A 70-year-old woman with atrial fibrillation presents with sudden onset of severe generalized abdominal pain out of proportion to physical exam findings. Abdomen is soft without peritoneal signs. Serum lactate is 4.8 mmol/L. What diagnostic examination should be performed immediately?

Answer and explanation

Correct answer: C. CT mesenteric angiography of the abdomen and pelvis

  1. Step 1: Sudden excruciating abdominal pain with minimal physical tenderness in a patient with atrial fibrillation and elevated lactate is classic for acute mesenteric ischemia (superior mesenteric artery embolus).
  2. Step 2: Delay in diagnosis leads to transmural bowel infarction, peritonitis, and high mortality.
  3. Step 3: Contrast-enhanced CT mesenteric angiography is the diagnostic gold standard, offering >95% sensitivity for vascular occlusion.
Answer
CT mesenteric angiography of the abdomen and pelvis.
Why not the others: Plain abdominal X-rays only show late signs (pneumatosis); ultrasound is obscured by bowel gas; barium enema is contraindicated.

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