Acute Surgical Presentations — MCQs
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A 29-year-old woman who is 16 weeks pregnant presents with a 10-hour history of right-sided abdominal pain and fever. She has been vomiting and has right flank tenderness on examination. Ultrasound shows a non-dilated appendix but moderate right hydronephrosis. Urinalysis shows 15 white cells and 5 red cells per high-power field but no nitrites or bacteria on microscopy. Temperature is 38.4°C. What is the most likely diagnosis requiring urgent intervention?
A 53-year-old woman with no significant past medical history presents with a 36-hour history of severe lower abdominal pain and fever. CT abdomen shows a sigmoid colonic perforation with a 6 cm pelvic abscess and extensive free fluid. She is haemodynamically stable with temperature 38.9°C, heart rate 105 bpm, blood pressure 118/72 mmHg. Blood tests show WCC 16.8 × 10⁹/L, lactate 2.8 mmol/L. She has no significant co-morbidities. What is the most appropriate surgical management strategy?
Which of the following clinical features most reliably differentiates small bowel obstruction from large bowel obstruction in the acute presentation?
A 48-year-old man presents with a 3-hour history of sudden onset severe upper abdominal pain. He takes regular omeprazole for reflux. Erect chest X-ray shows no free air under the diaphragm. CT abdomen with oral contrast performed 6 hours after symptom onset shows a small amount of extraluminal gas adjacent to the posterior wall of the duodenum and fluid tracking into the right paracolic gutter. What is the most appropriate next step in management?
A 66-year-old woman presents with a 5-day history of cramping abdominal pain and bilious vomiting. She has no previous surgical history. CT abdomen shows dilated small bowel loops up to 4 cm, a transition point in the terminal ileum with an intraluminal gallstone measuring 3 cm, and a collapsed colon. The gallbladder is thick-walled with a cholecystoduodenal fistula visible. What is the underlying pathophysiological process that allowed this condition to develop?
A 35-year-old man with Crohn's disease on infliximab presents with a 12-hour history of severe abdominal pain and fever. He has had multiple previous resections. On examination, he is tachycardic at 128 bpm, temperature 39.3°C, and has generalized peritonism. CT shows free air and a contained collection in the right lower quadrant with surrounding inflammation. Inflammatory markers show WCC 18.2 × 10⁹/L and CRP 285 mg/L. What is the most significant factor influencing the management approach in this patient?
What is the pathophysiological mechanism that best explains why the caecum is the most common site of perforation in patients with distal large bowel obstruction?
A 42-year-old man presents with sudden onset severe right iliac fossa pain for 4 hours. He describes the pain as constant and has vomited twice. He has had intermittent episodes of right-sided abdominal pain over the past 2 years. On examination, there is a tender mass in the right iliac fossa with involuntary guarding. CT shows an inflamed appendix with an appendicolith, but also reveals a 3.5 cm diameter caecal mass adjacent to the appendix. What is the most appropriate management?
A 77-year-old man presents with a 72-hour history of abdominal pain, distension, and absolute constipation. He has a history of previous sigmoid colectomy for diverticular disease 15 years ago. Plain abdominal X-ray shows dilated small bowel loops centrally with valvulae conniventes visible. CT abdomen shows a transition point at the level of the previous anastomosis with proximal bowel dilatation and distal bowel collapse. What is the most likely cause of his bowel obstruction?
A 59-year-old man with inflammatory bowel disease presents with a 24-hour history of severe abdominal pain and distension. Plain abdominal X-ray shows grossly dilated transverse colon measuring 11 cm in diameter with loss of haustral markings. His observations show temperature 38.7°C, heart rate 118 bpm, and blood pressure 98/55 mmHg. Haemoglobin is 95 g/L and albumin 22 g/L. What is the most appropriate initial management?
Acute Surgical Presentations UK Medical PG Practice Questions and MCQs
Question 181: A 29-year-old woman who is 16 weeks pregnant presents with a 10-hour history of right-sided abdominal pain and fever. She has been vomiting and has right flank tenderness on examination. Ultrasound shows a non-dilated appendix but moderate right hydronephrosis. Urinalysis shows 15 white cells and 5 red cells per high-power field but no nitrites or bacteria on microscopy. Temperature is 38.4°C. What is the most likely diagnosis requiring urgent intervention?
- A. Acute pyelonephritis secondary to physiological hydronephrosis of pregnancy
- B. Acute appendicitis with retrocaecal appendix accounting for atypical features (Correct Answer)
- C. Obstructing right ureteric calculus causing hydronephrosis and infection
- D. Ovarian torsion affecting the right adnexa
- E. Ectopic pregnancy with rupture despite ultrasound findings
Explanation: ***Acute appendicitis with retrocaecal appendix accounting for atypical features*** - In pregnancy, the **gravid uterus** displaces the appendix, and a **retrocaecal position** can present with **flank tenderness** and irritable urinary symptoms due to its proximity to the ureter, making diagnosis challenging. - The presence of right-sided pain, fever, vomiting, and flank tenderness, even with a non-dilated appendix on ultrasound and some WBCs in urine (due to inflammation), strongly suggests **appendicitis** as the most likely urgent surgical diagnosis. *Acute pyelonephritis secondary to physiological hydronephrosis of pregnancy* - While **physiological hydronephrosis** is common in pregnancy, especially on the right, **acute pyelonephritis** typically presents with significant **bacteriuria** and positive nitrites on urinalysis, which are absent here. - The lack of bacterial evidence in the urine, despite WBCs and hydronephrosis, makes primary bacterial kidney infection less likely to be the direct cause of the acute, surgical-type pain and fever. *Obstructing right ureteric calculus causing hydronephrosis and infection* - A **ureteric calculus** could cause hydronephrosis and flank pain, but the absence of **nitrites** and **bacteria** in the urinalysis makes a concurrent infection (pyelonephritis secondary to obstruction) unlikely to be the primary pathology requiring urgent intervention. - Pain from a ureteric calculus is often **colicky** and may radiate to the groin, and while microhematuria is present, the overall picture does not fully align with an infected obstructed kidney needing immediate intervention. *Ovarian torsion affecting the right adnexa* - **Ovarian torsion** typically causes acute, severe **pelvic pain** and nausea, and while it can occur in pregnancy, it usually does not present with prominent flank tenderness or fever unless there is infarction and secondary infection. - Ultrasound for ovarian torsion would usually show an **enlarged, edematous ovary** with altered Doppler flow, which is not described, and it's less common at 16 weeks compared to the first trimester. *Ectopic pregnancy with rupture despite ultrasound findings* - An **ectopic pregnancy** is a **first-trimester** diagnosis; at **16 weeks gestation**, the presence of an established intrauterine pregnancy makes a ruptured ectopic pregnancy biologically impossible. - Even the extremely rare occurrence of a heterotopic pregnancy (intrauterine and ectopic simultaneously) would have presented with ectopic rupture much earlier in gestation.
Question 182: A 53-year-old woman with no significant past medical history presents with a 36-hour history of severe lower abdominal pain and fever. CT abdomen shows a sigmoid colonic perforation with a 6 cm pelvic abscess and extensive free fluid. She is haemodynamically stable with temperature 38.9°C, heart rate 105 bpm, blood pressure 118/72 mmHg. Blood tests show WCC 16.8 × 10⁹/L, lactate 2.8 mmol/L. She has no significant co-morbidities. What is the most appropriate surgical management strategy?
- A. Hartmann's procedure with end colostomy and rectal stump (Correct Answer)
- B. Primary resection with anastomosis and defunctioning loop ileostomy
- C. Laparoscopic peritoneal lavage and drainage only
- D. Percutaneous drainage of abscess followed by interval surgery
- E. Segmental resection with primary anastomosis without stoma
Explanation: ***Hartmann's procedure with end colostomy and rectal stump***- This patient presents with **Hinchey Stage III/IV diverticulitis** (perforation, abscess, and extensive free fluid), making **surgical resection** of the diseased segment and **source control** the gold standard.- A **Hartmann’s procedure** is the safest traditional approach in the emergency setting of gross contamination, as it avoids the high risk of **anastomotic leakage** in an infected environment.*Primary resection with anastomosis and defunctioning loop ileostomy*- While increasingly considered in stable patients, an **anastomosis** is risky in the presence of **extensive free fluid** and elevated **lactate**, which suggest significant physiological stress.- The degree of peritoneal contamination and bowel wall inflammation often makes a **primary anastomosis** technically less favorable compared to a diversion.*Laparoscopic peritoneal lavage and drainage only*- Clinical trials (e.g., **LOLA/LADIES trial**) have shown that lavage alone is associated with higher rates of **re-intervention** and poor outcomes in patients with **purulent peritonitis**.- This technique fails to address the anatomical source of the infection, which is the **perforated segment** of the colon.*Percutaneous drainage of abscess followed by interval surgery*- Percutaneous drainage is appropriate for **Hinchey Stage II** (contained large abscesses), but not when there is radiological evidence of **free perforation** and **extensive free fluid**.- This patient's **tachycardia**, fever, and elevated **lactate** indicate systemic sepsis requiring urgent **surgical source control** rather than a localized drain.*Segmental resection with primary anastomosis without stoma*- Performing an **anastomosis without a stoma** in the setting of fecal or purulent contamination is contraindicated due to the extremely high risk of **sepsis** and breakdown.- The inflammatory process and the patient's **septic state** (elevated WCC and lactate) severely impair the **healing capacity** of the newly formed bowel connection.
Question 183: Which of the following clinical features most reliably differentiates small bowel obstruction from large bowel obstruction in the acute presentation?
- A. The timing and character of vomiting - early and bilious in small bowel, late and faeculentinlarge bowel (Correct Answer)
- B. The severity of abdominal pain - colicky pain in small bowel, constant pain in large bowel
- C. The presence of abdominal distension - minimal in small bowel, marked in large bowel
- D. The pattern of constipation - relative in small bowel, absolute in large bowel
- E. The presence of bowel sounds - hyperactive in small bowel, absent in large bowel
Explanation: ***The timing and character of vomiting - early and bilious in small bowel, late and faeculent in large bowel*** - **Small bowel obstruction (SBO)** typically manifests with **early, profuse, and bilious vomiting** because the blockage is proximal and digestive juices quickly accumulate. - In **large bowel obstruction (LBO)**, vomiting is a **late feature** or may be absent; if it occurs, it is often **faeculent** due to prolonged stasis and bacterial overgrowth. *The severity of abdominal pain - colicky pain in small bowel, constant pain in large bowel* - Both SBO and LBO primarily present with **colicky (intermittent) pain** due to persistent peristaltic waves attempting to bypass the obstruction. - Constant pain is more indicative of **ischemia, strangulation, or perforation** rather than a definitive differentiator between SBO and LBO. *The presence of abdominal distension - minimal in small bowel, marked in large bowel* - While distension is often more pronounced in LBO, it can also be **marked in distal SBO**, making it a less reliable discriminator. - Distension depends more on the **location (proximal vs. distal)** of the obstruction and the duration of symptoms rather than being solely tied to SBO vs. LBO. *The pattern of constipation - relative in small bowel, absolute in large bowel* - **Absolute constipation** (failure to pass flatus or stool) occurs in complete obstructions of both the small and large bowel. - While it may develop more rapidly in LBO, it is not a definitive differentiator as **distal SBO** will eventually lead to the same clinical state. *The presence of bowel sounds - hyperactive in small bowel, absent in large bowel* - In both conditions, bowel sounds are initially **hyperactive and high-pitched (tinkling)** during the acute phase as the bowel struggles against the blockage. - **Absent bowel sounds** usually signify a late stage where the bowel is fatigued or has developed **peritonitis/ileus**, regardless of the obstruction's location.
Question 184: A 48-year-old man presents with a 3-hour history of sudden onset severe upper abdominal pain. He takes regular omeprazole for reflux. Erect chest X-ray shows no free air under the diaphragm. CT abdomen with oral contrast performed 6 hours after symptom onset shows a small amount of extraluminal gas adjacent to the posterior wall of the duodenum and fluid tracking into the right paracolic gutter. What is the most appropriate next step in management?
- A. Emergency laparotomy with primary repair and omental patch
- B. Conservative management with nil by mouth, intravenous fluids, antibiotics, and proton pump inhibitor (Correct Answer)
- C. Urgent upper GI endoscopy to identify and clip the perforation
- D. Laparoscopic repair with omental patch and peritoneal lavage
- E. Percutaneous drainage of fluid collection and antibiotic therapy
Explanation: ***Conservative management with nil by mouth, intravenous fluids, antibiotics, and proton pump inhibitor*** - The CT findings of **extraluminal gas adjacent to the posterior wall of the duodenum** and **fluid tracking into the right paracolic gutter**, combined with a normal chest X-ray, are highly suggestive of a **contained retroperitoneal duodenal perforation**. - For hemodynamically stable patients with **contained perforations** or those presenting later (e.g., >6 hours), conservative management (often called the **Taylor regimen**) is the appropriate initial approach. *Emergency laparotomy with primary repair and omental patch* - This aggressive surgical intervention is typically reserved for patients with **generalized peritonitis**, **hemodynamic instability**, or widespread contamination from an **uncontained perforation**. - In a stable patient with evidence of a **contained perforation**, immediate open surgery is usually not the first-line treatment. *Urgent upper GI endoscopy to identify and clip the perforation* - **Endoscopy is generally contraindicated** in acute suspected gastrointestinal perforation, as insufflation can exacerbate the leak and convert a contained perforation into a free one. - While clips are used for certain small iatrogenic perforations, they are not the standard of care for an **acutely perforated peptic ulcer**. *Laparoscopic repair with omental patch and peritoneal lavage* - While a less invasive surgical option, surgical intervention (laparoscopic or open) is indicated for **free perforations**, **generalized peritonitis**, or failure of conservative management. - **Peritoneal lavage** is relevant for generalized peritonitis, which is not indicated by the localized findings of this contained retroperitoneal leak. *Percutaneous drainage of fluid collection and antibiotic therapy* - Percutaneous drainage is indicated for **well-defined, established fluid collections or abscesses** that may form secondary to a perforation. - This approach alone does not address the acute source of the leak and is not appropriate as the **initial management** for an acute contained perforation.
Question 185: A 66-year-old woman presents with a 5-day history of cramping abdominal pain and bilious vomiting. She has no previous surgical history. CT abdomen shows dilated small bowel loops up to 4 cm, a transition point in the terminal ileum with an intraluminal gallstone measuring 3 cm, and a collapsed colon. The gallbladder is thick-walled with a cholecystoduodenal fistula visible. What is the underlying pathophysiological process that allowed this condition to develop?
- A. Chronic cholecystitis causing fistulation between gallbladder and duodenum allowing stone passage (Correct Answer)
- B. Ampullary stenosis causing retrograde migration of bile duct stones into the bowel
- C. Sphincter of Oddi dysfunction allowing gallstones to pass into the duodenum
- D. Congenital biliary-enteric fistula allowing stone passage from birth
- E. Iatrogenic biliary-enteric anastomosis from previous unrecognized surgery
Explanation: ***Chronic cholecystitis causing fistulation between gallbladder and duodenum allowing stone passage***- This condition is known as **gallstone ileus**, where recurrent inflammation from **chronic cholecystitis** leads to adhesions and pressure necrosis, creating a **cholecystoenteric fistula**.- A large gallstone (typically >2.5 cm) passes through the fistula and obstructs the bowel, most commonly at the **terminal ileum** due to its narrow lumen.*Ampullary stenosis causing retrograde migration of bile duct stones into the bowel*- **Ampullary stenosis** restricts the passage of stones into the duodenum rather than facilitating it, and it does not explain a large 3 cm stone or a cholecystoduodenal fistula.- Stones that pass through the **common bile duct** are generally too small to cause a mechanical small bowel obstruction (ileus).*Sphincter of Oddi dysfunction allowing gallstones to pass into the duodenum*- **Sphincter of Oddi dysfunction** relates to motility and pressure issues of the biliary sphincter, which would not accommodate the passage of a **3 cm gallstone**.- This mechanism lacks the characteristic **cholecystoduodenal fistula** and the overall clinical picture of gallstone ileus.*Congenital biliary-enteric fistula allowing stone passage from birth*- **Congenital biliary-enteric fistulae** are extremely rare anatomical anomalies and are not the standard pathway for acquired gallstone ileus in the elderly.- The presence of a **thick-walled gallbladder** and cramping pain points toward an acquired inflammatory process rather than a lifelong congenital defect.*Iatrogenic biliary-enteric anastomosis from previous unrecognized surgery*- The clinical vignette explicitly states the patient has **no previous surgical history**, making an iatrogenic cause impossible.- **Iatrogenic anastomoses** are intentional surgical connections (like a choledochoduodenostomy) and would not present with the acute inflammatory features of a spontaneous fistula.
Question 186: A 35-year-old man with Crohn's disease on infliximab presents with a 12-hour history of severe abdominal pain and fever. He has had multiple previous resections. On examination, he is tachycardic at 128 bpm, temperature 39.3°C, and has generalized peritonism. CT shows free air and a contained collection in the right lower quadrant with surrounding inflammation. Inflammatory markers show WCC 18.2 × 10⁹/L and CRP 285 mg/L. What is the most significant factor influencing the management approach in this patient?
- A. The immunosuppressive effect of infliximab therapy masking the severity of sepsis (Correct Answer)
- B. The presence of free air mandating immediate laparotomy regardless of clinical status
- C. The history of multiple previous resections risking short bowel syndrome
- D. The contained collection suggesting suitability for percutaneous drainage alone
- E. The duration of symptoms being less than 24 hours favouring conservative management
Explanation: ***The immunosuppressive effect of infliximab therapy masking the severity of sepsis*** - Patients on **anti-TNF therapy** like infliximab have an impaired **inflammatory response**, which can significantly mask the classic clinical signs and severity of **intra-abdominal sepsis**. - This immunosuppression necessitates a high index of suspicion and low threshold for **surgical intervention**, as the patient may be more physiologically compromised than their physical examination suggests. *The presence of free air mandating immediate laparotomy regardless of clinical status* - While **pneumoperitoneum** often requires surgery, in **Crohn's disease**, small contained perforations may sometimes be managed conservatively if the patient is stable. - However, clinical status and **systemic sepsis** (tachycardia and fever) are the primary drivers of management rather than the radiological finding alone. *The history of multiple previous resections risking short bowel syndrome* - While preserving **bowel length** is a critical long-term goal in Crohn's to prevent **short bowel syndrome**, it does not override the immediate need to manage **life-threatening perforation**. - Previous surgeries may increase **surgical complexity** due to adhesions but do not change the acute indication for managing sepsis. *The contained collection suggesting suitability for percutaneous drainage alone* - **Percutaneous drainage** is ideal for well-contained abscesses in stable patients, but the presence of **generalized peritonism** and **free air** indicates a free perforation. - The systemic toxicity (high **WCC** and **CRP**) and peritoneal signs suggest that drainage alone would be inadequate to control the source of infection. *The duration of symptoms being less than 24 hours favouring conservative management* - Early presentation of **perforation** does not favor conservative management; instead, it is an indication for rapid intervention to prevent worsening **fecal peritonitis**. - Conservative management is generally reserved for stable patients with localized symptoms, not those with **tachycardia**, high fever, and **generalized peritonism**.
Question 187: What is the pathophysiological mechanism that best explains why the caecum is the most common site of perforation in patients with distal large bowel obstruction?
- A. Law of Laplace - the caecum has the largest diameter and thinnest wall, experiencing the highest tension (Correct Answer)
- B. The caecum has the poorest blood supply in the colon making it prone to ischaemic perforation
- C. The ileocaecal valve prevents decompression into the small bowel increasing caecal pressure
- D. The caecum contains the highest bacterial load in the gastrointestinal tract
- E. Caecal distension causes venous congestion leading to mucosal breakdown and perforation
Explanation: ***Law of Laplace - the caecum has the largest diameter and thinnest wall, experiencing the highest tension*** - According to the **Law of Laplace**, wall tension is proportional to the **radius** of the vessel or organ (T = P × r); thus, the **caecum**, having the largest diameter, generates the most tension. - As **wall tension** increases due to distal obstruction, the thin-walled caecum reaches its critical threshold for **perforation** before other colonic segments. *The caecum has the poorest blood supply in the colon making it prone to ischaemic perforation* - The **watershed areas** of the colon (like Griffith's point at the splenic flexure) are typically more prone to primary ischemia, not the caecum. - While **ischemia** occurs during distension, it is a secondary result of high **intramural pressure** rather than a baseline poor blood supply. *The ileocaecal valve prevents decompression into the small bowel increasing caecal pressure* - A **competent ileocaecal valve** creates a **closed-loop obstruction**, which is a necessary condition for rapid pressure buildup. - However, this condition increases pressure throughout the entire segment; it does not explain why the **caecum specifically** is the site of failure compared to the rest of the colon. *The caecum contains the highest bacterial load in the gastrointestinal tract* - High **bacterial load** contributes to the severity of **peritonitis** after a perforation occurs but is not the physical cause of the rupture. - Mechanical forces and **wall tension**, rather than microbial activity, are the primary drivers of **diastatic perforation**. *Caecal distension causes venous congestion leading to mucosal breakdown and perforation* - **Venous congestion** and subsequent mucosal ischemia are intermediate steps in the process of wall weakening during massive distension. - This mechanism is a consequence of the **distension** itself, which is governed by the **Law of Laplace**, making it a less fundamental explanation than the physics of wall tension.
Question 188: A 42-year-old man presents with sudden onset severe right iliac fossa pain for 4 hours. He describes the pain as constant and has vomited twice. He has had intermittent episodes of right-sided abdominal pain over the past 2 years. On examination, there is a tender mass in the right iliac fossa with involuntary guarding. CT shows an inflamed appendix with an appendicolith, but also reveals a 3.5 cm diameter caecal mass adjacent to the appendix. What is the most appropriate management?
- A. Right hemicolectomy with en bloc appendicectomy (Correct Answer)
- B. Laparoscopic appendicectomy only
- C. Interval appendicectomy after 6-8 weeks with colonoscopy
- D. Percutaneous drainage of appendiceal abscess followed by imaging
- E. Conservative management with antibiotics and colonoscopy first
Explanation: ***Right hemicolectomy with en bloc appendicectomy*** - In a patient over 40 with **acute appendicitis** and a concurrent **3.5 cm caecal mass**, an oncological resection is required to address the high risk of **caecal carcinoma**. - A **right hemicolectomy** ensures adequate lymph node clearance and definitive management, as caecal tumors can mimic or cause appendicitis by obstructing the appendiceal orifice. *Laparoscopic appendicectomy only* - This procedure is inadequate because it fails to address the **caecal mass**, potentially leaving behind a **malignancy** and violating oncological principles. - Simple resection of the appendix may lead to **tumor spillage** or recurrences if the mass at the base is cancerous. *Interval appendicectomy after 6-8 weeks with colonoscopy* - Waiting for an interval procedure unnecessarily delays the treatment of a potentially **resectable malignancy** and risks ongoing sepsis from the current appendicitis. - While interval procedures are used for uncomplicated **appendiceal masses**, the diagnostic uncertainty of a large caecal mass favors immediate surgical intervention. *Percutaneous drainage of appendiceal abscess followed by imaging* - This approach is reserved for stable patients with a **walled-off abscess**, but the presence of a **discrete caecal mass** and involuntary guarding necessitates definitive surgery. - Drainage does not provide a **tissue diagnosis** of the mass and would be insufficient if the primary pathology is a **caecal tumor**. *Conservative management with antibiotics and colonoscopy first* - High-risk features like **involuntary guarding** and a large mass suggest the patient needs urgent surgical control rather than just **medical management**. - Delaying surgery for a **colonoscopy** in the presence of acute peritonitis or clinical appendicitis increases the risk of **perforation** and sepsis.
Question 189: A 77-year-old man presents with a 72-hour history of abdominal pain, distension, and absolute constipation. He has a history of previous sigmoid colectomy for diverticular disease 15 years ago. Plain abdominal X-ray shows dilated small bowel loops centrally with valvulae conniventes visible. CT abdomen shows a transition point at the level of the previous anastomosis with proximal bowel dilatation and distal bowel collapse. What is the most likely cause of his bowel obstruction?
- A. Adhesional small bowel obstruction secondary to previous surgery (Correct Answer)
- B. Anastomotic stricture at the site of previous colectomy
- C. Recurrent diverticular disease with abscess formation
- D. Internal hernia through a mesenteric defect
- E. Primary small bowel malignancy
Explanation: ***Adhesional small bowel obstruction secondary to previous surgery*** - **Post-operative adhesions** are the most common cause of small bowel obstruction, particularly in patients with a history of prior abdominal surgery like a colectomy. - The plain abdominal X-ray showing **dilated small bowel loops** with visible **valvulae conniventes** and the CT identifying a **transition point** at the previous anastomosis with proximal dilatation and distal collapse are classic findings for mechanical small bowel obstruction due to adhesions. *Anastomotic stricture at the site of previous colectomy* - While the transition point is near the anastomosis, an **anastomotic stricture** would typically involve the **large bowel lumen** and cause symptoms more consistent with large bowel obstruction or chronic changes, not acute small bowel obstruction. - Strictures presenting 15 years post-surgery often have a more chronic or subacute course, unless malignant, which is not suggested by the acute presentation. *Recurrent diverticular disease with abscess formation* - The patient had a **sigmoid colectomy**, which removes the most common segment affected by diverticular disease, making recurrence causing small bowel obstruction less likely. - An abscess would usually be accompanied by **fever**, **leukocytosis**, and localized tenderness or other signs of infection, which are absent in this presentation. *Internal hernia through a mesenteric defect* - An **internal hernia** can occur after abdominal surgery but is a significantly **less frequent** cause of small bowel obstruction compared to adhesions. - CT imaging might show specific features like **clustered bowel loops** in an unusual location or a **whirl sign** of the mesentery, which are not explicitly described as the primary finding here. *Primary small bowel malignancy* - **Primary small bowel malignancies** are rare and typically present with more chronic symptoms such as unexplained weight loss, anemia, or intermittent abdominal pain. - Given the patient's surgical history, an adhesional cause for acute small bowel obstruction is statistically far more probable than a rare small bowel malignancy.
Question 190: A 59-year-old man with inflammatory bowel disease presents with a 24-hour history of severe abdominal pain and distension. Plain abdominal X-ray shows grossly dilated transverse colon measuring 11 cm in diameter with loss of haustral markings. His observations show temperature 38.7°C, heart rate 118 bpm, and blood pressure 98/55 mmHg. Haemoglobin is 95 g/L and albumin 22 g/L. What is the most appropriate initial management?
- A. Urgent surgical intervention with subtotal colectomy (Correct Answer)
- B. Flexible sigmoidoscopy with decompression
- C. Intravenous corticosteroids and medical optimization
- D. CT colonography to assess extent of disease
- E. Nasogastric decompression and 48-hour trial of conservative management
Explanation: ***Urgent surgical intervention with subtotal colectomy*** - The patient presents with classic signs of **toxic megacolon** (transverse colon >6 cm, here 11 cm, with loss of haustral markings) and profound **systemic toxicity** (fever, tachycardia, hypotension). - This constellation indicates a high risk of **perforation** and sepsis, necessitating immediate **subtotal colectomy** with ileostomy to prevent a lethal outcome. *Flexible sigmoidoscopy with decompression* - This procedure carries an extremely high risk of **colonic perforation** in the setting of acute toxic megacolon due to the friable and thinned bowel wall. - It is an ineffective approach for the systemic inflammatory response and the extensive colonic dilation observed, and does not address the underlying pathology requiring definitive removal. *Intravenous corticosteroids and medical optimization* - While corticosteroids are used for severe IBD flares, they are inadequate as the sole initial management for **toxic megacolon with systemic shock** and extreme dilation. - Delaying surgical intervention in this critical scenario would significantly increase the risk of **perforation** and associated mortality. *CT colonography to assess extent of disease* - **CT colonography** requires colonic insufflation, which is absolutely **contraindicated** in a patient with toxic megacolon due to the imminent risk of **bowel perforation**. - The plain abdominal X-ray has already provided sufficient information (11 cm dilation) to guide immediate management, making further risky imaging unnecessary. *Nasogastric decompression and 48-hour trial of conservative management* - Conservative management is reserved for **hemodynamically stable** patients without signs of perforation; this patient's **hypotension, tachycardia, and fever** indicate severe systemic illness. - A 48-hour delay in surgical intervention for toxic megacolon with systemic toxicity dramatically increases the rates of **perforation and mortality**.
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