A patient is found to have an asymptomatic common bile duct (CBD) stone two years after cholecystectomy on routine imaging. What is the most appropriate initial management?
In which condition is gas under the diaphragm most commonly seen on imaging?
A patient with a left hypochondrium contusion presents with systolic blood pressure of 70 mm Hg and pulse rate of 110 bpm. What is the best step in management?
Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?
A patient involved in a Road Traffic Accident (RTA) presents with: - Absent air entry on the left side of the chest. - Tenderness in the left lower chest wall. What is the next step in the Emergency Medicine Room (EMR) management?
NEET-PG 2021 - Surgery NEET-PG Practice Questions and MCQs
Question 11: A patient is found to have an asymptomatic common bile duct (CBD) stone two years after cholecystectomy on routine imaging. What is the most appropriate initial management?
- A. ERCP with sphincterotomy and stone extraction (Correct Answer)
- B. Keep on active surveillance
- C. Medical dissolution therapy with ursodeoxycholic acid
- D. Surgical exploration and choledochotomy
Explanation: ***ERCP with sphincterotomy and stone extraction*** - This is the **gold standard management** for CBD stones discovered after cholecystectomy, even when asymptomatic - **Post-cholecystectomy CBD stones will not pass spontaneously** as there is no gallbladder to contract and propel stones forward - The **risk of complications** (acute cholangitis, acute pancreatitis, biliary obstruction) from leaving the stone in place outweighs the risk of ERCP - ERCP has a **high success rate (>90%)** with acceptable complication rates (pancreatitis 3-5%, bleeding <1%, perforation <1%) - **Prophylactic stone removal** prevents future emergency presentations and allows for planned intervention under optimal conditions *Keep on active surveillance* - **Not appropriate** for CBD stones in post-cholecystectomy patients, as these stones will not pass spontaneously - Unlike gallbladder stones, CBD stones carry a **significant risk of serious complications** including ascending cholangitis and acute biliary pancreatitis - Active surveillance might be considered only in patients with **prohibitive surgical risk** or very limited life expectancy - Modern guidelines recommend **intervention for all CBD stones** found post-cholecystectomy regardless of symptoms *Surgical exploration and choledochotomy* - This is a more **invasive approach** with higher morbidity compared to ERCP - Reserved for cases where **ERCP fails or is not feasible** (altered anatomy, large impacted stones, intrahepatic stones) - Not appropriate as **initial management** when less invasive endoscopic options are available - May be considered if ERCP is unsuccessful after 1-2 attempts *Medical dissolution therapy with ursodeoxycholic acid* - **Ineffective for CBD stones** - UDCA works only for small cholesterol stones in a functioning gallbladder - Requires months to years of therapy with **poor success rates** even for gallbladder stones - **Not recommended** for choledocholithiasis in any clinical scenario - This patient has already undergone cholecystectomy, making dissolution therapy completely irrelevant
Question 12: In which condition is gas under the diaphragm most commonly seen on imaging?
- A. Tertiary
- B. Retained stone
- C. Secondary (Correct Answer)
- D. Primary
Explanation: ***Correct: Secondary*** - **Gas under the diaphragm** is a classic sign of a **perforated viscus**, which is a severe form of **secondary peritonitis**. - Secondary peritonitis typically arises from the **rupture or perforation of an abdominal organ**, allowing gas and contents to leak into the peritoneal cavity. *Incorrect: Tertiary* - **Tertiary peritonitis** refers to persistent or recurrent peritonitis after seemingly adequate surgical and antibiotic treatment for primary or secondary peritonitis. - It is associated with **immunocompromised states** or **low-virulence organisms** and does not typically present with free gas under the diaphragm. *Incorrect: Retained stone* - A **retained stone** (e.g., gallstone, renal stone) can cause obstruction or inflammation but does not directly lead to **gas under the diaphragm**. - While it might indirectly lead to perforation if neglected, it's not the most common direct cause of **free peritoneal gas**. *Incorrect: Primary* - **Primary peritonitis** (also known as spontaneous bacterial peritonitis) occurs without an apparent source of contamination within the abdominal cavity, often in patients with ascites and **liver cirrhosis**. - It is characterized by bacterial infection of the ascitic fluid but does not involve a perforated viscus or **free gas under the diaphragm**.
Question 13: A patient with a left hypochondrium contusion presents with systolic blood pressure of 70 mm Hg and pulse rate of 110 bpm. What is the best step in management?
- A. Conservative management with observation
- B. Chest tube insertion
- C. Antibiotic therapy
- D. Emergency surgical exploration (Correct Answer)
Explanation: ***Emergency surgical exploration*** - The patient's **hypotension** (BP 70 mmHg) and **tachycardia** (HR 110 bpm) indicate **hemodynamic instability**, suggesting active bleeding, likely from a splenic or liver injury in the context of a left hypochondrium contusion. - While initial resuscitation with IV fluids is started simultaneously, this degree of shock (class III-IV hemorrhage) with a high-risk mechanism typically requires **emergency surgical exploration** to identify and control the source of bleeding. - According to **ATLS protocols**, patients who are non-responders or transient responders to initial resuscitation with ongoing hemodynamic instability are candidates for immediate operative intervention. *Conservative management with observation* - This approach is appropriate only for **hemodynamically stable** patients with solid organ injuries, often with minor extravasation or hematomas that are not actively bleeding. - The patient's severe hypotension and tachycardia preclude conservative management, as it would risk further decompensation and mortality due to ongoing blood loss. *Chest tube insertion* - This procedure is indicated for managing conditions like **pneumothorax** or **hemothorax**, which might present with respiratory distress, decreased breath sounds, and potentially hemodynamic compromise if severe. - While a chest injury could coexist, the primary concern here is profound shock following an abdominal contusion, suggesting intra-abdominal hemorrhage rather than a thoracic injury as the initial priority. *Antibiotic therapy* - **Antibiotic therapy** is important for preventing or treating infections, particularly in cases of bowel perforation or open wounds, but it does not address acute hemodynamic instability from hemorrhage. - Administering antibiotics before surgically addressing the source of bleeding in a hypotensive patient would be a misprioritization and would not stabilize their condition.
Question 14: Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?
- A. CECT Abdomen
- B. FAST
- C. Abdomen X-ray
- D. Retrograde urethrogram (Correct Answer)
Explanation: ***Retrograde urethrogram*** - **Blood at the urethral meatus** after a straddle injury is highly suggestive of **urethral injury**, and a retrograde urethrogram is the diagnostic test of choice to assess the integrity of the urethra. - This procedure involves injecting contrast into the urethra to visualize any extravasation, strictures, or complete disruptions before attempting catheterization. *CECT Abdomen* - A CECT abdomen is primarily used to assess **solid organ injuries** or **intra-abdominal bleeding**, which is not the primary concern suggested by blood at the urethral meatus. - While broad abdominal trauma may warrant a CECT, it does not directly evaluate urethral integrity. *FAST* - **FAST (Focused Assessment with Sonography for Trauma)** is a rapid ultrasound examination to detect **free fluid (blood)** in the peritoneal or pericardial cavities. - It is used to identify **intra-abdominal or pericardial hemorrhage** and guide resuscitation, but it does not visualize the urethra. *Abdomen X-ray* - An abdomen X-ray can detect **fractures of the pelvis** or foreign bodies, but it does not provide detailed imaging of soft tissues like the urethra. - It would not show urethral extravasation or disruption, making it insufficient for diagnosing urethral injury.
Question 15: A patient involved in a Road Traffic Accident (RTA) presents with: - Absent air entry on the left side of the chest. - Tenderness in the left lower chest wall. What is the next step in the Emergency Medicine Room (EMR) management?
- A. X-ray (Correct Answer)
- B. FAST
- C. DPL
- D. CT
Explanation: ***X-ray*** - In a **hemodynamically stable** patient with absent air entry and chest wall tenderness post-RTA, a **chest X-ray** is the most appropriate initial imaging in the EMR. - It quickly diagnoses conditions like **pneumothorax**, **hemothorax**, or **rib fractures** and guides management decisions. - **Important**: Clinical assessment for **tension pneumothorax** (hypotension, tracheal deviation, distended neck veins) must be done first. If tension pneumothorax is suspected, **immediate needle decompression** is required without waiting for imaging. - X-ray is **rapidly available** and provides crucial information for trauma management in stable patients. *FAST* - **Focused Assessment with Sonography for Trauma (FAST)** is primarily used to detect **intra-abdominal free fluid** (hemoperitoneum) or pericardial effusion in trauma. - While valuable in RTA evaluation, it is not the primary diagnostic tool for absent air entry in the chest. - FAST has limited sensitivity for **pneumothorax** and does not visualize **rib fractures** in detail. *DPL* - **Diagnostic Peritoneal Lavage (DPL)** is an invasive procedure used to detect **intra-abdominal injury** and hemorrhage. - It has largely been replaced by FAST and CT scans due to its invasive nature and lower specificity. - DPL provides **no information about chest injuries** and is irrelevant for evaluating absent air entry. *CT* - A **CT scan** (chest CT) provides highly detailed imaging and is excellent for diagnosing specific chest injuries. - However, it is **time-consuming**, requires patient transport, and is typically reserved for **stable patients** after initial X-ray assessment. - In the immediate EMR setting, X-ray is preferred for rapid decision-making, with CT used for further evaluation if needed.