Approach to pneumoperitoneum and peritonitis (perforated viscus) Quiz: Ace Your Exams
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A 47-year-old man presents to the emergency department for evaluation of abdominal pain, nausea, and vomiting for the past four days. The patient lives alone and was discovered by a family member today covered in vomitus. The patient drinks alcohol daily and does not have other known medical problems. Temperature is 39 ºC (102.2 ºF), pulse is 101/min, blood pressure is 100/77 mmHg and respirations are 18/min. The patient has evidence of scleral icterus and appears jaundiced. Physical examination demonstrates a distended abdomen, with evidence of rebound pain and guarding, as well as a positive fluid wave. Abdominal radiograph is within normal limits and initial blood work is shown below. A CT of the abdomen and pelvis demonstrates evidence of large intra abdominal ascites and cirrhotic liver morphology. Which of the following is the most likely cause of this patient's presentation?
| Laboratory value | Result |
| Complete Blood Count (CBC) | |
| Hemoglobin | 9.8 g/dL |
| White blood cell count (WBC) | 27,000/mm3 |
| Liver Function Tests | |
| Alkaline phosphatase (ALP) | 300 u/L |
| Alanine aminotransferase (ALT) | 238 u/L |
| Aspartate aminotransferase (AST) | 159 u/L |
| Total bilirubin | 6 mg/dL |
| INR | 1.8 |
| Serum chemistry | |
| Lipase | 50 U/L |
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