A 45-year-old man presents with sudden onset severe epigastric pain that started 2 hours ago while eating. He has a history of dyspepsia for which he takes over-the-counter antacids irregularly. On examination, he is diaphoretic, heart rate 115 bpm, blood pressure 100/65 mmHg. His abdomen shows generalized tenderness with board-like rigidity. Erect chest X-ray shows free air under both hemidiaphragms. What is the definitive treatment?
Q252
A 72-year-old woman with a history of diverticular disease presents with a 3-day history of worsening left lower quadrant pain, fever, and constipation. Vital signs show temperature 38.5°C, heart rate 105 bpm, blood pressure 130/80 mmHg. CT abdomen shows bowel wall thickening, pericolic fat stranding, and a 4 cm pelvic collection. White cell count is 16.2 × 10⁹/L. What is the most appropriate initial management?
Q253
A 65-year-old man presents to the emergency department with severe central abdominal pain radiating to the back. The pain started 4 hours ago and is associated with vomiting. His past medical history includes hypertension and hyperlipidaemia. On examination, his heart rate is 110 bpm, blood pressure 95/60 mmHg, and temperature 37.8°C. His abdomen is rigid with guarding and absent bowel sounds. What is the most appropriate initial investigation?
Acute Surgical Presentations UK Medical PG Practice Questions and MCQs
Question 251: A 45-year-old man presents with sudden onset severe epigastric pain that started 2 hours ago while eating. He has a history of dyspepsia for which he takes over-the-counter antacids irregularly. On examination, he is diaphoretic, heart rate 115 bpm, blood pressure 100/65 mmHg. His abdomen shows generalized tenderness with board-like rigidity. Erect chest X-ray shows free air under both hemidiaphragms. What is the definitive treatment?
A. High-dose proton pump inhibitor infusion and nil by mouth
B. Emergency laparotomy with omental patch repair (Correct Answer)
C. Urgent upper GI endoscopy
D. CT abdomen to confirm diagnosis
E. Percutaneous drainage of peritoneal cavity
Explanation: ***Emergency laparotomy with omental patch repair***
- The patient presents with classic signs of a **perforated peptic ulcer**, including sudden severe epigastric pain, **board-like rigidity**, and **free air under the diaphragm** on X-ray.
- This constitutes a surgical emergency, and **emergency laparotomy** with an **omental (Graham) patch repair** is the definitive surgical management to close the perforation and prevent further peritonitis.
*High-dose proton pump inhibitor infusion and nil by mouth*
- This conservative approach (Taylor's method) is rarely indicated and typically reserved for **hemodynamically stable** patients with very small, **sealed-off perforations** or those unfit for surgery.
- Given the patient's **hemodynamic instability** and clear signs of **generalized peritonitis**, this management would be inadequate and dangerous.
*Urgent upper GI endoscopy*
- Performing an upper GI endoscopy in suspected hollow viscus perforation is **contraindicated**.
- **Insufflation of air** during endoscopy can worsen the **pneumoperitoneum** and potentially extend the perforation, increasing patient morbidity.
*CT abdomen to confirm diagnosis*
- While CT is highly sensitive for free air, the diagnosis is already **clinically evident** and confirmed by the **erect chest X-ray** showing **subdiaphragmatic gas**.
- Delaying **definitive surgical intervention** for additional imaging in a patient with **septic shock** and clear peritonitis can significantly increase mortality.
*Percutaneous drainage of peritoneal cavity*
- This procedure is primarily used to drain **localized intra-abdominal fluid collections** or **abscesses**.
- It does not address the underlying **perforation** of the gastrointestinal tract, which is the source of ongoing contamination and peritonitis.
Question 252: A 72-year-old woman with a history of diverticular disease presents with a 3-day history of worsening left lower quadrant pain, fever, and constipation. Vital signs show temperature 38.5°C, heart rate 105 bpm, blood pressure 130/80 mmHg. CT abdomen shows bowel wall thickening, pericolic fat stranding, and a 4 cm pelvic collection. White cell count is 16.2 × 10⁹/L. What is the most appropriate initial management?
A. Immediate laparotomy
B. IV antibiotics and percutaneous drainage (Correct Answer)
C. IV antibiotics alone
D. Colonoscopy within 24 hours
E. Conservative management with oral antibiotics
Explanation: ***IV antibiotics and percutaneous drainage***
- This patient presents with **complicated diverticulitis** indicated by fever, leukocytosis, and a **4 cm pelvic collection** on CT, aligning with Hinchey Stage II.
- For diverticular abscesses typically **greater than 3-4 cm**, **percutaneous drainage** combined with **IV antibiotics** is the gold standard for source control and management, aiming to avoid emergency surgery.
*Immediate laparotomy*
- **Emergency laparotomy** is generally reserved for patients with signs of generalized **peritonitis** (e.g., purulent or feculent peritonitis, Hinchey III/IV) or severe sepsis unresponsive to less invasive measures.
- This patient is **hemodynamically stable** with a contained abscess, making a less invasive approach the preferred initial management strategy.
*IV antibiotics alone*
- While **IV antibiotics** are crucial for treating the infection, a **4 cm abscess** often requires **source control** through drainage to prevent treatment failure and achieve resolution.
- Medical therapy alone has a significantly higher failure rate for larger abscesses and may delay definitive management, increasing morbidity.
*Colonoscopy within 24 hours*
- **Colonoscopy** is **contraindicated** during the acute phase of diverticulitis due to the significant risk of **bowel perforation** from insufflation and instrumentation of an inflamed bowel.
- It should be postponed until **6-8 weeks** after resolution of the acute episode to exclude underlying malignancy, stricture, or other pathology.
*Conservative management with oral antibiotics*
- The presence of **fever**, **tachycardia**, and significant **leukocytosis** indicates systemic inflammation and complicated disease, necessitating **inpatient care** and **intravenous antibiotics**.
- **Oral antibiotics** and outpatient management are suitable only for **uncomplicated diverticulitis** in stable patients without signs of abscess, peritonitis, or systemic toxicity.
Question 253: A 65-year-old man presents to the emergency department with severe central abdominal pain radiating to the back. The pain started 4 hours ago and is associated with vomiting. His past medical history includes hypertension and hyperlipidaemia. On examination, his heart rate is 110 bpm, blood pressure 95/60 mmHg, and temperature 37.8°C. His abdomen is rigid with guarding and absent bowel sounds. What is the most appropriate initial investigation?
A. Erect chest radiograph (Correct Answer)
B. Abdominal ultrasound
C. CT angiography of the abdomen
D. Serum amylase
E. Contrast-enhanced CT abdomen and pelvis
Explanation: ***Erect chest radiograph***- The patient presents with **peritonism** (rigid abdomen, guarding, absent bowel sounds), which is highly suggestive of a **perforated viscus**.- An **erect chest X-ray** is the most appropriate initial investigation to detect **pneumoperitoneum** (free air under the diaphragm), confirming the diagnosis rapidly at the bedside.*Abdominal ultrasound*- Primarily used for diagnosing **gallstones**, **cholecystitis**, or assessing the **aortic diameter** in a suspected AAA.- It is not the preferred initial test for suspected bowel perforation as **intraluminal gas** can obscure the visualization of the retroperitoneum and free air.*CT angiography of the abdomen*- This is the investigation of choice for suspected **vascular emergencies** such as a **ruptured abdominal aortic aneurysm (AAA)** or mesenteric ischemia.- While the patient has risk factors for AAA, the clinical presentation of a **rigid abdomen** and guarding more specifically points toward a **perforated peptic ulcer**.*Serum amylase*- Elevated levels are diagnostic for **acute pancreatitis**, which can present with severe epigastric pain radiating to the back.- However, it does not address the urgent need to rule out a **surgical emergency** like perforation in a patient with a rigid abdomen and **hemodynamic instability**.*Contrast-enhanced CT abdomen and pelvis*- This is the most sensitive test for identifying the **site of perforation** and other intra-abdominal pathologies if the initial X-ray is negative.- While highly diagnostic, it is not the *initial* step in an unstable patient when a quicker **erect chest radiograph** can provide immediate confirmation of free air.
