Question:
A patient comes to the emergency department with severe abdominal pain, pulse 112 per minute and systolic BP 80 mm Hg, with the chest X-ray shown below. What is the next appropriate step for this patient?
A patient comes to the emergency department with severe abdominal pain, pulse 112 per minute and systolic BP 80 mm Hg, with the chest X-ray shown below. What is the next appropriate step for this patient?
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Air under the diaphragm plus shock = perforation; resuscitate and operate.
Updated On: Jun 23, 2026
- Exploratory laparotomy
- Saline wash of stomach
- Intercostal tube drainage
- None
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The Correct Option is A
Solution and Explanation
Step 1: The chest X-ray shows free air under the left diaphragm (pneumoperitoneum), which indicates perforation of a hollow viscus.
Step 2: Combined with severe abdominal pain and shock (pulse 112 per minute, systolic BP 80 mm Hg), this is a hollow viscus perforation causing peritonitis and haemodynamic instability - one of the commonest surgical emergencies.
Step 3: The correct next step is emergency exploratory laparotomy to find and repair the perforation after resuscitation. Why the distractors are wrong: a saline gastric wash is useless and dangerous in a perforation; intercostal tube drainage treats pleural collections (pneumothorax or effusion), not subdiaphragmatic free gas; and choosing none ignores a life-threatening surgical emergency.
Step 2: Combined with severe abdominal pain and shock (pulse 112 per minute, systolic BP 80 mm Hg), this is a hollow viscus perforation causing peritonitis and haemodynamic instability - one of the commonest surgical emergencies.
Step 3: The correct next step is emergency exploratory laparotomy to find and repair the perforation after resuscitation. Why the distractors are wrong: a saline gastric wash is useless and dangerous in a perforation; intercostal tube drainage treats pleural collections (pneumothorax or effusion), not subdiaphragmatic free gas; and choosing none ignores a life-threatening surgical emergency.
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