Acute Surgical Presentations Practice Questions

Q: What is the most common cause of large bowel obstruction in adults in the United Kingdom?

Colorectal carcinoma. ***Colorectal carcinoma*** - **Colorectal carcinoma** is the most common cause of **large bowel obstruction** in the UK, accounting for approximately **60%** of all cases. - Obstruction is most frequently seen with **left-sided tumors** in the sigmoid colon or rectosigmoid junction due to a narrower lumen and more **solid stool**. *Sigmoid volvulus* - This is the **second most common** cause of large bowel obstruction, representing roughly **15-20%** of cases in Western populations. - It is more common in **elderly, institutionalized** patients or those with chronic constipation leading to a redundant sigmoid colon. *Diverticular stricture* - **Diverticular disease** can cause large bowel obstruction via **chronic inflammation** and fibrosis leading to **stricture formation**, occurring in about 10-15% of cases. - Differentiation from malignancy often requires **CT imaging** or endoscopy once the acute phase of obstruction is resolved. *Adhesions* - While **adhesions** are the leading cause of **small bowel obstruction**, they are an **extremely rare** cause of large bowel obstruction. - This is because the large bowel is relatively **fixed retroperitoneally** and has a larger diameter compared to the small intestine. *Hernia* - Incarcerated **hernias** are a frequent cause of small bowel obstruction but represent an **uncommon** etiology for large bowel obstruction. - Only certain segments like the **sigmoid colon** or **cecum** inside an inguinal or femoral sac can lead to a large bowel blockage.

Q: A 29-year-old man presents with sudden onset severe generalized abdominal pain following blunt trauma to the abdomen during a football match 3 hours ago. On examination, he has generalized tenderness and guarding with absent bowel sounds. HR 118 bpm, BP 105/68 mmHg. FAST scan is negative. CT with IV contrast shows free fluid, bowel wall thickening in the jejunum, and subtle discontinuity of the bowel wall. What is the most appropriate management?

Emergency laparotomy. ***Emergency laparotomy*** - The patient presents with **peritonitis** (guarding, generalized tenderness, absent bowel sounds) and CT evidence of **hollow viscus injury**, which are absolute indications for immediate surgical exploration. - Findings of **bowel wall discontinuity**, unexplained free fluid, and thickening of the jejunum after blunt trauma signify a high risk of **bowel perforation** or ischemia. *Observation with serial abdominal examinations* - This approach is only appropriate for hemodynamically stable patients with **mild symptoms** and reassuring imaging studies. - Delaying surgery in the presence of **clinical peritonitis** and CT findings of bowel injury significantly increases the risk of **sepsis** and mortality. *Diagnostic peritoneal lavage* - This procedure has largely been replaced by **FAST** and CT; it is non-specific and cannot confirm the need for surgery better than the already performed CT. - A **negative FAST** scan often occurs in hollow viscus injury because it is designed to detect large volumes of **hemoperitoneum**, not small amounts of enteric fluid. *Repeat CT in 6 hours* - Repeating imaging causes an unnecessary delay in management for a patient who already has a **surgical abdomen**. - Substantial clinical deterioration from **peritonitis** would likely occur during the waiting period, leading to worse surgical outcomes. *Laparoscopic exploration* - While minimally invasive, **emergency laparotomy** remains the gold standard for definitive repair and thorough inspection of the entire bowel in **blunt trauma**. - Hemodynamic instability (tachycardia) and the potential for **mesenteric injuries** often necessitate the better visualization and access provided by an open approach.

Q: A 67-year-old woman taking long-term NSAIDs for osteoarthritis presents with sudden onset severe generalized abdominal pain for 4 hours. On examination, she has a rigid, board-like abdomen with absent bowel sounds and rebound tenderness. HR 105 bpm, BP 110/70 mmHg. Erect CXR shows free air under the diaphragm. After resuscitation, what is the most appropriate definitive management?

Emergency laparotomy. ***Emergency laparotomy*** - The patient presents with **pneumoperitoneum** (free air under the diaphragm) and **generalized peritonitis** (rigid, board-like abdomen), necessitating immediate surgical intervention to source-control the perforation. - An **omental patch repair** (Graham patch) is the standard procedure used during laparotomy to seal a **perforated peptic ulcer**, typically caused by chronic **NSAID use** in this demographic. *Urgent upper GI endoscopy* - This procedure is strictly **contraindicated** in suspected perforation as **insufflation of air** can worsen the pneumoperitoneum and tension in the peritoneal cavity. - Endoscopy is used to manage **bleeding ulcers**, but not perforated ones where surgical closure is required. *Conservative management with IV proton pump inhibitors and antibiotics* - Known as **Taylor’s approach**, this is reserved only for clinically stable patients with **sealed-off perforations** and no signs of peritonitis. - This patient has **peritonitis and tachycardia**, indicating an active surgical emergency that cannot be managed with medication alone. *Laparoscopic repair within 24 hours* - While laparoscopy is a valid surgical technique, the phrase "within 24 hours" implies an unnecessary delay for a patient with **acute peritonitis**. - **Emergency intervention** is required immediately after resuscitation to minimize the risk of developing **septic shock**. *CT abdomen to confirm diagnosis before surgery* - A **CT scan** is unnecessary and results in a **delay of care** because the diagnosis of perforation is already confirmed by the **Erect CXR** showing free gas. - Clinical signs of a **rigid abdomen** and radiologic evidence of free air provide sufficient indication for immediate surgery.

Q: A 34-year-old woman presents with sudden onset severe epigastric pain radiating to the back, nausea and vomiting for 8 hours. She drinks 40 units of alcohol weekly. BP 100/65 mmHg, HR 115 bpm, temperature 37.9°C. Examination reveals epigastric tenderness with guarding. Serum amylase is 1850 U/L. CT shows pancreatic oedema and peripancreatic fluid stranding. What is her modified Glasgow score?

Cannot be calculated without complete laboratory parameters. ***Cannot be calculated without complete laboratory parameters*** - The **modified Glasgow (Imrie) score** requires evaluation of 8 specific parameters (PANCREAS mnemonic) including **PaO2, white cell count, calcium, urea, LDH, albumin, and glucose**. - While the patient's age (34 years) contributes 0 points, the absence of these other crucial **laboratory parameters** prevents calculation of a complete score. *2 points* - The patient's **tachycardia** (HR 115 bpm) and **hypotension** (BP 100/65 mmHg) are signs of systemic response to pancreatitis but are **not direct criteria** in the modified Glasgow score. - The scoring system prioritizes **biochemical markers** and **arterial blood gas results**, not vital signs alone, for prognosis. *3 points* - A score of 3 points or more indicates **severe acute pancreatitis**, but this classification requires at least three positive biochemical or age-related parameters. - We lack essential data such as **hypocalcaemia** or **hyperglycaemia** to determine if 3 points are met. *4 points* - This score implies a more severe disease, necessitating four positive criteria from the **PANCREAS** mnemonic, such as **Urea >16 mmol/L** or **Albumin <32 g/L**, which are not provided. - Higher scores are associated with increased risk of **pancreatic necrosis** and systemic complications, requiring more aggressive management. *5 points* - A score of 5 represents a very high risk of **mortality** and **multi-organ failure**, which cannot be assigned solely based on clinical presentation. - While **serum amylase** (1850 U/L) confirms the diagnosis of pancreatitis, its level is **not included** in the modified Glasgow prognostic scoring criteria.

Question 1

What is the most common cause of large bowel obstruction in adults in the United Kingdom?

Accepted Answer

Colorectal carcinoma

Answer

Sigmoid volvulus

Answer

Diverticular stricture

Answer

Adhesions

Answer

Hernia

Question 2

A 71-year-old man with atrial fibrillation presents with sudden onset severe periumbilical pain for 2 hours. The pain is out of proportion to examination findings. His abdomen is soft with minimal tenderness. Blood tests show: WCC 18.2 × 10⁹/L, lactate 4.8 mmol/L, pH 7.32, base excess -6. CT angiography shows superior mesenteric artery occlusion. What is the most appropriate management?

Accepted Answer

Emergency laparotomy with embolectomy and assessment of bowel viability

Answer

Conservative management with IV fluids and anticoagulation

Answer

Urgent endovascular thrombectomy and anticoagulation

Answer

Emergency exploratory laparotomy and bowel resection

Answer

Thrombolysis followed by delayed surgical assessment

Question 3

A 44-year-old woman presents with a 6-hour history of right upper quadrant pain. Examination reveals Murphy's sign is positive. Her blood pressure is 118/76 mmHg, pulse 92 bpm, temperature 37.8°C. Blood tests show: WCC 12.8 × 10⁹/L, CRP 45 mg/L, bilirubin 18 µmol/L, ALP 156 U/L, ALT 68 U/L. Ultrasound shows gallstones, gallbladder wall thickening 5mm, and pericholecystic fluid. What is the most appropriate initial management?

Accepted Answer

IV antibiotics and early cholecystectomy within 72 hours

Answer

Emergency cholecystectomy within 24 hours

Answer

IV antibiotics and elective cholecystectomy in 6-8 weeks

Answer

Percutaneous cholecystostomy

Answer

ERCP with sphincterotomy

Question 4

A 52-year-old woman presents with a 4-day history of severe colicky central abdominal pain, vomiting, and absolute constipation. She had a hysterectomy 15 years ago. Examination reveals a distended abdomen with high-pitched tinkling bowel sounds. CT shows multiple dilated small bowel loops measuring 4.2 cm with collapsed large bowel and a transition point in the pelvis with a 'whirl sign'. After initial resuscitation with IV fluids and NG decompression, what is the most appropriate definitive management?

Accepted Answer

Emergency laparotomy within 6 hours

Answer

Continue conservative management for 72 hours before considering surgery

Answer

Water-soluble contrast study to assess for resolution

Answer

Laparoscopic adhesiolysis within 24 hours

Answer

Exploratory laparotomy only if signs of strangulation develop

Question 5

A 58-year-old man with alcoholic cirrhosis and large volume ascites develops sudden severe abdominal pain and fever. Diagnostic paracentesis shows neutrophil count 320 cells/µL. He is started on IV cefotaxime. After 48 hours of antibiotics, he remains febrile and a repeat paracentesis shows neutrophil count 380 cells/µL. What is the most important next step?

Accepted Answer

Arrange urgent CT abdomen to exclude secondary peritonitis

Answer

Change antibiotics to meropenem

Answer

Add metronidazole to current antibiotic regimen

Answer

Perform therapeutic large volume paracentesis

Answer

Start antifungal therapy with fluconazole

Question 6

A 29-year-old man presents with sudden onset severe generalized abdominal pain following blunt trauma to the abdomen during a football match 3 hours ago. On examination, he has generalized tenderness and guarding with absent bowel sounds. HR 118 bpm, BP 105/68 mmHg. FAST scan is negative. CT with IV contrast shows free fluid, bowel wall thickening in the jejunum, and subtle discontinuity of the bowel wall. What is the most appropriate management?

Accepted Answer

Emergency laparotomy

Answer

Observation with serial abdominal examinations

Answer

Diagnostic peritoneal lavage

Answer

Repeat CT in 6 hours

Answer

Laparoscopic exploration

Question 7

A 73-year-old man with atrial fibrillation on warfarin presents with sudden onset severe left-sided abdominal pain and rectal bleeding for 6 hours. His INR is 3.2. On examination, he has left-sided abdominal tenderness without peritonism. CT shows segmental wall thickening of the descending colon with pericolic fat stranding but no pneumatosis or portal venous gas. Lactate is 1.8 mmol/L. What is the most appropriate management?

Accepted Answer

Supportive care with bowel rest, IV fluids, and monitoring

Answer

Emergency laparotomy with colonic resection

Answer

Immediate angiography with consideration for vasopressin infusion

Answer

Urgent colonoscopy for mucosal assessment

Answer

Emergency Hartmann's procedure

Question 8

A 41-year-old woman presents with right iliac fossa pain and fever for 48 hours. She has had similar episodes in the past. CT abdomen shows an inflamed appendix with a well-defined 4 cm pericaecal collection and surrounding fat stranding. She is haemodynamically stable with temperature 38.2°C and WCC 14.8×10⁹/L. What is the most appropriate management strategy?

Accepted Answer

Percutaneous drainage of collection followed by interval appendicectomy

Answer

Immediate appendicectomy

Answer

Conservative management with IV antibiotics alone

Answer

CT-guided aspiration of collection with IV antibiotics but no interval appendicectomy

Answer

Laparoscopic washout and drainage without appendicectomy

Question 9

A 67-year-old woman taking long-term NSAIDs for osteoarthritis presents with sudden onset severe generalized abdominal pain for 4 hours. On examination, she has a rigid, board-like abdomen with absent bowel sounds and rebound tenderness. HR 105 bpm, BP 110/70 mmHg. Erect CXR shows free air under the diaphragm. After resuscitation, what is the most appropriate definitive management?

Accepted Answer

Emergency laparotomy

Answer

Urgent upper GI endoscopy

Answer

Conservative management with IV proton pump inhibitors and antibiotics

Answer

Laparoscopic repair within 24 hours

Answer

CT abdomen to confirm diagnosis before surgery

Question 10

A 34-year-old woman presents with sudden onset severe epigastric pain radiating to the back, nausea and vomiting for 8 hours. She drinks 40 units of alcohol weekly. BP 100/65 mmHg, HR 115 bpm, temperature 37.9°C. Examination reveals epigastric tenderness with guarding. Serum amylase is 1850 U/L. CT shows pancreatic oedema and peripancreatic fluid stranding. What is her modified Glasgow score?

Accepted Answer

Cannot be calculated without complete laboratory parameters

Answer

2 points

Answer

3 points

Answer

4 points

Answer

5 points

Acute Surgical Presentations — MCQs

Acute Surgical Presentations — MCQs

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