A 74-year-old male with atrial fibrillation presents with sudden excruciating abdominal pain. Physical examination reveals a soft, non-tender abdomen with minimal guarding. What is the diagnosis?

Answer and explanation

Correct answer: B. Acute mesenteric ischemia

  1. Step 1: Severe abdominal pain that is strikingly out of proportion to physical examination findings in an elderly patient with atrial fibrillation is classic for acute mesenteric ischemia.
  2. Step 2: Cardioembolism to the superior mesenteric artery occludes splanchnic perfusion, producing severe ischemic pain before transmural necrosis and peritoneal signs develop.
Answer
Acute mesenteric ischemia.
Why not the others: Perforated duodenal ulcer causes chemical peritonitis resulting in a rigid, board-like abdomen with marked guarding. Acute cholecystitis produces localized right upper quadrant tenderness with a positive Murphy sign. Ruptured aortic aneurysm classically presents with severe hypotension, back pain, and a pulsatile abdominal mass.

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