Acute Surgical Presentations — MCQs
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A 68-year-old man with a background of atrial fibrillation and hypertension presents with a 12-hour history of sudden onset severe periumbilical pain that has now become generalized. He describes the pain as initially colicky but now constant. On examination, he appears unwell with a temperature of 37.8°C, heart rate 110 bpm irregularly irregular, and blood pressure 95/60 mmHg. His abdomen is rigid with generalized guarding and rebound tenderness. Blood tests show: lactate 6.2 mmol/L, white cell count 18.5 × 10⁹/L. CT demonstrates pneumoperitoneum with fluid levels and thickened, oedematous small bowel loops. What is the most likely underlying diagnosis?
A 45-year-old woman presents to the emergency department with a 6-hour history of severe, constant right iliac fossa pain. She has previously undergone three caesarean sections. On examination, her temperature is 38.2°C, heart rate 105 bpm, and blood pressure 125/78 mmHg. Her abdomen is distended with marked tenderness and guarding in the right iliac fossa. Bowel sounds are absent. CT abdomen reveals a closed-loop small bowel obstruction with wall thickening and reduced enhancement of the affected segment. What is the most appropriate immediate management?
A 64-year-old man with metastatic colon cancer on palliative chemotherapy presents with a 72-hour history of abdominal distension, vomiting, and absolute constipation. CT shows multiple transition points with small bowel and large bowel dilatation, ascites, and peritoneal nodules. He has no peritonism and is haemodynamically stable. Oncology notes indicate he has an estimated prognosis of 2-3 months. After MDT discussion, conservative management is planned. Which of the following interventions would be most appropriate for symptom control?
Which of the following is the definition of 'strangulated bowel' in the context of intestinal obstruction?
In a patient with suspected intestinal perforation, which of the following clinical or radiological features most reliably indicates that urgent surgical intervention is required rather than conservative management?
A 48-year-old woman with known gallstone disease presents with a 4-day history of worsening right upper quadrant pain, nausea, and vomiting. She is febrile at 38.2°C. Ultrasound shows gallstones, gallbladder wall thickening of 5 mm, and pericholecystic fluid. There is also incidental finding of dilated small bowel loops on the scan. Plain abdominal radiograph confirms small bowel dilatation and shows a 2.5 cm calcified opacity in the right iliac fossa. What is the most likely diagnosis?
A 37-year-old man presents with a 6-hour history of severe generalized abdominal pain. He admits to ingesting multiple button batteries 8 hours previously during a bet. Initial plain radiographs show three circular opacities in the stomach and proximal small bowel. He is tachycardic at 108 bpm with diffuse abdominal tenderness. What is the most important immediate complication to consider?
A 71-year-old man with atrial fibrillation on warfarin (INR 2.3) presents with sudden onset severe abdominal pain for 3 hours. He has marked generalized tenderness with guarding and rebound. Plain radiographs show non-specific bowel gas pattern. CT abdomen with IV contrast shows diffuse bowel wall thickening, portal venous gas, and pneumatosis intestinalis affecting multiple segments of small bowel. What is the most likely diagnosis?
What is the pathophysiological mechanism by which adhesional small bowel obstruction most commonly causes bowel ischaemia?
A 63-year-old woman presents with a 48-hour history of severe left lower quadrant pain and fever. CT abdomen shows sigmoid diverticulitis with a 4 cm pericolic abscess. She is haemodynamically stable with localized left iliac fossa tenderness but no generalized peritonism. WCC is 16.8 × 10⁹/L and CRP 245 mg/L. What is the most appropriate management according to current evidence-based guidelines?
Acute Surgical Presentations UK Medical PG Practice Questions and MCQs
Question 131: A 68-year-old man with a background of atrial fibrillation and hypertension presents with a 12-hour history of sudden onset severe periumbilical pain that has now become generalized. He describes the pain as initially colicky but now constant. On examination, he appears unwell with a temperature of 37.8°C, heart rate 110 bpm irregularly irregular, and blood pressure 95/60 mmHg. His abdomen is rigid with generalized guarding and rebound tenderness. Blood tests show: lactate 6.2 mmol/L, white cell count 18.5 × 10⁹/L. CT demonstrates pneumoperitoneum with fluid levels and thickened, oedematous small bowel loops. What is the most likely underlying diagnosis?
- A. Perforated duodenal ulcer with secondary bacterial peritonitis
- B. Acute mesenteric ischaemia with intestinal infarction and perforation (Correct Answer)
- C. Strangulated internal hernia with gangrenous perforation
- D. Perforated caecal carcinoma with faecal peritonitis
- E. Toxic megacolon secondary to pseudomembranous colitis with perforation
Explanation: ***Acute mesenteric ischaemia with intestinal infarction and perforation*** - The patient has a high-risk factor for **atrial fibrillation**, which causes **embolectomy into the superior mesenteric artery**, leading to sudden, severe periumbilical pain. - The progression from colicky pain to **peritonitis**, high **lactate (6.2 mmol/L)**, and **pneumoperitoneum** on CT indicates the transition from ischemia to bowel necrosis and subsequent perforation. *Perforated duodenal ulcer with secondary bacterial peritonitis* - While it causes **pneumoperitoneum** and **peritonitis**, it is typically preceded by a history of dyspepsia rather than the sudden-onset colicky pain associated with AF. - CT would primarily show gas in the subphrenic space without the **thickened, oedematous small bowel loops** seen in mesenteric ischemia. *Strangulated internal hernia with gangrenous perforation* - This typically presents with signs of **mechanical small bowel obstruction** such as vomiting and lack of flatus/feces prior to the onset of peritonitis. - While it can cause ischemia, the **atrial fibrillation** and generalized bowel edema favor a primary vascular embolic event over a localized mechanical strangulation. *Perforated caecal carcinoma with faecal peritonitis* - This usually presents in an older patient with a more chronic history of **altered bowel habits**, weight loss, or **iron-deficiency anemia**. - The acute, sudden presentation and **periumbilical** starting point are less characteristic of a primary colonic malignancy perforation. *Toxic megacolon secondary to pseudomembranous colitis with perforation* - This condition is typically preceded by severe **bloody or profuse diarrhea** and a history of recent **antibiotic use** or hospitalization. - CT would demonstrate massive **colonic dilatation** rather than the focus on oedematous small bowel loops and sudden periumbilical pain.
Question 132: A 45-year-old woman presents to the emergency department with a 6-hour history of severe, constant right iliac fossa pain. She has previously undergone three caesarean sections. On examination, her temperature is 38.2°C, heart rate 105 bpm, and blood pressure 125/78 mmHg. Her abdomen is distended with marked tenderness and guarding in the right iliac fossa. Bowel sounds are absent. CT abdomen reveals a closed-loop small bowel obstruction with wall thickening and reduced enhancement of the affected segment. What is the most appropriate immediate management?
- A. Administer intravenous antibiotics and arrange urgent surgical consultation within 6 hours
- B. Insert nasogastric tube, commence intravenous fluids, and arrange emergency laparotomy within 2 hours (Correct Answer)
- C. Trial of conservative management with nasogastric decompression and serial abdominal examinations
- D. Arrange for water-soluble contrast follow-through study to assess for resolution
- E. Perform urgent colonoscopy to decompress the obstructed segment
Explanation: ***Insert nasogastric tube, commence intravenous fluids, and arrange emergency laparotomy within 2 hours*** - The patient presents with a **closed-loop small bowel obstruction** and clear signs of **strangulation** (fever, tachycardia, peritonitis, absent bowel sounds, and reduced wall enhancement on CT), making it a surgical emergency. - Immediate **resuscitation** with intravenous fluids, **gastric decompression** with an NGT, and rapid arrangement for **emergency laparotomy** within 2 hours are critical to prevent irreversible **bowel necrosis** and perforation. *Administer intravenous antibiotics and arrange urgent surgical consultation within 6 hours* - While **intravenous antibiotics** are appropriate for suspected ischemia, waiting up to 6 hours for surgical consultation or intervention is far too long for a patient with signs of **strangulated bowel** and impending peritonitis. - A **closed-loop obstruction** with features of **ischemia** requires immediate surgical exploration, transitioning from an "urgent" to an "emergency" timeframe. *Trial of conservative management with nasogastric decompression and serial abdominal examinations* - **Conservative management** with NGT decompression is strictly **contraindicated** when there is clinical or radiological evidence of **bowel strangulation** or **peritonitis**. - Delaying definitive surgical intervention in the presence of signs like fever, tachycardia, guarding, and CT findings of wall ischemia significantly increases morbidity and mortality due to **bowel infarction**. *Arrange for water-soluble contrast follow-through study to assess for resolution* - **Water-soluble contrast studies** (e.g., Gastrografin) are sometimes used in uncomplicated adhesive small bowel obstructions to aid resolution or diagnosis, but they are **contraindicated** with signs of strangulation or peritonitis. - Such a study would unnecessarily and dangerously **delay the emergency surgical intervention** required to salvage the compromised bowel. *Perform urgent colonoscopy to decompress the obstructed segment* - This patient has a **small bowel obstruction**, which is anatomically upstream from the colon and therefore **cannot be accessed or decompressed via colonoscopy**. - Furthermore, **colonoscopy** is contraindicated when there is high clinical suspicion of **bowel ischemia** or threatened **perforation** due to the risk of iatrogenic injury.
Question 133: A 64-year-old man with metastatic colon cancer on palliative chemotherapy presents with a 72-hour history of abdominal distension, vomiting, and absolute constipation. CT shows multiple transition points with small bowel and large bowel dilatation, ascites, and peritoneal nodules. He has no peritonism and is haemodynamically stable. Oncology notes indicate he has an estimated prognosis of 2-3 months. After MDT discussion, conservative management is planned. Which of the following interventions would be most appropriate for symptom control?
- A. Immediate surgical exploration to relieve obstruction
- B. Percutaneous endoscopic gastrostomy (PEG) tube insertion
- C. Nasogastric decompression combined with pharmacological management including antiemetics and antisecretory agents (Correct Answer)
- D. Total parenteral nutrition via central venous catheter
- E. Colonic stenting via colonoscopy
Explanation: ***Nasogastric decompression combined with pharmacological management including antiemetics and antisecretory agents*** - In **malignant bowel obstruction (MBO)** with multiple transition points and **peritoneal carcinomatosis**, conservative management focusing on symptom relief is the gold standard for patients with a limited prognosis. - Pharmacological management involves **antisecretory agents** (e.g., octreotide or hyoscine butylbromide) to reduce fluid accumulation and **antiemetics** (e.g., haloperidol or levomepromazine) to manage nausea and vomiting, alongside **nasogastric decompression** for immediate relief. *Immediate surgical exploration to relieve obstruction* - Surgical intervention is generally inappropriate in cases of **peritoneal nodules** and **multiple obstruction points** due to high morbidity and poor functional outcomes in advanced cancer. - The patient’s short prognosis of **2-3 months** and the definitive MDT decision for conservative care prioritize **quality of life** over aggressive, invasive procedures. *Percutaneous endoscopic gastrostomy (PEG) tube insertion* - While a **venting PEG** can be used for long-term decompression in MBO, it is usually reserved for those failing medical management and is not the first-line intervention in an acute 72-hour presentation. - **Nasogastric decompression** is the preferred initial step to provide immediate relief from severe vomiting and distension before considering semi-permanent venting options. *Total parenteral nutrition via central venous catheter* - **TPN** is rarely indicated in end-of-life care as it does not improve survival or quality of life in patients with **advanced metastatic cancer** and MBO. - It carries significant risks, such as **catheter-related bloodstream infections** and metabolic imbalances, which are counterproductive to palliative goals. *Colonic stenting via colonoscopy* - **Colonic stenting** is primarily indicated for a **single-point** large bowel obstruction to act as a bridge to surgery or as palliation for specific focal lesions. - It is ineffective in this patient because the CT shows **multiple transition points** and involvement of the **small bowel**, which a colonic stent cannot bypass.
Question 134: Which of the following is the definition of 'strangulated bowel' in the context of intestinal obstruction?
- A. Complete luminal occlusion preventing passage of intestinal contents
- B. Bowel obstruction associated with closed-loop configuration
- C. Mechanical obstruction with compromised vascular supply leading to bowel ischaemia (Correct Answer)
- D. Bowel obstruction requiring surgical intervention within 24 hours
- E. Presence of systemic sepsis secondary to bacterial translocation from obstructed bowel
Explanation: ***Mechanical obstruction with compromised vascular supply leading to bowel ischaemia***- **Strangulated bowel** is specifically defined as an obstruction where the **blood supply** (arterial inflow or venous outflow) is impaired, posing an immediate risk of **infarction**.- This is most common in **incarcerated hernias**, **volvulus**, or tight **adhesional bands**, and it represents a true surgical emergency requiring immediate intervention.*Complete luminal occlusion preventing passage of intestinal contents*- This describes **simple mechanical obstruction**, where the flow of contents is blocked but the **mesenteric blood vessels** remain patent.- While serious, simple obstruction does not carry the same immediate risk of **gangrene** as strangulation unless secondary pressure effects occur.*Bowel obstruction associated with closed-loop configuration*- A **closed-loop obstruction** occurs when a segment of bowel is blocked at two points, but this term describes the **anatomical configuration**, not the vascular status.- Although closed loops are at very high risk for **strangulation**, they are not synonymous with it until **ischaemia** actually develops.*Bowel obstruction requiring surgical intervention within 24 hours*- This is a clinical management guideline rather than a **pathophysiological definition** of strangulation.- While strangulation mandates **immediate surgery**, many non-strangulated obstructions (like complete simple obstructions) also require surgery within similar timeframes.*Presence of systemic sepsis secondary to bacterial translocation from obstructed bowel*- This describes a **complication** of late-stage obstruction or infarction, such as **systemic inflammatory response syndrome (SIRS)**, rather than the definition of strangulation.- **Bacterial translocation** can occur in simple obstructions due to increased pressure, even before **vascular compromise** characterizes the state as strangulated.
Question 135: In a patient with suspected intestinal perforation, which of the following clinical or radiological features most reliably indicates that urgent surgical intervention is required rather than conservative management?
- A. Pneumoperitoneum visible on CT scan alone
- B. Serum lactate of 3.2 mmol/L with metabolic acidosis
- C. Free intraperitoneal fluid on CT without loculation
- D. Generalized peritonitis with haemodynamic instability despite resuscitation (Correct Answer)
- E. CRP elevation to 180 mg/L within 12 hours of symptom onset
Explanation: ***Generalized peritonitis with haemodynamic instability despite resuscitation*** - This clinical presentation signifies **overwhelming sepsis** and uncontrolled **intra-abdominal contamination**, demanding urgent **surgical source control**. - **Haemodynamic instability** despite adequate fluid resuscitation indicates that conservative measures are failing and immediate surgical intervention is critical to prevent further deterioration. *Pneumoperitoneum visible on CT scan alone* - While **pneumoperitoneum** confirms a perforation, a small amount of free air in a **clinically stable patient** without diffuse peritonitis may sometimes be managed non-operatively. - The finding alone does not reliably mandate urgent surgery, as some **contained perforations** can seal spontaneously. *Serum lactate of 3.2 mmol/L with metabolic acidosis* - **Hyperlactatemia** and **metabolic acidosis** are signs of tissue hypoperfusion or sepsis but can be caused by various factors, not solely by an uncontained perforation. - These parameters might improve with **aggressive fluid resuscitation** and do not, in isolation, reliably indicate the need for urgent surgery as definitively as generalized peritonitis. *Free intraperitoneal fluid on CT without loculation* - The presence of **simple free intraperitoneal fluid** is a non-specific finding that can be seen in numerous inflammatory or infectious conditions without necessarily indicating a **frank perforation**. - Without concurrent signs of **generalized peritonitis** or haemodynamic compromise, this finding alone does not necessitate immediate surgical intervention. *CRP elevation to 180 mg/L within 12 hours of symptom onset* - **C-reactive protein (CRP)** is a **non-specific acute-phase reactant** that indicates significant inflammation or infection but does not pinpoint the specific cause or dictate the need for surgery. - A high CRP level cannot reliably distinguish between a surgical emergency and other severe infections that might respond to **medical management** with antibiotics alone.
Question 136: A 48-year-old woman with known gallstone disease presents with a 4-day history of worsening right upper quadrant pain, nausea, and vomiting. She is febrile at 38.2°C. Ultrasound shows gallstones, gallbladder wall thickening of 5 mm, and pericholecystic fluid. There is also incidental finding of dilated small bowel loops on the scan. Plain abdominal radiograph confirms small bowel dilatation and shows a 2.5 cm calcified opacity in the right iliac fossa. What is the most likely diagnosis?
- A. Acute cholecystitis with concurrent adhesional small bowel obstruction
- B. Gallstone ileus causing small bowel obstruction (Correct Answer)
- C. Acute cholecystitis with reactive ileus
- D. Ascending cholangitis with paralytic ileus
- E. Perforated gallbladder with fecal peritonitis
Explanation: ***Gallstone ileus causing small bowel obstruction*** - The patient's presentation with **small bowel dilatation** and a **2.5 cm calcified opacity** in the right iliac fossa, combined with a history of gallstone disease and signs of gallbladder inflammation, is pathognomonic for **gallstone ileus**. - This condition occurs when a large gallstone erodes through a **cholecystoenteric fistula** into the small bowel, eventually causing **mechanical obstruction**, typically in the terminal ileum. *Acute cholecystitis with concurrent adhesional small bowel obstruction* - While symptoms of **acute cholecystitis** are present, the identification of a **migrated gallstone** acting as an obstructing lesion rules out an adhesional cause. - **Adhesional small bowel obstruction** is usually a sequela of prior abdominal surgery, which is not mentioned here, and does not involve a calcified luminal obstruction. *Acute cholecystitis with reactive ileus* - **Reactive ileus** is a functional motility disorder characterized by generalized bowel dilation and does not involve a **mechanical obstruction** by a specific object like a large gallstone. - The distinct **calcified opacity** in the iliac fossa strongly indicates a physical blockage rather than a functional ileus. *Ascending cholangitis with paralytic ileus* - **Ascending cholangitis** is typically associated with **Charcot's triad** (fever, RUQ pain, jaundice), and jaundice is not reported in this case. - **Paralytic ileus** is a diffuse bowel dysfunction, unlike the focal **mechanical obstruction** caused by a gallstone identified in the right iliac fossa. *Perforated gallbladder with fecal peritonitis* - A **perforated gallbladder** would lead to localized or generalized **biliary peritonitis**, but it does not typically involve a large gallstone migrating to obstruct the small bowel. - **Fecal peritonitis** is associated with colonic perforation and would not involve a calcified gallstone as the primary cause of obstruction.
Question 137: A 37-year-old man presents with a 6-hour history of severe generalized abdominal pain. He admits to ingesting multiple button batteries 8 hours previously during a bet. Initial plain radiographs show three circular opacities in the stomach and proximal small bowel. He is tachycardic at 108 bpm with diffuse abdominal tenderness. What is the most important immediate complication to consider?
- A. Small bowel obstruction requiring surgical removal
- B. Electrical burn injury causing perforation within hours of ingestion (Correct Answer)
- C. Lead poisoning from battery contents
- D. Aspiration pneumonitis from vomiting
- E. Delayed gastric emptying requiring endoscopic removal in 24 hours
Explanation: ***Electrical burn injury causing perforation within hours of ingestion***- **Button batteries** generate an **electrical current** when lodged against moist tissue, leading to rapid **liquefactive necrosis** and potential **perforation** within as little as 2-8 hours.- The patient's **severe generalized abdominal pain**, **tachycardia (108 bpm)**, and **diffuse abdominal tenderness** 8 hours post-ingestion are highly concerning for a **perforation** and **peritonitis** due to the caustic burn. *Small bowel obstruction requiring surgical removal*- While a battery could physically obstruct, the primary and most dangerous immediate complication of button battery ingestion is the **electrical and chemical burn** causing **tissue necrosis** and **perforation**.- The diffuse tenderness and tachycardia point towards a rapidly evolving inflammatory or septic process like **peritonitis** from perforation, rather than just mechanical **obstruction**. *Lead poisoning from battery contents*- **Lead poisoning** is a chronic toxicity that develops over time with sustained exposure, not an acute emergency presenting within hours of ingestion.- The immediate threat from button batteries comes from their **electrical discharge** and the leakage of **alkaline electrolytes**, leading to **caustic injury**, not heavy metal toxicity. *Aspiration pneumonitis from vomiting*- **Aspiration pneumonitis** is a potential complication if the patient vomits, but it does not explain the **severe generalized abdominal pain** and **diffuse abdominal tenderness** originating from the abdomen itself.- The direct and most significant danger is localized damage to the **gastrointestinal mucosa** by the battery, which takes precedence as the primary immediate concern. *Delayed gastric emptying requiring endoscopic removal in 24 hours*- Waiting **24 hours** for removal is contraindicated in button battery ingestion due to the rapid onset of **tissue damage** and **perforation**.- Immediate intervention, often endoscopic or surgical depending on location and symptoms, is crucial to prevent catastrophic complications caused by the battery's **electrical current** and **caustic properties**.
Question 138: A 71-year-old man with atrial fibrillation on warfarin (INR 2.3) presents with sudden onset severe abdominal pain for 3 hours. He has marked generalized tenderness with guarding and rebound. Plain radiographs show non-specific bowel gas pattern. CT abdomen with IV contrast shows diffuse bowel wall thickening, portal venous gas, and pneumatosis intestinalis affecting multiple segments of small bowel. What is the most likely diagnosis?
- A. Ischaemic colitis
- B. Acute mesenteric ischaemia from superior mesenteric artery thromboembolism (Correct Answer)
- C. Perforated sigmoid diverticulitis
- D. Closed-loop small bowel obstruction
- E. Spontaneous bacterial peritonitis
Explanation: ***Acute mesenteric ischaemia from superior mesenteric artery thromboembolism*** - The sudden onset of severe abdominal pain in a patient with **atrial fibrillation** (a high-risk source for **cardioembolism**) strongly indicates an embolic superior mesenteric artery occlusion. - The CT findings of **pneumatosis intestinalis** and **portal venous gas** affecting multiple segments of small bowel are key indicators of advanced, transmural **bowel infarction** requiring urgent surgical intervention. *Ischaemic colitis* - This typically presents with lower abdominal pain and **bloody diarrhea**, usually affecting "watershed" areas like the **splenic flexure** rather than diffuse small bowel. - It is generally caused by **hypoperfusion** or transient low-flow states rather than a sudden thromboembolic event in major mesenteric arteries. *Perforated sigmoid diverticulitis* - While it causes peritonitis, the CT would typically show **extraluminal air** (pneumoperitoneum) near the sigmoid colon and localized inflammation or an **abscess**. - It does not explain the specific findings of **portal venous gas** or **pneumatosis intestinalis** affecting multiple small bowel segments. *Closed-loop small bowel obstruction* - This occurs when two points of the bowel are obstructed, often leading to a **C-shaped** or **U-shaped** dilated loop on imaging. - While it can lead to ischemia, the clinical history of **atrial fibrillation** and the diffuse nature of the bowel wall thickening point more toward a primary **vascular etiology**. *Spontaneous bacterial peritonitis* - This condition is almost exclusively found in patients with **cirrhosis** and pre-existing **ascites**, presenting as localized or diffuse abdominal pain. - The diagnosis is confirmed via **paracentesis** (neutrophil count >250/mm³) and would not produce imaging findings of **pneumatosis intestinalis**.
Question 139: What is the pathophysiological mechanism by which adhesional small bowel obstruction most commonly causes bowel ischaemia?
- A. Direct arterial compression by the adhesion band
- B. Venous congestion due to external compression leading to bowel wall oedema and subsequent arterial insufficiency (Correct Answer)
- C. Thrombosis of mesenteric vessels due to local inflammation
- D. Bacterial translocation causing septic thrombophlebitis
- E. Hypovolemia from third-space losses reducing mesenteric perfusion pressure
Explanation: ***Venous congestion due to external compression leading to bowel wall oedema and subsequent arterial insufficiency***- In mechanical obstruction, the lower-pressure **venous system** is compressed first, leading to **venous congestion** and significant **mural oedema**.- As tissue pressure rises and exceeds **arterial capillary pressure**, oxygenated blood flow is halted, resulting in **ischaemia**, infarction, and eventual **transmural necrosis**.*Direct arterial compression by the adhesion band*- High-pressure **arterial walls** are thicker and more resistant to external mechanical compression compared to the **venous vasculature**.- Primary arterial compromise is rare in adhesional cases unless there is a **torsion or volvulus** that exerts extreme force directly on the mesentery.*Thrombosis of mesenteric vessels due to local inflammation*- This describes **mesenteric venous thrombosis**, which is typically associated with **hypercoagulable states** or portal hypertension rather than simple mechanical bands.- While inflammation occurs in late-stage obstruction, it is a **consequence of ischaemia** rather than the primary cause of vessel occlusion.*Bacterial translocation causing septic thrombophlebitis*- **Bacterial translocation** occurs because the compromised bowel wall loses its **mucosal barrier function**, allowing enteric flora to enter the bloodstream.- This leads to **systemic sepsis** and SIRS, but the mechanical ischaemia occurs much earlier in the pathological timeline than **thrombophlebitis**.*Hypovolemia from third-space losses reducing mesenteric perfusion pressure*- **Hypovolaemia** and "third-spacing" result from fluid accumulation in the bowel lumen and peritoneal cavity during obstruction.- While this can exacerbate poor tissue oxygenation, it causes **non-occlusive mesenteric ischaemia** (NOMI) rather than the localized mechanical ischaemia characteristic of an adhesion.
Question 140: A 63-year-old woman presents with a 48-hour history of severe left lower quadrant pain and fever. CT abdomen shows sigmoid diverticulitis with a 4 cm pericolic abscess. She is haemodynamically stable with localized left iliac fossa tenderness but no generalized peritonism. WCC is 16.8 × 10⁹/L and CRP 245 mg/L. What is the most appropriate management according to current evidence-based guidelines?
- A. Emergency sigmoid colectomy
- B. IV antibiotics alone with interval elective surgery in 6-8 weeks
- C. Percutaneous drainage of abscess with IV antibiotics, followed by interval surgery after 6-8 weeks (Correct Answer)
- D. IV antibiotics alone without planned interval surgery
- E. Immediate Hartmann's procedure
Explanation: ***Percutaneous drainage of abscess with IV antibiotics, followed by interval surgery after 6-8 weeks*** - For **Hinchey Stage II** diverticulitis, characterized by a **pericolic or distant abscess** (often > 3 cm), **percutaneous drainage** combined with **IV antibiotics** is the recommended initial management for hemodynamically stable patients. - Following successful drainage and resolution of acute symptoms, **interval sigmoid colectomy** is advised after 6-8 weeks to prevent recurrence and further complications given the history of complicated diverticulitis. *Emergency sigmoid colectomy* - This is generally reserved for patients with **generalized peritonitis** (Hinchey III or IV), sepsis not responding to resuscitation, or uncontrolled bleeding. - Performing an emergency colectomy in a stable patient without generalized peritonism or signs of organ failure significantly increases **morbidity** and the risk of a temporary or permanent **stoma**. *IV antibiotics alone with interval elective surgery in 6-8 weeks* - While **small diverticular abscesses** (typically < 3 cm) may resolve with **IV antibiotics alone**, a 4 cm abscess is less likely to fully resolve and has a higher risk of treatment failure with antibiotics alone. - **Image-guided percutaneous drainage** is indicated for larger abscesses to ensure adequate source control and prevent progression, making antibiotics alone insufficient in this scenario. *IV antibiotics alone without planned interval surgery* - This approach is typically suitable for **uncomplicated diverticulitis** (Hinchey 0 or Ia) or very small abscesses that completely resolve with antibiotics. - However, a **complicated diverticulitis episode** with a 4 cm abscess carries a high risk of recurrence and future complications, making **elective interval surgery** a crucial part of long-term management to reduce this risk. *Immediate Hartmann's procedure* - An **immediate Hartmann's procedure** is a significant surgical intervention primarily indicated for **faecal peritonitis**, severe generalized peritonitis, or in hemodynamically unstable patients with uncontrolled sepsis from perforated diverticulitis. - The patient in this scenario is **haemodynamically stable** with localized tenderness and a drainable abscess, making this highly morbid procedure overly aggressive and inappropriate as an initial step.
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