Appendicitis — MCQs
A patient with right lower quadrant pain shows target sign on ultrasound. Diagnosis?
Alvarado score is used for
A 25-year-old patient presents with RLQ pain, fever, and vomiting. CT shows a ruptured appendix. What is the next step?
In a female with appendicitis in pregnancy the treatment of choice is:
Which of the following nerves is commonly damaged during McBurney's incision?
A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
Match the following drugs in Column A with their contraindications in Column B. | Column A | Column B | | :-- | :-- | | 1. Morphine | 1. QT prolongation | | 2. Amiodarone | 2. Thromboembolism | | 3. Vigabatrin | 3. Pregnancy | | 4. Estrogen preparations | 4. Head injury |
A 40-year-old male with right iliac fossa pain, fever. CT shows 4cm appendix with faecolith. Best management?
A patient presents with acute appendicitis. What is NOT to be done?
Which of the following is NOT a classical symptom of acute appendicitis ?
Appendicitis Indian Medical PG Practice Questions and MCQs
Question 1: A patient with right lower quadrant pain shows target sign on ultrasound. Diagnosis?
- A. Intussusception (Correct Answer)
- B. Diverticulitis
- C. Mesenteric cyst
- D. Appendicitis
Explanation: ***Intussusception*** - The **target sign** on ultrasound is a classic radiological finding in **intussusception**, indicating a segment of bowel telescoping into an adjacent segment. - This condition is a common cause of **acute abdominal pain** and bowel obstruction, particularly in young children, though it can occur in adults. *Diverticulitis* - Diverticulitis presents with **inflammation of diverticula**, often in the left lower quadrant, but can occur in the right. - Ultrasound findings typically include **thickened bowel wall**, pericolic fat stranding, and sometimes abscesses, not a target sign. *Mesenteric cyst* - A mesenteric cyst is a **fluid-filled mass** located within the mesentery and would appear as a well-defined, anechoic (fluid-filled) structure on ultrasound. - It would not exhibit the characteristic concentric layers of the target sign. *Appendicitis* - Acute appendicitis is characterized by a **dilated, non-compressible appendix** with a thickened wall and surrounding inflammation on ultrasound. - While it causes right lower quadrant pain, the specific **target sign** is not typical for appendicitis.
Question 2: Alvarado score is used for
- A. Acute epididymitis
- B. Acute appendicitis (Correct Answer)
- C. Acute pancreatitis
- D. Acute cholecystitis
Explanation: ***Acute appendicitis*** - The **Alvarado score**, also known as the MANTRELS score, is a clinical prediction rule used to assist in the diagnosis of **acute appendicitis**. - It assigns points based on symptoms (migratory pain, anorexia, nausea/vomiting), signs (tenderness in the right iliac fossa, rebound tenderness), and laboratory findings (elevated temperature, leukocytosis, left shift of neutrophils). *Acute epididymitis* - Diagnosis typically relies on clinical findings like **unilateral testicular pain and swelling**, often associated with dysuria or urethral discharge. - While it has scoring systems (like the Epididymitis Severity Score), the **Alvarado score** is not used for its diagnosis. *Acute pancreatitis* - Diagnosed based on characteristic **epigastric pain**, elevated serum amylase or lipase levels, and imaging findings. - Severity is often assessed using scoring systems like **Ranson's criteria** or APACHE II, not the Alvarado score. *Acute cholecystitis* - Diagnosed by symptoms such as **right upper quadrant pain**, fever, and leukocytosis, often with **positive Murphy's sign** and imaging evidence (e.g., gallbladder wall thickening on ultrasound). - The **Alvarado score** is not relevant to the diagnosis or severity assessment of acute cholecystitis.
Question 3: A 25-year-old patient presents with RLQ pain, fever, and vomiting. CT shows a ruptured appendix. What is the next step?
- A. Percutaneous drainage
- B. Open appendectomy (Correct Answer)
- C. Conservative treatment
- D. Laparoscopic appendectomy
Explanation: ***Open appendectomy*** - For a **ruptured appendix** with generalized peritonitis, **open appendectomy** is the traditional gold standard and most appropriate approach. - Open surgery allows for **thorough peritoneal lavage**, better visualization of the entire abdominal cavity, and effective drainage of contaminated fluid. - In the setting of **perforation with peritoneal contamination**, open approach ensures complete source control and reduces risk of missed abscesses or inadequate irrigation. *Laparoscopic appendectomy* - While laparoscopic appendectomy can be used in **selected cases** of perforated appendicitis, it is not the first-line approach for a ruptured appendix with generalized peritonitis. - Laparoscopic approach may be limited in cases with **extensive contamination** and may not allow adequate peritoneal toilet. - It is more appropriate for **uncomplicated appendicitis** or **early/localized perforation** in experienced hands. *Percutaneous drainage* - This is typically reserved for patients with a **well-defined appendiceal abscess** presenting late (>5 days after symptom onset) where a phlegmon or organized abscess has formed. - Used as part of **interval appendectomy** approach: drain abscess, treat with antibiotics, then perform appendectomy 6-8 weeks later. - Not appropriate for **acute rupture** with active peritonitis requiring immediate surgical source control. *Conservative treatment* - **Antibiotics alone** might be considered for **uncomplicated appendicitis** in select cases or when surgery is contraindicated. - A **ruptured appendix** is a surgical emergency requiring operative intervention to prevent sepsis, abscess formation, and other life-threatening complications. - Conservative management is contraindicated in the presence of perforation and peritonitis.
Question 4: In a female with appendicitis in pregnancy the treatment of choice is:
- A. Continue pregnancy with medical Rx
- B. Surgery after delivery
- C. Surgery at earliest (Correct Answer)
- D. Abortion with appendectomy
Explanation: ***Surgery at earliest*** - **Prompt surgical intervention** is crucial for appendicitis in pregnancy to prevent complications such as perforation, peritonitis, and maternal or fetal morbidity and mortality. - Delaying surgery increases the risk of rupture, which can be devastating for both the mother and the fetus. *Continue pregnancy with medical Rx* - **Medical management (antibiotics alone)** is generally ineffective for acute appendicitis in pregnant women and carries a high risk of progression to perforation. - This approach would expose the mother and fetus to serious complications, including sepsis and preterm labor, without addressing the underlying surgical pathology. *Surgery after delivery* - Delaying surgery until after delivery is unsafe and potentially fatal, as **appendiceal rupture could occur at any time** during pregnancy. - The risk of **perforation, peritonitis, and subsequent complications** is too high to justify waiting. *Abortion with appendectomy* - **Therapeutic abortion** is not indicated for uncomplicated appendicitis in pregnancy and does not improve the maternal prognosis for the appendicitis itself. - The focus is on treating the underlying medical condition (appendicitis) while preserving the pregnancy, if possible.
Question 5: Which of the following nerves is commonly damaged during McBurney's incision?
- A. Subcostal nerve
- B. Iliohypogastric nerve (Correct Answer)
- C. 11th thoracic nerve
- D. 10th thoracic nerve
Explanation: ***Iliohypogastric nerve*** - The **iliohypogastric nerve** is most commonly injured during **McBurney's incision** due to its superficial position and transverse course at the level of the incision. - Damage can lead to **numbness** or altered sensation in the suprapubic region, and sometimes **weakness of the lower abdominal wall**. *Subcostal nerve* - The **subcostal nerve** (T12) runs inferior to the 12th rib and is generally superior to the typical site of a McBurney's incision. - Injury to this nerve is less common during this procedure compared to the iliohypogastric and ilioinguinal nerves. *10th thoracic nerve* - The **10th thoracic nerve** (T10) provides sensation around the umbilicus. - While it contributes to innervation of the abdominal wall, its location is typically well above the area of a standard McBurney's incision, making injury unlikely. *11th thoracic nerve* - The **11th thoracic nerve** (T11) innervates the abdominal wall and is located superior to the typical incision site for appendectomy. - Injury to T11 during a McBurney's incision is uncommon as the nerve's course lies cephalad to the surgical field.
Question 6: A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
- A. Proceed to laparotomy and appendicectomy (Correct Answer)
- B. Intravenous antibiotics
- C. Continue Ochsner Sherren regimen with close monitoring
- D. Continue conservative management
Explanation: ***Proceed to laparotomy and appendicectomy*** - A **rising pulse rate, tachycardia, and fever** indicate **worsening sepsis** or **perforation** of the appendicular mass, necessitating urgent surgical intervention. - Continuing conservative management in the face of these signs carries a high risk of **morbidity and mortality** from peritonitis or widespread sepsis. *Continue Ochsner Sherren regimen with close monitoring* - The Ochsner Sherren regimen is a **conservative approach** for a stable appendicular mass, which is no longer the case with signs of deterioration. - **Clinical worsening** (tachycardia, rising fever, increased pulse) signifies failure of conservative management and requires a shift to surgical intervention. *Continue conservative management* - Continuing conservative management despite **signs of deterioration** (rising pulse, tachycardia, fever) would lead to further progression of the disease and potential life-threatening complications. - These symptoms suggest that the infection is **not contained** and is likely spreading, indicating the need for immediate surgical treatment. *Intravenous antibiotics* - While intravenous antibiotics are part of the initial conservative management, they are **insufficient** alone for an appendicular mass showing signs of deterioration. - The worsening clinical picture suggests a **failed antibiotic response** or a more severe underlying issue (e.g., abscess rupture) that requires surgical drainage or removal.
Question 7: Match the following drugs in Column A with their contraindications in Column B. | Column A | Column B | | :-- | :-- | | 1. Morphine | 1. QT prolongation | | 2. Amiodarone | 2. Thromboembolism | | 3. Vigabatrin | 3. Pregnancy | | 4. Estrogen preparations | 4. Head injury |
- A. A-1, B-3, C-2, D-4
- B. A-4, B-1, C-3, D-2 (Correct Answer)
- C. A-3, B-2, C-4, D-1
- D. A-2, B-4, C-1, D-3
Explanation: ***A-4, B-1, C-3, D-2*** - **Morphine** is contraindicated in **head injury** as it can increase intracranial pressure and mask neurological symptoms. - **Amiodarone** is contraindicated in patients with **QT prolongation** due to its risk of inducing more severe arrhythmias like Torsades de Pointes. - **Vigabatrin** is contraindicated during **pregnancy** due to its potential for teratogenicity and adverse effects on fetal development. - **Estrogen preparations** are contraindicated in patients with a history of **thromboembolism** due to their increased risk of blood clot formation. *A-1, B-3, C-2, D-4* - This option incorrectly matches **Morphine** with QT prolongation and **Estrogen preparations** with head injury, which are not their primary contraindications. - It also incorrectly links **Vigabatrin** with thromboembolism and **Amiodarone** with pregnancy. *A-3, B-2, C-4, D-1* - This choice incorrectly associates **Morphine** with pregnancy and **Vigabatrin** with head injury, which are not the most critical or direct contraindications. - It also misaligns **Amiodarone** with thromboembolism and **Estrogen preparations** with QT prolongation. *A-2, B-4, C-1, D-3* - This option incorrectly matches **Morphine** with thromboembolism and **Amiodarone** with head injury, which are not their most significant contraindications. - It also incorrectly links **Vigabatrin** with QT prolongation and **Estrogen preparations** with pregnancy.
Question 8: A 40-year-old male with right iliac fossa pain, fever. CT shows 4cm appendix with faecolith. Best management?
- A. Conservative treatment
- B. Interval appendectomy
- C. Percutaneous drainage
- D. Immediate appendectomy (Correct Answer)
Explanation: ***Immediate appendectomy*** - The presence of **right iliac fossa pain, fever**, and a **4cm appendix with a faecolith** on CT scan strongly indicates acute appendicitis, which requires urgent surgical intervention. - A faecolith suggests **luminal obstruction**, increasing the risk of perforation and complications if not treated promptly. *Conservative treatment* - While some cases of uncomplicated appendicitis can be managed conservatively with antibiotics, this patient's presentation with a **faecolith and inflamed appendix (4cm)** suggests a higher risk of progression and complications. - Delaying surgery could lead to **abscess formation** or **perforation**, increasing morbidity. *Interval appendectomy* - This approach is typically considered for patients who initially present with a **well-contained appendiceal mass or abscess** that is managed non-operatively in the acute phase. - The current presentation is one of **acute appendicitis** requiring immediate attention, not deferred surgery after initial conservative management. *Percutaneous drainage* - **Percutaneous drainage** is primarily indicated for patients with a **well-defined appendiceal abscess** large enough to be drained. - This patient's CT shows an inflamed appendix with a faecolith, but not explicitly a drained abscess, making immediate appendectomy the most appropriate first-line treatment for the acute inflammation.
Question 9: A patient presents with acute appendicitis. What is NOT to be done?
- A. Give antibiotics
- B. Do primary survey
- C. Perform appendectomy
- D. Check for visual acuity (Correct Answer)
Explanation: ***Check for visual acuity*** - **Visual acuity** assessment is not relevant to the diagnosis or management of **acute appendicitis**. - This examination is typically performed in cases of suspected eye injury, vision changes, or neurological issues that affect vision. - In the context of acute appendicitis, checking visual acuity would be inappropriate and waste valuable time. *Give antibiotics* - **Antibiotics** are crucial in managing **acute appendicitis** to prevent progression to perforation and reduce postoperative infection risk. - They are typically administered preoperatively and continued postoperatively, especially in cases of complicated appendicitis. - Broad-spectrum antibiotics covering **gram-negative organisms and anaerobes** are standard practice. *Do primary survey* - A **primary survey** (ABCDE approach) is essential in any emergent patient presentation to assess and manage immediate **life-threatening conditions**. - While appendicitis itself may not be immediately life-threatening, ensuring patient stability and ruling out other serious conditions is critical. - This is standard emergency medicine practice and should always be performed. *Perform appendectomy* - **Appendectomy** (surgical removal of the appendix) is the definitive treatment for **acute appendicitis**. - This is the standard of care and should be performed once the diagnosis is confirmed and the patient is stable. - Either open or laparoscopic approach can be used depending on clinical factors and surgeon expertise.
Question 10: Which of the following is NOT a classical symptom of acute appendicitis ?
- A. Periumbilical colic
- B. Anorexia
- C. Constipation (Correct Answer)
- D. Nausea
Explanation: ***Constipation*** - While patients with appendicitis may experience altered bowel habits, **constipation is not a classic or defining symptom**; **diarrhea** can even be present. - The primary symptoms relate to inflammation and irritation of the appendix, not typically leading to significant constipation. *Periumbilical colic* - This is a very common early symptom, often described as a **vague, dull pain around the umbilicus** as the appendix initially becomes inflamed. - The pain later **migrates to the right lower quadrant** as the inflammation localizes to the parietal peritoneum. *Anorexia* - **Loss of appetite** is a highly characteristic and almost universal symptom in patients with acute appendicitis. - It often precedes the onset of abdominal pain and is considered a significant diagnostic indicator. *Nausea* - **Nausea and vomiting** are very common symptoms, often following the onset of abdominal pain. - These gastrointestinal symptoms are due to the visceral irritation caused by the inflamed appendix.
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