take several hours to manifest. Perforation is usually secondary to intrinsic
disease of the colon (eg, diverticulitis) or to vigorous manipulation during
colonoscopy. Most patients require immediate laparotomy. However, expec-
tant management is appropriate in some patients with a late presentation
(1-2 days later), or without signs of peritonitis. The radiograph in the fig-
ure demonstrates air under the diaphragm,which is pathognomonic for
pneumoperitoneum.
Ascending cholangitis (a)and pancreatitis (d)may occur as a complica-
tion from endoscopic retrograde cholangiopancreatography (ERCP). (b)There
is no evidence of pulmonary edema in this radiograph. (c)Liver failure with
ascites does not cause pneumoperitoneum.
90.The answer is c.(Rosen, pp 1268-1269.)The patient’s clinical picture
is consistent with cholangitis,which is caused by an obstruction of the bil-
iary tract leading to bacterial infection. Obstruction is commonly secondary
to a stone, but may be because of malignancy or stricture. Cholangitis is a sur-
gical emergency. The classic triadof physical findings described by Charcot
isRUQ pain, fever, and jaundice.Sepsis is a common complication. Sonog-
raphy may demonstrate intrahepatic or ductal dilation. The presence of
stones in the gallbladder suggests obstruction as the etiology.
There is overlap in the clinical presentation with cholecystitis (a),how-
ever, the presence of jaundice and evidence of dilated common and intra-
hepatic ducts—which are not characteristic of cholecystitis—is helpful to
distinguish it from cholangitis. Acute hepatitis (b)will not have the same
sonographic findings seen in cholangitis. Pancreatic cancer (d)can present
with jaundice, but it is usually painless. Bowel obstruction (e)generally pre-
sents with intermittent crampy abdominal pain, vomiting, and distention.
91.The answer is b. (Rosen, pp 2416-2419.) β-Human chronic
gonadotropin (β-hCG)should be obtained in all women of child-bearing age
who present with abdominal pain or vaginal bleeding. Diagnostically, it is one
of the most important tests in female patients. A positive pregnancy test in the
setting of abdominal pain and vaginal bleeding demands that the physician
rule out an ectopic pregnancy. Even though the patient states she always uses
condoms during intercourse, there is still a small risk of pregnancy.
(a)Women with lower abdominal pain and vaginal discharge may have
cervicitis or pelvic inflammatory disease and require a Chlamydiaantigen test.
However, a pelvic examination should be performed first. (c)With a positive
pregnancy test, transvaginal ultrasound is the next step in management. This
112 Emergency Medicine