A 75-year-old woman with a history of atrial fibrillation presents with sudden, agonizing diffuse abdominal pain. Physical examination shows a soft, non-distended abdomen with minimal tenderness, completely out of proportion to her severe pain. Lactate is 4.8 mmol/L. What is the diagnosis?

Answer and explanation

Correct answer: B. Acute mesenteric ischemia (superior mesenteric artery embolism)

  1. Step 1: Severe abdominal pain out of proportion to physical examination findings in a patient with a cardiac source for emboli (atrial fibrillation) is the hallmark of acute mesenteric ischemia.
  2. Step 2: Embolic occlusion typically lodges in the superior mesenteric artery (SMA).
  3. Step 3: Elevated serum lactate reflects advancing bowel ischemia, demanding emergent CT angiography and surgical revascularization.
Answer
Acute mesenteric ischemia (superior mesenteric artery embolism).
Why not the others: 'Acute cholecystitis with gallbladder perforation' presents with focal right upper quadrant peritonitis; 'Ruptured ovarian cyst with hemoperitoneum' occurs in premenopausal women and produces pelvic peritoneal signs; 'Chronic functional constipation' presents with chronic bloating without lactic acidosis.

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