Step 1: What the picture shows:
Rigidity, guarding and free air under the diaphragm show a perforated hollow organ with generalized peritonitis.
The pulse is 132 and the BP is 78/46, with falling urine output. This is septic shock, and the 48 hour delay means a lot of bacterial load in the abdomen.
Step 2: Decide the order of treatment:
Two problems need fixing: the shock and the leak. The leak is the cause, and the shock is the immediate threat to life.
A shocked patient cannot tolerate general anaesthesia and a big abdominal operation. So blood pressure and perfusion are improved first.
The surgeon does not delay for long, because the leak keeps feeding sepsis. Resuscitation and theatre preparation go together.
Step 3: Why surgery cannot be skipped:
Peritoneal contamination goes on until the hole is closed or the segment is removed. Antibiotics cannot sterilize a cavity that keeps getting fresh bowel content.
Laparotomy allows closure or resection of the perforation, peritoneal lavage and, when needed, a stoma or drain. This is source control.
Step 4: Eliminate the options:
Option (A) skips resuscitation and risks cardiovascular collapse during induction.
Option (C) drains the abdomen but leaves the perforation untreated, so the leak continues.
Option (D) treats generalized peritonitis with shock by antibiotics alone, which fails. Conservative care is only for a stable patient with a sealed, localized leak.
Option (B) is left, and it fits every point above.
Step 5: What resuscitation includes in practice:
Two large-bore IV cannulas, a crystalloid bolus and a urinary catheter to track hourly urine output.
Vasopressors if the BP stays low after fluids, oxygen, and correction of electrolytes and acid-base balance.
IV antibiotics that cover Gram-negative bacilli, enterococci and anaerobes are started in the same period, before the first incision.
Once the patient responds, even partly, the laparotomy goes ahead without further delay. Waiting for full normalisation is a mistake, because the shock cannot fully reverse while the perforation is still leaking.
Final Answer:
Resuscitate, start broad-spectrum IV antibiotics, and take the patient for urgent laparotomy for source control. The answer is option (B).