.2026, 14:15 Centrum Egzaminów Medycznych https://test.cem.edu.pl/pytcem/wyswietl_baza_pdf.php and antibiotics and performing laparotomy if clinical worsening occurs.
5. EE. in-hospital treatment with urgent surgery with concomitant pain killers, proton pump inhibitors and antibiotics.