Acute Surgical Presentations — MCQs
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A 69-year-old man with a background of chronic constipation and laxative dependence presents with a 5-day history of lower abdominal pain, distension, and obstipation. On examination, the abdomen is grossly distended and tympanic with a resonant mass palpable in the left upper quadrant. Plain abdominal radiograph shows a massively dilated loop of colon extending from the left lower quadrant to the right upper quadrant with loss of haustral markings. What is the most appropriate initial intervention?
A 56-year-old man with Crohn's disease on infliximab presents with a 72-hour history of worsening right lower quadrant pain and fever. CT abdomen shows thickened terminal ileum with a 6 cm peripherally enhancing fluid collection containing air-fluid level adjacent to the caecum. He is haemodynamically stable. What is the most appropriate initial management?
A 47-year-old woman with no previous abdominal surgery presents with a 24-hour history of central colicky abdominal pain and bilious vomiting. Examination reveals mild distension and hyperactive bowel sounds. CT abdomen shows a closed-loop small bowel obstruction in the right lower quadrant with a 'C-shaped' configuration and the mesenteric vessels converging in a 'whirl sign'. What is the most appropriate management?
What is the pathophysiological mechanism underlying the development of hypochloraemic, hypokalaemic metabolic alkalosis in patients with prolonged pyloric stenosis or high small bowel obstruction?
A 72-year-old man undergoes emergency laparotomy for perforated sigmoid diverticulitis with faecal peritonitis. Hartmann's procedure is performed. On post-operative day 3, he develops fever, tachycardia, and increasing abdominal pain. CT shows fluid collection in the pelvis with gas bubbles. Drain amylase from percutaneous drainage measures 8,500 U/L (serum amylase 120 U/L). What is the most likely diagnosis?
A 64-year-old man with metastatic gastric adenocarcinoma presents with a 4-day history of severe colicky abdominal pain and absolute constipation. CT abdomen reveals dilated loops of small bowel with a transition point showing circumferential wall thickening and a central area of fatty attenuation. Multiple peritoneal deposits are noted. What is the most likely mechanism of obstruction?
A 58-year-old woman presents to the emergency department with a 12-hour history of severe periumbilical pain, vomiting, and abdominal distension. She has had multiple episodes of similar pain over the past year but they resolved spontaneously. On examination, her abdomen is distended with visible peristalsis and high-pitched bowel sounds. CT abdomen shows transition point in the mid-ileum with proximal bowel dilatation and collapsed distal bowel. A round calcified opacity is seen in the terminal ileum measuring 3.5 cm. What is the most appropriate immediate management?
What is Chilaiditi syndrome and how does it differ from Chilaiditi sign in terms of clinical significance and management?
A 59-year-old woman presents with a 5-day history of left iliac fossa pain and fever. CT abdomen shows sigmoid diverticulitis with a 4 cm pericolic abscess. She is treated with IV antibiotics and CT-guided drainage, with good clinical response. She is discharged after 7 days. At 6-week follow-up outpatient review, she is asymptomatic and has fully recovered. Colonoscopy performed 4 weeks post-discharge shows diverticular disease but no other abnormality. What is the most appropriate ongoing management?
Which of the following biochemical and physiological changes occurs earliest in the pathophysiological sequence of complete small bowel obstruction?
Acute Surgical Presentations UK Medical PG Practice Questions and MCQs
Question 11: A 69-year-old man with a background of chronic constipation and laxative dependence presents with a 5-day history of lower abdominal pain, distension, and obstipation. On examination, the abdomen is grossly distended and tympanic with a resonant mass palpable in the left upper quadrant. Plain abdominal radiograph shows a massively dilated loop of colon extending from the left lower quadrant to the right upper quadrant with loss of haustral markings. What is the most appropriate initial intervention?
- A. Emergency laparotomy with sigmoid resection and end colostomy
- B. Flexible sigmoidoscopy with decompression tube insertion (Correct Answer)
- C. CT abdomen to exclude malignancy before intervention
- D. Immediate nasogastric decompression and fluid resuscitation
- E. Water-soluble contrast enema to confirm diagnosis
Explanation: ***Flexible sigmoidoscopy with decompression tube insertion*** - The patient's presentation with acute **lower abdominal pain**, **distension**, **obstipation**, and classic radiographic findings (massively dilated loop of colon extending from LLQ to RUQ with loss of haustral markings, consistent with a **coffee bean sign**) strongly indicates **sigmoid volvulus**. - In a stable patient without signs of peritonitis or bowel ischemia, **flexible sigmoidoscopy** is the most appropriate initial intervention as it allows for both **detorsion** of the sigmoid colon and placement of a **decompression tube** (flatus tube) to prevent immediate recurrence. *Emergency laparotomy with sigmoid resection and end colostomy* - This major surgical intervention (e.g., Hartmann's procedure) is reserved for cases of **sigmoid volvulus** complicated by **peritonitis**, bowel **gangrene**, perforation, or when endoscopic decompression fails. - Immediate surgery for uncomplicated volvulus carries a higher **morbidity and mortality** rate compared to initial non-surgical decompression followed by elective resection, if necessary. *CT abdomen to exclude malignancy before intervention* - While a CT scan can confirm the diagnosis and identify a **"whirl sign"**, the clinical picture and plain abdominal radiograph are already highly diagnostic of **sigmoid volvulus**, which is an acute emergency. - Delaying the necessary decompression for further imaging, even to exclude malignancy, increases the risk of **bowel ischemia** and perforation in an acutely obstructed and distended colon. *Immediate nasogastric decompression and fluid resuscitation* - **Fluid resuscitation** is a crucial supportive measure for any acutely ill patient with obstruction, but **nasogastric decompression** is primarily effective for upper gastrointestinal obstruction. - For a **distal colonic obstruction** like **sigmoid volvulus**, nasogastric decompression will not relieve the mechanical torsion or significantly decompress the colon, leading to continued distension and risk of complications. *Water-soluble contrast enema to confirm diagnosis* - A **water-soluble contrast enema** can demonstrate the characteristic **"bird's beak" deformity** at the site of the volvulus, confirming the diagnosis. - However, it is primarily a diagnostic tool, not therapeutic, and carries a risk of **perforation** in a massively distended or potentially ischemic colon, thus it should not delay the more definitive therapeutic flexible sigmoidoscopy.
Question 12: A 56-year-old man with Crohn's disease on infliximab presents with a 72-hour history of worsening right lower quadrant pain and fever. CT abdomen shows thickened terminal ileum with a 6 cm peripherally enhancing fluid collection containing air-fluid level adjacent to the caecum. He is haemodynamically stable. What is the most appropriate initial management?
- A. Continue infliximab and add antibiotics for inflammatory mass
- B. Emergency laparotomy with ileocaecal resection
- C. Escalate immunosuppression with high-dose corticosteroids
- D. Urgent colonoscopy with endoscopic drainage of abscess
- E. CT-guided percutaneous drainage with antibiotics and withhold infliximab (Correct Answer)
Explanation: ***CT-guided percutaneous drainage with antibiotics and withhold infliximab***- The patient has a large (6 cm) **intra-abdominal abscess** with an air-fluid level. For stable patients with collections >3-4 cm, **percutaneous drainage** combined with **broad-spectrum antibiotics** is the gold standard initial management.- **Infliximab** (an anti-TNF agent) must be **withheld** during the acute infection phase as it can impair the immune response, complicating the resolution of **sepsis** and potentially worsening the infection.*Continue infliximab and add antibiotics for inflammatory mass*- This is incorrect because the CT shows a **defined abscess** (peripherally enhancing with air-fluid level), not just a phlegmon or inflammatory mass, requiring drainage.- Maintaining **immunosuppression** with infliximab in the presence of an undrained abscess significantly increases the risk of worsening **sepsis** and clinical deterioration.*Emergency laparotomy with ileocaecal resection*- **Emergency surgery** should be avoided in the acute phase for stable patients with drainable abscesses to prevent the need for a temporary or permanent **stoma**.- Surgical intervention is generally reserved for patients with **generalized peritonitis**, **bowel perforation**, uncontrolled sepsis, or those who fail to improve after percutaneous drainage.*Escalate immunosuppression with high-dose corticosteroids*- **Corticosteroids** are contraindicated in the setting of an active, undrained abscess as they can mask clinical symptoms and further impair the body's ability to localize and fight the infection.- Escalating immunosuppression would likely lead to **septic shock** by further compromising the host's immune response to the localized bacterial infection.*Urgent colonoscopy with endoscopic drainage of abscess*- **Colonoscopy** is contraindicated in acute severe Crohn's disease with a suspected extra-luminal abscess due to the high risk of **iatrogenic bowel perforation**.- **Endoscopic drainage** is not a standard or safe approach for **extra-luminal abdominal abscesses** adjacent to the caecum; these are best accessed via percutaneous routes under radiological guidance.
Question 13: A 47-year-old woman with no previous abdominal surgery presents with a 24-hour history of central colicky abdominal pain and bilious vomiting. Examination reveals mild distension and hyperactive bowel sounds. CT abdomen shows a closed-loop small bowel obstruction in the right lower quadrant with a 'C-shaped' configuration and the mesenteric vessels converging in a 'whirl sign'. What is the most appropriate management?
- A. Emergency laparotomy within 2 hours (Correct Answer)
- B. Nasogastric decompression with 48-hour trial of conservative management
- C. Water-soluble contrast study to assess for spontaneous resolution
- D. Urgent interventional radiology for percutaneous decompression
- E. Diagnostic laparoscopy with decision for conversion based on findings
Explanation: ***Emergency laparotomy within 2 hours***- A **closed-loop small bowel obstruction** combined with a **'whirl sign'** (indicating mesenteric torsion) is a surgical emergency that requires immediate operative intervention.- Emergency surgery is essential to prevent or address **bowel strangulation**, ischemia, and necrosis which develop rapidly in closed-loop systems.*Nasogastric decompression with 48-hour trial of conservative management*- Conservative management is reserved for **simple adhesional obstructions** where the bowel is not trapped at two points.- In a **closed-loop obstruction**, conservative measures like NG decompression cannot decompress the trapped segment, leading to a high risk of **perforation**.*Water-soluble contrast study to assess for spontaneous resolution*- This technique is typically used to predict the resolution of **adhesional small bowel obstruction** and promote bowel motility.- It is **contraindicated** in cases with suspected **strangulation** or closed-loop pathology as it delays the definitive surgical treatment needed.*Urgent interventional radiology for percutaneous decompression*- Percutaneous decompression is not a viable treatment for **small bowel volvulus** or closed-loop obstructions.- Management requires direct visualization and manual **detorsion** or resection, which cannot be achieved via **interventional radiology**.*Diagnostic laparoscopy with decision for conversion based on findings*- While laparoscopy is used in some cases of SBO, an **emergency laparotomy** is generally preferred when there is high suspicion of **ischaemic bowel** or complex volvulus.- Extensive **bowel distension** increases the risk of iatrogenic injury during trocar insertion, making open surgery the safer standard in an acute **closed-loop obstruction**.
Question 14: What is the pathophysiological mechanism underlying the development of hypochloraemic, hypokalaemic metabolic alkalosis in patients with prolonged pyloric stenosis or high small bowel obstruction?
- A. Loss of gastric acid (HCl) through vomiting leading to chloride depletion, while renal retention of bicarbonate and excretion of potassium maintains electrochemical balance (Correct Answer)
- B. Decreased oral intake resulting in malnutrition with preferential loss of chloride and potassium through renal excretion
- C. Bacterial overgrowth in stagnant bowel producing metabolic alkalosis with secondary electrolyte disturbances
- D. Third-space fluid sequestration causing relative concentration of bicarbonate and dilutional hyponatraemia
- E. Aldosterone excess from volume depletion causing sodium retention with proportional chloride and potassium losses
Explanation: ***Loss of gastric acid (HCl) through vomiting leading to chloride depletion, while renal retention of bicarbonate and excretion of potassium maintains electrochemical balance*** - Vomiting in **pyloric stenosis** or high small bowel obstruction causes a direct loss of **hydrogen ions (H+)** and **chloride ions (Cl-)** in gastric acid, leading to a primary **metabolic alkalosis** and **hypochloraemia**. - The resulting **volume depletion** activates the renin-angiotensin-aldosterone system, leading to renal reabsorption of **sodium** and **bicarbonate** while increasing the excretion of **potassium** and additional **hydrogen ions** in the urine (paradoxical aciduria), worsening hypokalaemia and alkalosis. *Decreased oral intake resulting in malnutrition with preferential loss of chloride and potassium through renal excretion* - **Malnutrition** and decreased oral intake typically lead to a **metabolic acidosis** (e.g., from starvation ketosis) or a neutral pH, not the profound metabolic alkalosis seen in obstruction. - The primary pathophysiological driver here is the **active mechanical loss** of highly acidic gastric contents, not a passive lack of nutrient or electrolyte intake. *Bacterial overgrowth in stagnant bowel producing metabolic alkalosis with secondary electrolyte disturbances* - **Small intestinal bacterial overgrowth (SIBO)** is more commonly associated with **malabsorption** and can lead to **metabolic acidosis** (e.g., D-lactic acidosis) rather than alkalosis. - Pyloric stenosis involves gastric outlet obstruction, where **bacterial fermentation** is not the primary mechanism explaining the specific electrolyte imbalance of hypochloraemic, hypokalaemic metabolic alkalosis. *Third-space fluid sequestration causing relative concentration of bicarbonate and dilutional hyponatraemia* - While **third-space fluid sequestration** can occur in bowel obstruction, the characteristic **hypochloraemia** and **metabolic alkalosis** are directly attributable to the loss of gastric HCl from vomiting, not just fluid shifts. - **Dilutional hyponatraemia** is inconsistent with the significant **volume contraction** and activated **renin-angiotensin-aldosterone system (RAAS)** typically observed, which promotes sodium retention. *Aldosterone excess from volume depletion causing sodium retention with proportional chloride and potassium losses* - **Aldosterone excess**, driven by **volume depletion**, does promote **sodium retention** and **potassium excretion** (contributing to hypokalaemia), but it primarily acts to conserve sodium. - The profound **chloride loss** in this condition is overwhelmingly due to the **vomiting of gastric acid**, and the kidneys actually work to avidly reabsorb chloride to compensate for volume. The chloride loss is not a proportional renal loss induced by aldosterone.
Question 15: A 72-year-old man undergoes emergency laparotomy for perforated sigmoid diverticulitis with faecal peritonitis. Hartmann's procedure is performed. On post-operative day 3, he develops fever, tachycardia, and increasing abdominal pain. CT shows fluid collection in the pelvis with gas bubbles. Drain amylase from percutaneous drainage measures 8,500 U/L (serum amylase 120 U/L). What is the most likely diagnosis?
- A. Anastomotic leak with intra-abdominal abscess
- B. Rectal stump leak with pelvic collection (Correct Answer)
- C. Pancreatic fistula from surgical trauma
- D. Infected haematoma with gas-forming organisms
- E. Small bowel perforation from unrecognised enterotomy
Explanation: ***Rectal stump leak with pelvic collection*** - In a **Hartmann's procedure**, the distal rectal stump is oversewn; a breakdown of this closure leads to a **rectal stump leak**, typically presenting with sepsis and pelvic fluid containing gas. - A **markedly elevated drain amylase** (often >3-5 times serum levels) is a known biochemical marker for **gastrointestinal tract leaks**, as gut bacteria produce amylase that accumulates in the collection. *Anastomotic leak with intra-abdominal abscess* - This diagnosis is impossible because a **Hartmann's procedure** specifically involves an end colostomy and **no primary anastomosis** is created. - While signs of sepsis and collections appear similar, the surgical anatomy of this procedure excludes this option. *Pancreatic fistula from surgical trauma* - A **pancreatic fistula** is highly unlikely given the surgical site was the **pelvis/sigmoid colon**, which is anatomically distant from the pancreas. - While amylase would be high, the patient's **serum amylase is normal**, and the presence of gas bubbles in a pelvic collection point toward a lower GI source. *Infected haematoma with gas-forming organisms* - Although an **infected haematoma** causes fever and gas on CT, it would not explain the **extremely high drain amylase** level of 8,500 U/L. - The biochemical profile of the fluid is specifically indicative of **enteric contents** or bacterial enzymes from the gut lumen. *Small bowel perforation from unrecognised enterotomy* - While **small bowel perforation** could cause high amylase and gas, it usually presents early with **generalized peritonitis** and free intraperitoneal air rather than a localized pelvic collection. - The location of the collection in the **pelvis** post-sigmoidectomy makes the **rectal stump** the most statistically likely and anatomically relevant source of the leak.
Question 16: A 64-year-old man with metastatic gastric adenocarcinoma presents with a 4-day history of severe colicky abdominal pain and absolute constipation. CT abdomen reveals dilated loops of small bowel with a transition point showing circumferential wall thickening and a central area of fatty attenuation. Multiple peritoneal deposits are noted. What is the most likely mechanism of obstruction?
- A. Intussusception with metastatic deposit acting as lead point (Correct Answer)
- B. Malignant stricture from direct tumour invasion
- C. Intraluminal tumour mass causing luminal occlusion
- D. Omental cake causing external compression of bowel loops
- E. Adhesional obstruction from previous peritoneal disease
Explanation: ***Intussusception with metastatic deposit acting as lead point*** - The CT finding of a transition point with **central fatty attenuation** represents the mesenteric fat being pulled into the lumen, which is a classic sign of **intussusception**. - In adults, a pathological **lead point** is present in over 90% of cases, and in a patient with gastric cancer, **metastatic deposits** or peritoneal seeds are common triggers.*Malignant stricture from direct tumour invasion* - While common in metastatic disease, a stricture would present as **fixed narrowing** without the inclusion of mesenteric fat within the bowel lumen. - It typically lacks the **sausage-shaped** or target-like appearance characteristic of intussuscepted bowel segments.*Intraluminal tumour mass causing luminal occlusion* - An intraluminal mass would appear as a **soft tissue density** filling the lumen but would not explain the **central fatty attenuation** observed on the CT scan. - This mechanism is less common for causing a discrete transition point with the specific imaging features of **mesenteric entrapment**.*Omental cake causing external compression of bowel loops* - An **omental cake** consists of thickened, infiltrated omentum that causes **extrinsic compression** and fixed kinking of bowel loops rather than internal telescoping. - While signs of carcinomatosis are present, the specific description of the transition point points toward **intraluminal telescoping** rather than external pressure.*Adhesional obstruction from previous peritoneal disease* - Adhesions typically show a **narrow band-like transition point** or abrupt collapse without significant wall thickening or fat entrapment. - Chronic inflammation can cause adhesions, but the **internal fatty attenuation** is a specific radiological indicator that rules out simple fibrous bands.
Question 17: A 58-year-old woman presents to the emergency department with a 12-hour history of severe periumbilical pain, vomiting, and abdominal distension. She has had multiple episodes of similar pain over the past year but they resolved spontaneously. On examination, her abdomen is distended with visible peristalsis and high-pitched bowel sounds. CT abdomen shows transition point in the mid-ileum with proximal bowel dilatation and collapsed distal bowel. A round calcified opacity is seen in the terminal ileum measuring 3.5 cm. What is the most appropriate immediate management?
- A. Emergency laparotomy with enterolithotomy and cholecystectomy (Correct Answer)
- B. Urgent ERCP with sphincterotomy and stone extraction
- C. Conservative management with nasogastric decompression and observation
- D. Colonoscopic decompression and stone retrieval
- E. Laparoscopic cholecystectomy with intraoperative cholangiogram
Explanation: ***Emergency laparotomy with enterolithotomy and cholecystectomy*** - This patient presents with **gallstone ileus**, a mechanical small bowel obstruction caused by a large gallstone traversing a **cholecystoenteric fistula**. - The immediate surgical priority is an **enterolithotomy** to remove the obstructing stone, and a concurrent **cholecystectomy** and fistula repair are performed to prevent recurrence in stable patients. *Urgent ERCP with sphincterotomy and stone extraction* - **ERCP** is indicated for stones within the **biliary tree** (e.g., common bile duct stones), not for stones that have migrated into the small intestine. - This procedure cannot address a mechanical **small bowel obstruction** located at the terminal ileum. *Conservative management with nasogastric decompression and observation* - While initial stabilization is important, **gallstone ileus** is a complete mechanical obstruction that requires surgical intervention and rarely resolves spontaneously. - Delaying definitive treatment increases the risk of **bowel ischemia**, perforation, and generalized sepsis. *Colonoscopic decompression and stone retrieval* - The obstructing stone is in the **terminal ileum**, which is part of the small bowel and typically beyond the reach of a standard colonoscope. - This procedure is indicated for **large bowel obstructions**, such as sigmoid volvulus or distal colonic foreign bodies, not for small bowel impaction. *Laparoscopic cholecystectomy with intraoperative cholangiogram* - This procedure addresses the gallbladder pathology but does not immediately relieve the acute **mechanical small bowel obstruction** caused by the impacted gallstone. - A laparoscopic approach may be technically challenging in the setting of significant bowel distension and acute obstruction, often requiring conversion to an open procedure.
Question 18: What is Chilaiditi syndrome and how does it differ from Chilaiditi sign in terms of clinical significance and management?
- A. Chilaiditi syndrome refers to symptomatic interposition of bowel between liver and diaphragm causing abdominal pain, whereas Chilaiditi sign is the asymptomatic radiological finding; syndrome requires treatment while sign is an incidental finding (Correct Answer)
- B. Chilaiditi syndrome is the presence of free intraperitoneal air indicating perforation requiring surgery, while Chilaiditi sign is pneumatosis intestinalis managed conservatively
- C. Chilaiditi syndrome refers to gas in the biliary tree from gallstone ileus requiring surgery, while Chilaiditi sign is portal venous gas from intestinal ischaemia
- D. Chilaiditi syndrome is intramural bowel gas indicating imminent perforation requiring urgent surgery, while Chilaiditi sign is simple pneumoperitoneum from recent laparoscopy
- E. Chilaiditi syndrome and sign are interchangeable terms both referring to the same asymptomatic radiological finding with no clinical significance
Explanation: ***Chilaiditi syndrome refers to symptomatic interposition of bowel between liver and diaphragm causing abdominal pain, whereas Chilaiditi sign is the asymptomatic radiological finding; syndrome requires treatment while sign is an incidental finding***- **Chilaiditi syndrome** is defined by the presence of symptoms, such as **abdominal pain**, nausea, or vomiting, caused by the **interposition of a bowel loop** between the liver and the diaphragm.- **Chilaiditi sign** is the **asymptomatic radiological finding** of bowel interposition, which is an incidental discovery requiring no specific medical or surgical intervention.*Chilaiditi syndrome is the presence of free intraperitoneal air indicating perforation requiring surgery, while Chilaiditi sign is pneumatosis intestinalis managed conservatively*- The presence of **free intraperitoneal air (pneumoperitoneum)** typically indicates a **perforated viscus**, which is a surgical emergency distinct from Chilaiditi.- **Pneumatosis intestinalis** refers to gas within the bowel wall, a condition structurally different from the interposition of normal bowel loops seen in Chilaiditi.*Chilaiditi syndrome refers to gas in the biliary tree from gallstone ileus requiring surgery, while Chilaiditi sign is portal venous gas from intestinal ischaemia*- **Gas in the biliary tree (pneumobilia)** is usually associated with conditions like **gallstone ileus** or surgical anastomoses, appearing as branching air within the bile ducts, not displaced bowel.- **Portal venous gas** is a serious sign, often indicative of **intestinal ischemia**, presenting as gas in the portal vein branches, which is unrelated to Chilaiditi sign.*Chilaiditi syndrome is intramural bowel gas indicating imminent perforation requiring urgent surgery, while Chilaiditi sign is simple pneumoperitoneum from recent laparoscopy*- **Intramural bowel gas** signifies gas within the bowel wall and suggests severe pathology, contrasting with Chilaiditi, which involves the **lumen of a displaced bowel segment**.- **Simple pneumoperitoneum** post-laparoscopy is usually benign and resolves spontaneously, whereas Chilaiditi sign shows **bowel loops with haustral markings** positioned between the liver and diaphragm.*Chilaiditi syndrome and sign are interchangeable terms both referring to the same asymptomatic radiological finding with no clinical significance*- The terms are **not interchangeable**; the key differentiator between Chilaiditi **sign** and **syndrome** is the presence or absence of **clinical symptoms**.- While the sign is asymptomatic and has no clinical significance, the **syndrome** requires evaluation and potential treatment due to associated symptoms or complications like **volvulus**.
Question 19: A 59-year-old woman presents with a 5-day history of left iliac fossa pain and fever. CT abdomen shows sigmoid diverticulitis with a 4 cm pericolic abscess. She is treated with IV antibiotics and CT-guided drainage, with good clinical response. She is discharged after 7 days. At 6-week follow-up outpatient review, she is asymptomatic and has fully recovered. Colonoscopy performed 4 weeks post-discharge shows diverticular disease but no other abnormality. What is the most appropriate ongoing management?
- A. Routine elective sigmoid colectomy should be offered during this admission to prevent recurrence
- B. Conservative management with high-fibre diet and advise surgery only if further complicated episodes occur (Correct Answer)
- C. Repeat CT in 3 months and consider surgery if abscess has not completely resolved
- D. Urgent sigmoid colectomy within 2-4 weeks while inflammation has settled but before dense adhesions form
- E. Long-term prophylactic rotating antibiotics to prevent recurrence
Explanation: ***Conservative management with high-fibre diet and advise surgery only if further complicated episodes occur***- For a first episode of **complicated diverticulitis** (Hinchey grade Ib) successfully treated with **CT-guided drainage** and followed by a normal colonoscopy, conservative management is now preferred over routine surgery.- Current guidelines recommend a **high-fibre diet** and lifestyle modifications, reserving **elective sigmoid colectomy** for patients with recurrent episodes or persistent symptoms.*Routine elective sigmoid colectomy should be offered during this admission to prevent recurrence*- Routine surgery after a single episode of complicated diverticulitis is no longer mandatory; the decision is now **individualized** based on patient factors and lifestyle impact.- Performing surgery during the **initial admission** for diverticulitis increases the risk of complications and the likelihood of needing a **stoma**.*Repeat CT in 3 months and consider surgery if abscess has not completely resolved*- This patient is **asymptomatic** and her colonoscopy was normal; there is no clinical indication for repeat cross-sectional imaging in the absence of symptoms.- Clinical response and **normalized inflammatory markers** are better indicators of resolution than serial CT scans for an successfully drained abscess.*Urgent sigmoid colectomy within 2-4 weeks while inflammation has settled but before dense adhesions form*- Surgery within this timeframe is associated with higher **morbidity** due to residual tissue inflammation and fragility.- Most surgeons wait at least **6 to 8 weeks** if surgery is indicated to allow for complete resolution of the inflammatory process.*Long-term prophylactic rotating antibiotics to prevent recurrence*- There is no evidence supporting the use of **long-term antibiotics** to prevent diverticulitis recurrence, and it increases the risk of **antibiotic resistance** and C. diff infection.- Management focuses on **fiber intake** and general gut health rather than pharmacological prophylaxis with antimicrobials.
Question 20: Which of the following biochemical and physiological changes occurs earliest in the pathophysiological sequence of complete small bowel obstruction?
- A. Metabolic alkalosis with hypochloraemia due to loss of gastric hydrochloric acid (Correct Answer)
- B. Metabolic acidosis with elevated lactate due to bacterial translocation
- C. Hypovolaemic shock from third-space fluid sequestration
- D. Hyperkalaemia from cellular breakdown and reduced renal excretion
- E. Respiratory acidosis from abdominal distension limiting diaphragmatic excursion
Explanation: ***Metabolic alkalosis with hypochloraemia due to loss of gastric hydrochloric acid*** - Early in **small bowel obstruction**, proximal accumulation of secretions leads to profuse **vomiting**, resulting in significant loss of **hydrogen (H+)** and **chloride (Cl-)** ions.- This loss, coupled with **volume contraction** which triggers aldosterone-mediated sodium reabsorption and further H+ excretion, produces a classic **hypochloraemic metabolic alkalosis**.*Metabolic acidosis with elevated lactate due to bacterial translocation*- This is a **late-stage** complication typically seen after 24-48 hours when **bowel ischemia** or severe **strangulation** leads to tissue hypoperfusion.- **Bacterial translocation** and sepsis contribute to lactic acid production, which occurs well after the initial electrolyte disturbances of proximal obstruction.*Hypovolaemic shock from third-space fluid sequestration*- **Third-space fluid sequestration** is an intermediate process where fluid moves into the bowel lumen and wall due to increased **intraluminal pressure**.- While it leads to **hypovolemia**, it generally follows the initial fluid and electrolyte losses from primary **vomiting**.*Hyperkalaemia from cellular breakdown and reduced renal excretion*- Obstruction initially causes **hypokalaemia** due to gastric losses and aldosterone-driven renal excretion in response to contraction.- **Hyperkalaemia** occurs only as a late finding in the context of **acute kidney injury** or extensive **tissue necrosis** (gangrenous bowel).*Respiratory acidosis from abdominal distension limiting diaphragmatic excursion*- This occurs as a result of severe **abdominal distension** interfering with ventilation, typically seen in very late or extremely **distal obstructions**.- It is rarely the primary or earliest biochemical change, as **metabolic derangements** from vomiting and fluid shifts manifest much sooner.
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