Acute Surgical Presentations — MCQs
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A 36-year-old woman with Crohn's disease presents with a 24-hour history of severe right lower quadrant pain, fever (38.6°C), and vomiting. She has been on azathioprine for 3 years. CT shows terminal ileal wall thickening with surrounding fat stranding, a 4cm abscess in the right iliac fossa, and proximal small bowel dilatation. What is the most appropriate management strategy?
What is the most common site of colonic perforation in patients with large bowel obstruction?
A 52-year-old woman with rheumatoid arthritis on methotrexate and NSAIDs presents with a 6-hour history of severe generalized abdominal pain. She appears unwell with a temperature of 38.4°C, pulse 126 bpm, BP 98/62 mmHg. Examination shows generalized peritonism. CT shows pneumoperitoneum and free intraperitoneal fluid. At laparotomy, a 2cm perforation is found in the gastric antrum with 500ml of contaminated fluid. What is the most appropriate surgical procedure?
A 41-year-old man presents with a 12-hour history of central abdominal pain, multiple episodes of bilious vomiting, and inability to pass flatus. He has had three previous laparotomies for trauma. Examination shows a distended abdomen with tinkling bowel sounds. Abdominal X-ray shows multiple dilated small bowel loops with valvulae conniventes visible. What is the most appropriate initial management?
A 78-year-old woman presents with a 2-day history of severe left lower quadrant pain, fever, and anorexia. CT abdomen shows sigmoid diverticulitis with a 6cm pericolic abscess and localized free air. She is haemodynamically stable. WCC 16.4 × 10⁹/L, CRP 198 mg/L. What is the most appropriate management according to current guidelines?
Which of the following CT findings in a patient with small bowel obstruction is most specific for requiring urgent surgical intervention?
A 64-year-old woman with a history of previous hysterectomy presents with a 3-day history of colicky abdominal pain, vomiting, and absolute constipation. CT scan shows dilated small bowel loops with a transition point in the pelvis and a 'whirl sign' of mesenteric vessels. There is no evidence of bowel ischaemia. What is the underlying cause of her obstruction?
A 57-year-old man with known peptic ulcer disease presents with sudden onset severe epigastric pain and vomiting 3 hours ago. Examination shows generalized peritonism with board-like rigidity. Erect chest X-ray shows free air under the diaphragm. Blood pressure 108/68 mmHg, pulse 118 bpm. He last ate 6 hours ago. What is the most appropriate surgical approach?
A 69-year-old man with no previous abdominal surgery presents with a 4-day history of abdominal distension, vomiting, and absolute constipation. Abdominal X-ray shows grossly dilated large bowel with maximum caecal diameter of 11cm and loss of haustra in the sigmoid colon creating a 'coffee bean' sign. What is the most appropriate initial management?
A 33-year-old woman presents with a 10-hour history of sudden onset severe right iliac fossa pain. She has had two previous caesarean sections. On examination, she has guarding and rebound tenderness in the right iliac fossa. Temperature 37.2°C, pulse 104 bpm, BP 128/82 mmHg. Urine pregnancy test is negative. CT abdomen shows free fluid and a thick-walled tubular structure in the right iliac fossa with periappendiceal fat stranding. What is the most appropriate management?
Acute Surgical Presentations UK Medical PG Practice Questions and MCQs
Question 211: A 36-year-old woman with Crohn's disease presents with a 24-hour history of severe right lower quadrant pain, fever (38.6°C), and vomiting. She has been on azathioprine for 3 years. CT shows terminal ileal wall thickening with surrounding fat stranding, a 4cm abscess in the right iliac fossa, and proximal small bowel dilatation. What is the most appropriate management strategy?
- A. Increase immunosuppression and start biologics (anti-TNF therapy)
- B. IV antibiotics, percutaneous drainage, optimize nutrition, then elective surgery in 6-12 weeks (Correct Answer)
- C. Emergency ileocaecal resection with primary anastomosis
- D. Emergency ileocaecal resection with ileostomy formation
- E. IV corticosteroids and antibiotics only
Explanation: ***IV antibiotics, percutaneous drainage, optimize nutrition, then elective surgery in 6-12 weeks*** - For a **Crohn's disease** patient with an **intra-abdominal abscess**, the primary goal is to control sepsis via **percutaneous CT-guided drainage** and **IV antibiotics** before considering surgical intervention. - A staged approach allows for **nutritional optimization** and time to taper immunosuppressants, which significantly reduces the risk of **anastomotic leakage** and postoperative complications compared to emergency surgery. *Increase immunosuppression and start biologics (anti-TNF therapy)* - Initiating **biologics** or increasing immunosuppression is strictly contraindicated in the presence of an **active intra-abdominal abscess** as it can lead to worsening sepsis and infection dissemination. - Sepsis must be fully resolved and the abscess drained before **anti-TNF therapy** can be safely resumed or escalated. *Emergency ileocaecal resection with primary anastomosis* - Performing a **primary anastomosis** in the setting of active sepsis, **malnutrition**, and chronic azathioprine use carries a dangerously high risk of **anastomotic breakdown** and subsequent peritonitis. - Emergency surgery is typically reserved only for patients with **free perforation**, generalized peritonitis, or those who fail conservative drainage. *Emergency ileocaecal resection with ileostomy formation* - While an **ileostomy** is safer than a primary anastomosis in an emergency, it is still more morbid than a **staged elective approach** for a stable patient with a drainable abscess. - Preoperative optimization over 6-12 weeks often allows for a successful **primary anastomosis** later, avoiding the need for a temporary stoma. *IV corticosteroids and antibiotics only* - **IV corticosteroids** should generally be avoided in the acute phase of an abscess as they can impair the body's ability to localize the infection and delay **wound healing**. - Medical therapy alone is insufficient to treat a 4cm abscess with associated **proximal small bowel dilatation**, which indicates a mechanical component likely requiring surgical resection.
Question 212: What is the most common site of colonic perforation in patients with large bowel obstruction?
- A. Site of obstructing lesion
- B. Caecum (Correct Answer)
- C. Sigmoid colon
- D. Splenic flexure
- E. Rectosigmoid junction
Explanation: ***Caecum*** - According to **Laplace's Law**, the wall tension in a hollow organ is proportional to its radius; since the **caecum** has the largest diameter in the colon, it experiences the highest tension. - Perforation typically occurs in a **closed-loop obstruction** where a competent **ileocaecal valve** prevents decompression into the small bowel, leading to rapid distension and **ischemia**. *Site of obstructing lesion* - Perforation here is less common and usually occurs secondary to **direct tumor necrosis** or localized inflammation rather than global pressure changes. - The segments proximal to the obstruction, particularly the caecum, bear the brunt of increased **intraluminal pressure**. *Sigmoid colon* - While the sigmoid is a common site for the **obstructing lesion** itself (e.g., malignancy or volvulus), it is rarely the site of secondary pressure-induced perforation. - Its thicker muscular wall and smaller diameter compared to the caecum make it more **resistant to wall tension**. *Splenic flexure* - This area is a **watershed zone** (Griffith's point) more prone to **ischemic colitis** rather than pressure-induced perforation from distal obstruction. - It does not possess the large diameter required to reach the threshold of **critical wall tension** seen in the caecum. *Rectosigmoid junction* - This is a common location for **annular carcinomas** which cause the obstruction, but the resulting proximal pressure shift bypasses this narrow region. - Under high intraluminal pressure, thin-walled proximal structures like the **caecum** fail long before the thick-walled rectosigmoid junction.
Question 213: A 52-year-old woman with rheumatoid arthritis on methotrexate and NSAIDs presents with a 6-hour history of severe generalized abdominal pain. She appears unwell with a temperature of 38.4°C, pulse 126 bpm, BP 98/62 mmHg. Examination shows generalized peritonism. CT shows pneumoperitoneum and free intraperitoneal fluid. At laparotomy, a 2cm perforation is found in the gastric antrum with 500ml of contaminated fluid. What is the most appropriate surgical procedure?
- A. Simple omental patch repair only (Correct Answer)
- B. Omental patch repair with highly selective vagotomy
- C. Omental patch repair with truncal vagotomy and pyloroplasty
- D. Distal gastrectomy with Billroth II reconstruction
- E. Distal gastrectomy with Roux-en-Y reconstruction
Explanation: ***Simple omental patch repair only*** - In the emergency setting of a **perforated peptic ulcer** with generalized peritonitis and hemodynamic instability, a simple, quick procedure like the **Graham patch** is the gold standard. - Definitive surgery is rarely indicated today because **Proton Pump Inhibitors (PPIs)** and **H. pylori eradication** effectively manage the underlying disease postoperatively. *Omental patch repair with highly selective vagotomy* - Adding a **highly selective vagotomy** significantly increases **operative time** and complexity in a patient who is already hemodynamically compromised. - There is no evidence that adding acid-reducing surgery in the acute phase improves outcomes compared to medical therapy with **PPIs**. *Omental patch repair with truncal vagotomy and pyloroplasty* - This procedure carries a high risk of postoperative complications such as **dumping syndrome** and requires a longer time under anesthesia while the patient is in **sepsis**. - Modern medical management has made this aggressive surgical approach to **peptic ulcer disease** largely obsolete in the acute setting. *Distal gastrectomy with Billroth II reconstruction* - A **distal gastrectomy** is excessive for a simple perforation and carries high morbidity and mortality in the presence of **peritoneal contamination**. - This procedure is generally reserved for gastric cancer or cases where the ulcer morphology makes a **patch repair** technically impossible. *Distal gastrectomy with Roux-en-Y reconstruction* - Similar to Billroth II, this is an extensive operation that is contraindicated in a patient showing signs of **systemic inflammatory response** and septic shock. - The primary goal in this emergency is **source control** through simple closure rather than definitive resection of the stomach.
Question 214: A 41-year-old man presents with a 12-hour history of central abdominal pain, multiple episodes of bilious vomiting, and inability to pass flatus. He has had three previous laparotomies for trauma. Examination shows a distended abdomen with tinkling bowel sounds. Abdominal X-ray shows multiple dilated small bowel loops with valvulae conniventes visible. What is the most appropriate initial management?
- A. Emergency laparotomy within 6 hours
- B. Conservative management with 'drip and suck' approach
- C. Laparoscopic adhesiolysis
- D. Water-soluble contrast study followed by early surgery if no resolution (Correct Answer)
- E. Conservative management for 72 hours then reassess
Explanation: ***Water-soluble contrast study followed by early surgery if no resolution*** - The presence of **abdominal pain**, **bilious vomiting**, **inability to pass flatus**, **distended abdomen**, **tinkling bowel sounds**, and **dilated small bowel loops with valvulae conniventes** on X-ray, combined with a history of **three previous laparotomies**, strongly points to **adhesive small bowel obstruction (SBO)**. - A **water-soluble contrast study** (e.g., Gastrografin) is both diagnostic and therapeutic. If contrast reaches the colon within 4-24 hours, it predicts resolution. Its **hyperosmolar** effect can draw fluid into the bowel lumen, reducing edema and stimulating peristalsis, often resolving the obstruction and guiding the need for surgery. *Emergency laparotomy within 6 hours* - Most cases of **adhesive SBO** resolve with non-operative management (60-80%). Emergency surgery is indicated only when there are signs of **strangulation** or **peritonitis**, such as fever, localized tenderness, increasing leukocytosis, or metabolic acidosis, which are not present here. - An immediate laparotomy without attempting conservative measures or a contrast study would subject the patient to an potentially unnecessary operation with its inherent risks, especially given a history of **multiple previous surgeries**. *Conservative management with 'drip and suck' approach* - **Intravenous fluids** ('drip') for hydration and **nasogastric tube decompression** ('suck') are essential supportive measures for SBO, but they are not a complete management strategy on their own. - This approach lacks the **diagnostic and therapeutic benefits** of a water-soluble contrast study, which can actively aid in resolution and provide critical prognostic information regarding the need for surgery. *Laparoscopic adhesiolysis* - With a history of **three previous laparotomies**, the likelihood of **dense and extensive intra-abdominal adhesions** is very high, making laparoscopic adhesiolysis technically challenging. - This approach carries a significantly elevated risk of **iatrogenic bowel injury** (enterotomy) and often necessitates conversion to an open procedure, making it an unsuitable initial management choice in this patient. *Conservative management for 72 hours then reassess* - While initial conservative management is appropriate, waiting for a full **72 hours** without an active measure to assess resolution (like a contrast study) can unduly delay definitive intervention if the obstruction is complete or fails to resolve. - Prolonged conservative management without progress increases the risk of **ischemia**, **bowel necrosis**, and **perforation**, leading to higher morbidity and mortality. A contrast study provides earlier and more definitive prognostic information.
Question 215: A 78-year-old woman presents with a 2-day history of severe left lower quadrant pain, fever, and anorexia. CT abdomen shows sigmoid diverticulitis with a 6cm pericolic abscess and localized free air. She is haemodynamically stable. WCC 16.4 × 10⁹/L, CRP 198 mg/L. What is the most appropriate management according to current guidelines?
- A. Emergency laparotomy with Hartmann's procedure
- B. IV antibiotics and percutaneous CT-guided drainage of abscess (Correct Answer)
- C. IV antibiotics alone with close monitoring
- D. Laparoscopic peritoneal lavage and drainage
- E. Emergency laparotomy with sigmoid resection and primary anastomosis
Explanation: ***IV antibiotics and percutaneous CT-guided drainage of abscess***- This patient presents with **Hinchey Stage II diverticulitis** due to a large (6cm) **pericolic abscess** and is **hemodynamically stable**.- **CT-guided percutaneous drainage** combined with **IV antibiotics** is the recommended management for large, localized abscesses in stable patients, providing effective source control and avoiding emergent surgery.*Emergency laparotomy with Hartmann's procedure*- This aggressive surgical procedure is typically reserved for patients with **generalized peritonitis** (Hinchey III/IV) or those who are **hemodynamically unstable**.- It is excessive for a stable patient with a **localized abscess** that can be managed less invasively, carrying higher morbidity and mortality risks.*IV antibiotics alone with close monitoring*- While appropriate for uncomplicated diverticulitis or very small abscesses (<3-4 cm), **antibiotics alone** are insufficient to resolve a **6 cm pericolic abscess**.- Large collections require **mechanical drainage** for effective source control and resolution of systemic inflammatory response.*Laparoscopic peritoneal lavage and drainage*- This technique is primarily considered for **generalized purulent peritonitis** (Hinchey III), though its efficacy remains debated and it has largely fallen out of favor due to high re-intervention rates.- It is not the appropriate treatment for a **localized, drainable abscess**, where percutaneous drainage is superior and less invasive.*Emergency laparotomy with sigmoid resection and primary anastomosis*- This is an **emergency surgical intervention** that is too aggressive for a stable patient whose abscess can be managed by percutaneous drainage.- Primary anastomosis in an acutely inflamed field carries a higher risk of **anastomotic leak** and complications compared to a delayed elective resection.
Question 216: Which of the following CT findings in a patient with small bowel obstruction is most specific for requiring urgent surgical intervention?
- A. Small bowel diameter greater than 3cm
- B. Presence of transition point
- C. Closed loop configuration with C-shaped dilated bowel (Correct Answer)
- D. Collapsed large bowel distal to obstruction
- E. Small amount of free fluid in the pelvis
Explanation: ***Closed loop configuration with C-shaped dilated bowel***- This finding indicates that a segment of bowel is obstructed at **two points**, which prevents decompression and carries an extremely high risk of **strangulation and ischemia**.- It is a classic CT hallmark of a **surgical emergency** as it can rapidly progress to perforation and necrosis within hours.*Small bowel diameter greater than 3cm*- While a diameter of >3cm is a key diagnostic criterion for **mechanical small bowel obstruction**, it does not inherently indicate the need for surgery.- Many patients with this degree of dilation can be successfully managed **conservatively** with nasogastric decompression and bowel rest.*Presence of transition point*- A **transition point** confirms the presence and location of a mechanical obstruction but does not specify the etiology or the presence of **ischemic complications**.- Adhesive obstructions often show a transition point but can frequently be resolved with **non-operative management**.*Collapsed large bowel distal to obstruction*- This is a secondary sign of **complete or near-complete obstruction** in the proximal intestinal tract but does not indicate bowel wall compromise.- It helps differentiate between a small bowel obstruction and a **paralytic ileus**, but it is not a specific indication for urgent surgery.*Small amount of free fluid in the pelvis*- **Intraperitoneal fluid** is a common finding in many types of bowel obstruction due to venous congestion and third-spacing.- It is a non-specific sign and, unless it is associated with **pneumoperitoneum** or high-density fluid suggesting hemorrhage, it does not mandate immediate surgical intervention.
Question 217: A 64-year-old woman with a history of previous hysterectomy presents with a 3-day history of colicky abdominal pain, vomiting, and absolute constipation. CT scan shows dilated small bowel loops with a transition point in the pelvis and a 'whirl sign' of mesenteric vessels. There is no evidence of bowel ischaemia. What is the underlying cause of her obstruction?
- A. Adhesional small bowel obstruction
- B. Internal hernia (Correct Answer)
- C. Small bowel volvulus
- D. Closed loop obstruction from adhesions
- E. Intussusception
Explanation: ***Internal hernia***- The presence of a **'whirl sign'** on CT, indicating **mesenteric vessel** and bowel rotation, is a classic finding for an internal hernia through a defect.- A history of **pelvic surgery** like a hysterectomy can create peritoneal or **broad ligament defects**, predisposing to internal hernias where bowel twists as it herniates.*Adhesional small bowel obstruction*- While common post-surgery, **adhesional SBO** typically shows a simple **transition point** without the specific **rotational whirl sign**.- Adhesions usually cause **kinking or compression**, rather than the twisting of the mesentery seen in this case.*Small bowel volvulus*- This can also produce a **whirl sign**, but it typically involves rotation around the **superior mesenteric artery** and is less common as a primary event in the pelvis without underlying malrotation.- In this scenario, a structural defect from previous surgery makes an internal hernia a more specific diagnosis.*Closed loop obstruction from adhesions*- This involves obstruction at **two points** by a single cause, often leading to rapid **bowel ischemia** due to vascular compromise.- Although serious, it does not inherently feature the characteristic **mesenteric whirl sign** unless complicated by a secondary volvulus.*Intussusception*- In adults, **intussusception** is often secondary to a **lead point** (e.g., tumor) and typically presents with a **'target sign'** on imaging.- It involves telescoping of bowel segments but not the distinct **mesenteric vessel rotation** described by the whirl sign.
Question 218: A 57-year-old man with known peptic ulcer disease presents with sudden onset severe epigastric pain and vomiting 3 hours ago. Examination shows generalized peritonism with board-like rigidity. Erect chest X-ray shows free air under the diaphragm. Blood pressure 108/68 mmHg, pulse 118 bpm. He last ate 6 hours ago. What is the most appropriate surgical approach?
- A. Emergency laparoscopic repair with omental patch within 2 hours (Correct Answer)
- B. Urgent laparotomy within 6 hours after adequate resuscitation
- C. Conservative management with IV proton pump inhibitors and antibiotics
- D. Diagnostic laparoscopy followed by conversion to laparotomy
- E. Delayed surgery after 24 hours of optimization with total parenteral nutrition
Explanation: ***Emergency laparoscopic repair with omental patch within 2 hours*** - This patient presents with classical signs of **perforated peptic ulcer**, including **pneumoperitoneum** (free air under the diaphragm) and **board-like rigidity**, requiring emergent surgical intervention. - **Laparoscopic repair** with a Graham **omental patch** is the preferred surgical approach in hemodynamically stable patients, as it reduces recovery time and wound complications, with a goal of intervention ideally **within 2 hours**. *Urgent laparotomy within 6 hours after adequate resuscitation* - While **laparotomy** is a valid alternative if laparoscopy is not feasible, the goal for a known perforation with generalized peritonitis is immediate intervention, ideally much sooner than delaying up to 6 hours. - The term "urgent" is less appropriate than **emergent** given the clear clinical evidence of widespread **peritonitis** and potential for rapid septic decline, making immediate source control paramount. *Conservative management with IV proton pump inhibitors and antibiotics* - Conservative management (Taylor method) is only considered for highly selected cases of **contained perforations** in stable patients presenting late (>24 hours) with minimal peritonitis. - It is contraindicated here due to **generalized peritonism**, **board-like rigidity**, and the acuity of the presentation (3 hours ago), indicating active and spreading contamination. *Diagnostic laparoscopy followed by conversion to laparotomy* - While **diagnostic laparoscopy** is often the initial approach, the aim is to proceed with definitive repair via a minimally invasive approach if possible, not an automatic conversion to **laparotomy**. - Many perforated ulcers can be managed entirely via **laparoscopic repair**, avoiding the increased morbidity associated with a large incision unless specific indications for conversion arise. *Delayed surgery after 24 hours of optimization with total parenteral nutrition* - Delaying surgery for 24 hours in the setting of **pneumoperitoneum** and peritonitis will lead to severe **sepsis**, multisystem organ failure, and significantly increased mortality. - **Total parenteral nutrition (TPN)** is not indicated for the acute management of a surgical emergency and should never delay immediate **source control** through surgery.
Question 219: A 69-year-old man with no previous abdominal surgery presents with a 4-day history of abdominal distension, vomiting, and absolute constipation. Abdominal X-ray shows grossly dilated large bowel with maximum caecal diameter of 11cm and loss of haustra in the sigmoid colon creating a 'coffee bean' sign. What is the most appropriate initial management?
- A. Emergency laparotomy with sigmoid colectomy and end colostomy
- B. Flexible sigmoidoscopy with rectal tube insertion (Correct Answer)
- C. Gastrografin enema followed by reassessment
- D. IV fluids, NBM, and nasogastric decompression only
- E. Emergency CT colonography to confirm diagnosis
Explanation: ***Flexible sigmoidoscopy with rectal tube insertion***- This patient presents with a **sigmoid volvulus**, evidenced by the classic **'coffee bean' sign** on X-ray and clinical signs of large bowel obstruction.- **Endoscopic decompression** via flexible sigmoidoscopy is the first-line treatment in the absence of peritonitis, as it provides immediate relief and prevents **caecal perforation** (risk increases at >10-12cm). *Emergency laparotomy with sigmoid colectomy and end colostomy*- This surgical approach (**Hartmann's procedure**) is reserved for patients with signs of **bowel ischemia**, **perforation**, or when endoscopic decompression fails.- Immediate surgery carries higher morbidity and mortality compared to semi-elective surgery performed after the patient has been stabilized following successful **endoscopic reduction**. *Gastrografin enema followed by reassessment*- Gastrografin enemas are primarily used for diagnosing and managing **pseudo-obstruction** (Ogilvie's syndrome) or for resolving **meconium ileus**, rather than mechanical volvulus.- In the case of a sigmoid volvulus, this procedure is less effective than **sigmoidoscopy** and carries a risk of failing to provide adequate decompression. *IV fluids, NBM, and nasogastric decompression only*- While these are essential supportive measures for any intestinal obstruction, they are insufficient to resolve a **mechanical twisting** of the sigmoid colon.- Relying solely on conservative management in a patient with an **11cm caecal diameter** would likely lead to progressive ischemia and eventual rupture. *Emergency CT colonography to confirm diagnosis*- A **CT colonography** is unnecessary and potentially harmful due to the risk of perforation from insufflation in an already obstructed, dilated bowel.- The **abdominal X-ray** findings are classic and diagnostic; further imaging would delay the critical **decompression** needed to prevent bowel necrosis.
Question 220: A 33-year-old woman presents with a 10-hour history of sudden onset severe right iliac fossa pain. She has had two previous caesarean sections. On examination, she has guarding and rebound tenderness in the right iliac fossa. Temperature 37.2°C, pulse 104 bpm, BP 128/82 mmHg. Urine pregnancy test is negative. CT abdomen shows free fluid and a thick-walled tubular structure in the right iliac fossa with periappendiceal fat stranding. What is the most appropriate management?
- A. Conservative management with IV antibiotics
- B. Diagnostic laparoscopy and proceed as indicated (Correct Answer)
- C. CT-guided percutaneous drainage
- D. Ultrasound scan to exclude ovarian pathology first
- E. Open appendicectomy via Lanz incision
Explanation: ***Diagnostic laparoscopy and proceed as indicated*** - This patient presents with signs of **peritonitis** (guarding, rebound tenderness) and CT findings consistent with **acute appendicitis** (thick-walled tubular structure, periappendiceal fat stranding, free fluid), making prompt surgical intervention mandatory. - **Laparoscopy** is the preferred approach as it offers both diagnostic certainty, especially in women of reproductive age to rule out gynecological pathology, and definitive treatment, alongside advantages like less pain and faster recovery. *Conservative management with IV antibiotics* - The presence of **peritoneal signs** like guarding and rebound tenderness indicates a higher risk of appendiceal perforation and complications, making conservative management generally inappropriate. - This approach is typically reserved for highly selected cases of **uncomplicated appendicitis** or a well-formed appendiceal phlegmon without signs of peritonitis. *CT-guided percutaneous drainage* - This intervention is indicated for a well-defined, **localized intra-abdominal abscess** that is amenable to drainage, which is not described in the CT findings. - The CT scan shows a **thick-walled tubular structure** consistent with inflamed appendix and periappendiceal stranding, not a drainable fluid collection. *Ultrasound scan to exclude ovarian pathology first* - A **CT scan** has already been performed and has provided a clear diagnosis of acute appendicitis, making a subsequent ultrasound scan redundant and a cause of unnecessary **delay to definitive surgical management**. - While ultrasound is a valuable initial imaging tool in women with right iliac fossa pain, its diagnostic utility is superseded by the positive findings on the CT abdomen in this case. *Open appendicectomy via Lanz incision* - Although effective, **laparoscopic appendicectomy** is generally preferred over open surgery due to benefits like reduced postoperative pain, faster recovery, and better cosmetic outcomes. - Given her history of **previous caesarean sections**, a laparoscopic approach also offers better visualization and safer navigation around potential **adhesions**, which could complicate an open approach.
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