308 Emergency Medicine
(d)Pseudomembranous enterocolitis is an inflammatory bowel disorder
that results from toxin-producing Clostridium difficile, a spore-forming
obligate anaerobic bacillus. The disease typically begins 7 to 10 days after
the institution of antibiotic therapy, most often in hospitalized patients.
However, incidence in the community is rising. (e)Diverticulitis is an
acute inflammatory disease caused by bacterial proliferation within existing
colonic diverticula. The most common presentation is pain, often in the left
lower quadrant (LLQ). Abdominal CT demonstrates inflammation of pericolic
fat, presence of diverticula, bowel wall thickening, or peridiverticular abscess.
278.The answer is b.(Rosen, pp 1241-1244.)This patient had an untreated
gastric ulcerthat just perforated.The history of epigastric pain related to
eating points to a gastric ulcer, whereas pain 2 to 3 hours after eating is more
likely caused by a duodenal ulcer. The sudden onset of generalizedabdominal
pain associated with a rigid abdomen is concerning for a perforated viscus,
in this case, a perforated gastric ulcer. This is a surgical emergency. An
abdominal and upright chest radiograph can be performed quickly to look
forfree air,which will be seen under the diaphragmon the chest radiograph.
This is useful for the majority of perforations, which are anterior, but may
miss posterior perforations because the posterior duodenum is retroperitoneal.
The treatment includes IV hydration, antibiotics, and immediate surgical
correction.
(a)Boerhaave syndrome is a full-thickness tear of the left posterolateral
aspect of the distal esophagus. It is typically associated with epigastric and
retrosternal chest pain that often radiates to the back, neck, left chest, or
shoulders. Although it may present similar to a perforated ulcer, in general
the pain is more focused in the chest. (c)While the history of untreated
hypertension is concerning for a ruptured AAA the history clearly points to
previously undiagnosed peptic ulcer disease. (d)IBD is a chronic condition
affecting the GI tract. The abdominal pain is usually crampy, while GI bleeding
is generally associated with bloody diarrhea. (e)Diverticula are saclike
herniations of colonic mucosa that occur at weak points in the bowel wall.
They may bleed (diverticulosis) or become filled with fecal matter and lead
to inflammation (diverticulitis). Diverticulosis is most commonly associ-
ated with substantial painless rectal bleeding, but not with significant
abdominal pain.
279.The answer is e.(Rosen, pp 179, 1243.)AMallory-Weiss tearusually
follows a forceful bout of retching and vomiting and involves a 1- to 4-cm