Abdominal pain assessment — KFP-style written assessment

KFP 1 (10 marks)

A 74-year-old man with atrial fibrillation (on apixaban) presents with two hours of severe periumbilical pain. He vomited once. Abdomen is soft with minimal tenderness; pain appears disproportionate to findings. He had a similar but milder episode yesterday that resolved.^[1]

1. What is the leading diagnosis and why? (3) ^[1]
2. What is the correct immediate action? (4) ^[1]
3. Why did the earlier self-resolving episode matter? (3) ^[1]

Model answers

1. Acute mesenteric ischaemia — embolic, from his atrial fibrillation. The signature is pain out of proportion to physical findings: severe pain with a soft abdomen. The systematic review of biomarkers confirms AMI is difficult to recognise, often diagnosed late, and has no established biomarker to assist — the diagnosis remains clinical with CT angiography. ^[1]
2. Emergency referral for CT angiography now. Nil by mouth, IV access, analgesia (safe), and alert the surgical team. Do not wait for blood tests to 'settle the picture' — lactate and WCC are neither sensitive nor specific early, and no established biomarker exists. Delay costs bowel viability; the mortality of late-diagnosed AMI is high. ^[1]
3. The prior self-resolving episode suggests embolic showering or non-occlusive mesenteric ischaemia — the current event may be a progression rather than a first insult. It also demonstrates the intermittent nature that fools both patient and clinician into reassurance. Document the timeline; it matters for surgical decision-making. ^[1]