A 40-year-old male presents with sudden-onset excruciating epigastric abdominal pain described as a 'bursting sensation'. Abdominal exam reveals board-like rigidity, involuntary guarding, and diffuse rebound tenderness. Upright chest radiograph demonstrates crescent-shaped free air beneath the right hemidiaphragm (pneumoperitoneum). What is the underlying condition and immediate management?

Answer and explanation

Correct answer: D. Perforated peptic ulcer; Urgent exploratory laparotomy / laparoscopy with Graham patch repair

  1. Step 1: The sudden onset of severe abdominal pain with board-like peritonitis and subdiaphragmatic free gas confirms a perforated hollow viscus, most commonly a duodenal or gastric peptic ulcer.
  2. Step 2: Immediate resuscitation with IV fluids, broad-spectrum antibiotics, nasogastric decompression, and urgent surgical exploration (closure with an omental Graham patch) is required.
  3. Step 3: Identify perforated peptic ulcer and urgent surgical repair.
Answer
Perforated peptic ulcer; Urgent exploratory laparotomy / laparoscopy with Graham patch repair.
Why not the others: 'Acute diverticulitis' typically presents in the left lower quadrant and free gas indicates complicated perforation requiring surgical intervention, not oral antibiotics; 'Acute pancreatitis' does not produce pneumoperitoneum; 'Ruptured aortic aneurysm' presents with hemorrhagic shock and retroperitoneal hematoma on CT.

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