Question

70-year-old man with atrial fibrillation and severe abdominal pain with disproportionate abdominal signs (pain out of proportion), hemodynamically stable, acute mesenteric ischemia due to embolic arterial occlusion. Next step?

• A. Doppler
• B. Urgent CT angiography of abdomen and pelvis
• C. Plain abdominal radiograph
• D. Exploratory laparotomy

Hint:

Stable patient with AF and pain out of proportion: image the mesenteric vessels at once.

Answer 1

The Correct Option is B

Step 1: Recognise the condition:
A 70-year-old man with atrial fibrillation has severe abdominal pain out of proportion to the findings on examination. He is hemodynamically stable.
This is acute mesenteric ischemia from an embolus. Atrial fibrillation throws clots, and they usually lodge in the superior mesenteric artery (SMA), just beyond the origin of the middle colic artery.

Step 2: Recall how to confirm and plan treatment:
Early diagnosis matters, because bowel can die within hours.
In a stable patient without peritonitis, the best next step is urgent CT angiography of the abdomen. It shows the exact site of occlusion, the extent of collateral flow, and signs of bowel injury.
Immediate laparotomy is kept for patients with peritonitis, shock or other signs of dead bowel.
After the diagnosis, give heparin, then restore flow by embolectomy or endovascular therapy, and resect any non-viable bowel.

Step 3: Check option (1): Doppler:
Duplex Doppler can show proximal SMA blockage but depends on the operator. Bowel gas often blocks the view and the study is not reliable for the whole picture. It is not the best next step, so option (1) is wrong.

Step 4: Check option (2): urgent CT angiography:
CT angiography is fast, widely available and highly accurate. It is the investigation of choice. So option (2) is right.

Step 5: Check option (3): plain abdominal radiograph:
A plain film is often normal early on. Later signs such as bowel wall gas or free air appear late. It cannot confirm or exclude mesenteric ischemia. Option (3) is wrong.

Step 6: Check option (4): exploratory laparotomy:
Laparotomy is needed if there is peritonitis or instability. This man is stable, so imaging comes first. Option (4) is wrong in this setting.

Final Answer:
In a stable patient with suspected embolic mesenteric ischemia, the next step is urgent CT angiography. This is option (2). \[ \boxed{\text{Option (2)}} \]