Acute Surgical Presentations — MCQs
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A 58-year-old woman presents with a 4-day history of left lower quadrant pain and fever. CT abdomen shows sigmoid diverticulitis with a 6cm pelvic abscess. She is haemodynamically stable with a heart rate of 88 bpm and blood pressure 128/76 mmHg. Temperature is 38.2°C. Her white cell count is 14.2 × 10⁹/L. She has been commenced on intravenous co-amoxiclav and metronidazole. What is the most appropriate next step in management?
What is the name of the clinical sign characterized by ecchymosis in the flanks, and which acute surgical condition is it most commonly associated with?
A 75-year-old woman presents with a 6-hour history of severe generalized abdominal pain. She takes aspirin, clopidogrel, and warfarin for atrial fibrillation and previous stroke. Her INR is 2.8. CT abdomen shows pneumatosis intestinalis involving a 40 cm segment of small bowel with gas in the mesenteric veins. The affected bowel shows minimal enhancement. Arterial phase imaging shows patent superior mesenteric artery and vein. What is the most appropriate immediate management?
A 52-year-old man with ulcerative colitis presents with a 4-day history of increasing abdominal pain, distension, and bloody diarrhoea (12 episodes per day). He appears unwell with temperature 38.5°C, HR 118 bpm, BP 105/65 mmHg. Abdominal examination reveals marked distension with tenderness but no peritonism. Blood tests show: Hb 98 g/L, WBC 16.4 × 10⁹/L, CRP 178 mg/L, albumin 28 g/L. Abdominal X-ray shows transverse colon diameter of 7.5 cm with mucosal islands visible. What is the most critical immediate complication to monitor for in this patient?
A 68-year-old man presents with a 3-day history of progressive abdominal distension, vomiting, and absolute constipation. He has no history of previous abdominal surgery. Plain abdominal radiograph shows massively dilated large bowel with a characteristic 'bent inner tube' appearance in the left upper quadrant and loss of haustral markings. What is the definitive management for this condition after initial resuscitation?
A 38-year-old woman undergoes emergency laparotomy for suspected perforated appendicitis. Intra-operatively, the appendix is found to be normal, but there is a 2 cm perforation in the terminal ileum 60 cm from the ileocaecal valve with surrounding healthy bowel. Multiple enlarged mesenteric lymph nodes are noted, and the perforation site shows a clean punched-out appearance. What is the most likely underlying diagnosis?
A 56-year-old man with a history of alcohol excess presents with sudden onset severe epigastric pain radiating to his back. He is vomiting and appears unwell. Examination shows epigastric tenderness with guarding. Serum amylase is 1450 U/L (normal <100). Erect chest X-ray shows no free air under the diaphragm but does show a dilated loop of small bowel in the left upper quadrant. What is the most likely explanation for the radiological finding?
A 72-year-old woman with a history of sigmoid diverticular disease presents with a 5-day history of left lower quadrant pain and fever. CT abdomen shows inflamed sigmoid colon with multiple diverticula, thickened bowel wall, and pericolic fat stranding. There is a 3 cm × 2 cm pericolic fluid collection. She is haemodynamically stable with temperature 37.9°C, HR 88 bpm, BP 135/80 mmHg. Blood tests show WBC 13.2 × 10⁹/L, CRP 145 mg/L. According to the Hinchey classification, what stage is this patient's diverticulitis?
What is the primary pathophysiological mechanism by which gallstone ileus causes small bowel obstruction?
A 45-year-old man with Crohn's disease maintained on adalimumab presents with a 12-hour history of right iliac fossa pain and fever. CT abdomen shows a thick-walled terminal ileum with a 6 cm × 4 cm rim-enhancing fluid collection in the right iliac fossa. His inflammatory markers show WBC 15.8 × 10⁹/L and CRP 185 mg/L. He is clinically stable with normal observations. What is the most appropriate initial management?
Acute Surgical Presentations UK Medical PG Practice Questions and MCQs
Question 71: A 58-year-old woman presents with a 4-day history of left lower quadrant pain and fever. CT abdomen shows sigmoid diverticulitis with a 6cm pelvic abscess. She is haemodynamically stable with a heart rate of 88 bpm and blood pressure 128/76 mmHg. Temperature is 38.2°C. Her white cell count is 14.2 × 10⁹/L. She has been commenced on intravenous co-amoxiclav and metronidazole. What is the most appropriate next step in management?
- A. Emergency sigmoid resection with end colostomy
- B. Urgent colonoscopy to assess the extent of disease
- C. CT-guided percutaneous drainage of the abscess (Correct Answer)
- D. Continue antibiotics and arrange elective colectomy in 6-8 weeks
- E. Laparoscopic peritoneal lavage without resection
Explanation: ***CT-guided percutaneous drainage of the abscess*** - For a **Hinchey stage II** diverticular abscess larger than **3–5 cm**, percutaneous drainage is the treatment of choice in a **hemodynamically stable** patient. - This minimally invasive approach achieves **source control**, reduces the inflammatory response, and avoids the high morbidity associated with **emergency surgery**. *Emergency sigmoid resection with end colostomy* - This procedure, known as a **Hartmann's procedure**, is reserved for patients with **purulent (Hinchey III)** or **fecal peritonitis (Hinchey IV)**. - It is not indicated as the first step for a stable patient with a drainable loculated abscess, as it carries a high risk of **stoma-related complications**. *Urgent colonoscopy to assess the extent of disease* - Colonoscopy is **strictly contraindicated** during the acute phase of diverticulitis due to the high risk of **iatrogenic bowel perforation**. - Endoscopic evaluation should be delayed for **6–8 weeks** after the resolution of symptoms to rule out **malignancy** or other inflammatory bowel conditions. *Continue antibiotics and arrange elective colectomy in 6-8 weeks* - Antibiotics alone are often insufficient for managing a **large abscess (>4 cm)**; drainage is required to ensure clinical resolution. - While elective surgery might be considered later, it is not the *next step* when an **undrained pelvic abscess** is actively causing fever and leukocytosis. *Laparoscopic peritoneal lavage without resection* - This technique is generally reserved for **Hinchey III (purulent) peritonitis** and is not the standard of care for a localized, drainable pelvic abscess. - Recent evidence suggests it may have higher rates of **secondary interventions** compared to resection or targeted drainage.
Question 72: What is the name of the clinical sign characterized by ecchymosis in the flanks, and which acute surgical condition is it most commonly associated with?
- A. Cullen's sign - acute pancreatitis
- B. Grey Turner's sign - acute pancreatitis (Correct Answer)
- C. Grey Turner's sign - ruptured abdominal aortic aneurysm
- D. Murphy's sign - acute cholecystitis
- E. McBurney's sign - acute appendicitis
Explanation: ***Grey Turner's sign - acute pancreatitis*** - **Grey Turner's sign** is characterized by **ecchymosis** (bruising) in the **flanks**, indicative of **retroperitoneal hemorrhage** tracking to the subcutaneous tissues. - This sign is most commonly associated with **severe acute necrotizing pancreatitis**, signifying a high risk of complications and a poor prognosis. *Cullen's sign - acute pancreatitis* - **Cullen's sign** presents as **periumbilical ecchymosis**, differentiating its location from the flank bruising seen in Grey Turner's sign. - Although also a sign of **retroperitoneal bleeding** in severe acute pancreatitis, its specific periumbilical location makes it distinct. *Grey Turner's sign - ruptured abdominal aortic aneurysm* - While rare, **retroperitoneal hemorrhage** from a **ruptured abdominal aortic aneurysm (AAA)** can sometimes cause flank ecchymosis. - However, **acute pancreatitis** is the classic and most commonly tested association for **Grey Turner's sign** in medical contexts. *Murphy's sign - acute cholecystitis* - **Murphy's sign** involves abrupt **inspiratory arrest** during deep palpation of the right upper quadrant, indicating **gallbladder inflammation**. - It is a specific sign for **acute cholecystitis** and does not manifest as skin discoloration or ecchymosis. *McBurney's sign - acute appendicitis* - **McBurney's sign** is characterized by localized **tenderness** at **McBurney's point**, which is crucial for diagnosing **acute appendicitis**. - This sign indicates **localized peritonitis** due to appendicitis and does not involve ecchymosis or bruising.
Question 73: A 75-year-old woman presents with a 6-hour history of severe generalized abdominal pain. She takes aspirin, clopidogrel, and warfarin for atrial fibrillation and previous stroke. Her INR is 2.8. CT abdomen shows pneumatosis intestinalis involving a 40 cm segment of small bowel with gas in the mesenteric veins. The affected bowel shows minimal enhancement. Arterial phase imaging shows patent superior mesenteric artery and vein. What is the most appropriate immediate management?
- A. Immediate laparotomy with resection of non-viable bowel (Correct Answer)
- B. Conservative management with bowel rest and monitoring
- C. Reverse anticoagulation, broad-spectrum antibiotics, and conservative management with close monitoring
- D. Emergency angiography with thrombolysis
- E. Laparoscopy for diagnostic assessment before committing to laparotomy
Explanation: ***Immediate laparotomy with resection of non-viable bowel*** - The presence of **pneumatosis intestinalis**, **mesenteric venous gas**, and **minimal bowel enhancement** on CT is highly indicative of transmural bowel infarction, demanding urgent surgical intervention. - With clear evidence of **irreversible bowel ischemia** and severe abdominal pain, **emergency laparotomy** is essential to resect the non-viable segments and prevent perforation and sepsis. *Conservative management with bowel rest and monitoring* - This approach is inappropriate for confirmed **bowel necrosis**, as it would lead to unavoidable progression to perforation, peritonitis, and patient demise. - Conservative management is reserved for milder forms of intestinal ischemia or benign pneumatosis, not for **established infarction**. *Reverse anticoagulation, broad-spectrum antibiotics, and conservative management with close monitoring* - While reversing **anticoagulation** and administering **broad-spectrum antibiotics** are necessary preoperative steps, they do not address the underlying **bowel infarction** itself. - Delaying surgical exploration in the presence of **mesenteric venous gas** and non-enhancing bowel significantly increases mortality due to the high risk of gangrene and perforation. *Emergency angiography with thrombolysis* - CT imaging explicitly states **patent superior mesenteric artery and vein**, ruling out a large-vessel occlusive event that would be targeted by thrombolysis. - Furthermore, **thrombolysis** is contraindicated given the patient's **INR of 2.8** and concurrent antiplatelet use, posing a high risk of life-threatening hemorrhage. *Laparoscopy for diagnostic assessment before committing to laparotomy* - With definitive CT evidence of **transmural bowel necrosis**, a diagnostic laparoscopy is redundant and would only **unnecessarily delay crucial definitive surgical management**. - **Laparotomy** remains the gold standard for assessing bowel viability, facilitating extensive resection if needed, and allowing for potential a **second-look procedure**, which is often required in such complex cases.
Question 74: A 52-year-old man with ulcerative colitis presents with a 4-day history of increasing abdominal pain, distension, and bloody diarrhoea (12 episodes per day). He appears unwell with temperature 38.5°C, HR 118 bpm, BP 105/65 mmHg. Abdominal examination reveals marked distension with tenderness but no peritonism. Blood tests show: Hb 98 g/L, WBC 16.4 × 10⁹/L, CRP 178 mg/L, albumin 28 g/L. Abdominal X-ray shows transverse colon diameter of 7.5 cm with mucosal islands visible. What is the most critical immediate complication to monitor for in this patient?
- A. Toxic megacolon with risk of perforation (Correct Answer)
- B. Acute thromboembolic event from hypercoagulable state
- C. Septic shock from bacterial translocation
- D. Hemorrhagic shock from massive lower GI bleeding
- E. Acute kidney injury from hypovolaemia
Explanation: ***Toxic megacolon with risk of perforation*** - The patient exhibits features of **acute severe ulcerative colitis** (frequent bloody stools, fever, tachycardia, anemia, elevated inflammatory markers) combined with **colonic dilation** (7.5 cm transverse colon diameter) and **systemic toxicity**, confirming **toxic megacolon**. - The most critical life-threatening risk is **colonic perforation**, which occurs due to transmural inflammation and necrosis, leading to diffuse peritonitis and carries extremely high mortality if not promptly identified and managed, often surgically. *Acute thromboembolic event from hypercoagulable state* - Patients with active **Inflammatory Bowel Disease (IBD)** are at a significantly higher risk for **venous thromboembolism (VTE)** due to chronic systemic inflammation and a hypercoagulable state. - While VTE prophylaxis is essential, it is not the most immediate or critically life-threatening concern compared to the imminent risk of **perforation** in a patient presenting with marked colonic dilation due to toxic megacolon. *Septic shock from bacterial translocation* - Severe inflammation in UC can compromise the intestinal barrier, leading to **bacterial translocation** from the gut lumen, which can certainly result in **sepsis** and subsequent **septic shock**. - Although sepsis is a serious potential outcome, the primary and most immediate structural risk in the presence of **toxic megacolon** (indicated by 7.5 cm colonic dilation) is mechanical **perforation** of the thinned colonic wall, making it a more acute and critical monitor point. *Hemorrhagic shock from massive lower GI bleeding* - Bloody diarrhoea is a characteristic of UC, and patients can experience significant bleeding, potentially leading to **hemorrhagic shock** (supported by Hb 98 g/L). - However, the clinical picture is dominated by signs of severe systemic toxicity, abdominal distension, and critical **colonic dilation** on X-ray, which are the hallmarks of **toxic megacolon** and its associated imminent risk of **perforation**, making this a more pressing concern than purely hemorrhagic shock. *Acute kidney injury from hypovolaemia* - The patient's hypotension (105/65 mmHg) and severe diarrhoea definitely put him at risk for **hypovolaemia** and subsequent **acute kidney injury (AKI)**. - While fluid resuscitation and monitoring renal function are crucial, in the context of **toxic megacolon** with impending **perforation**, AKI due to hypovolemia, though serious, is a secondary complication compared to the immediate, life-threatening surgical emergency of a ruptured colon.
Question 75: A 68-year-old man presents with a 3-day history of progressive abdominal distension, vomiting, and absolute constipation. He has no history of previous abdominal surgery. Plain abdominal radiograph shows massively dilated large bowel with a characteristic 'bent inner tube' appearance in the left upper quadrant and loss of haustral markings. What is the definitive management for this condition after initial resuscitation?
- A. Emergency laparotomy with sigmoid colectomy and end colostomy
- B. Flexible sigmoidoscopy with decompression and flatus tube insertion (Correct Answer)
- C. Urgent colonoscopy with stenting of the obstruction
- D. Conservative management with nasogastric decompression and IV fluids
- E. CT colonography to confirm the diagnosis followed by interval surgery
Explanation: ***Flexible sigmoidoscopy with decompression and flatus tube insertion*** - The classic **'bent inner tube'** or **'coffee bean' sign** on a plain abdominal radiograph in a patient with acute large bowel obstruction strongly suggests **sigmoid volvulus**. - **Flexible sigmoidoscopy** allows for immediate **decompression** of the twisted bowel and insertion of a **flatus tube**, which is the definitive initial management for a stable patient without signs of ischemia. *Emergency laparotomy with sigmoid colectomy and end colostomy* - This surgical intervention, a **Hartmann's procedure**, is reserved for cases where there is evidence of **bowel ischemia**, gangrene, perforation, or when endoscopic decompression fails. - It is not the primary definitive management in a stable patient where endoscopic reduction is feasible and safer as a first step. *Urgent colonoscopy with stenting of the obstruction* - **Colonoscopic stenting** is primarily indicated for **malignant large bowel obstructions** (e.g., colorectal cancer) as a bridge to surgery or for palliation. - It is generally contraindicated in **volvulus** due to the high risk of perforation and is ineffective in untwisting the mesentery. *Conservative management with nasogastric decompression and IV fluids* - While initial **resuscitation** with IV fluids and nasogastric decompression is crucial for all acutely unwell patients, it does not resolve the underlying **mechanical obstruction** of a volvulus. - Relying solely on conservative management in sigmoid volvulus carries a significant risk of **bowel infarction** and perforation due to ongoing torsion. *CT colonography to confirm the diagnosis followed by interval surgery* - The diagnosis of **sigmoid volvulus** is typically evident from the characteristic plain abdominal radiograph findings, rendering further diagnostic imaging like **CT colonography** often unnecessary and delaying treatment. - **CT colonography** involves colonic insufflation, which can be dangerous and increase the risk of perforation in an acutely obstructed and distended bowel.
Question 76: A 38-year-old woman undergoes emergency laparotomy for suspected perforated appendicitis. Intra-operatively, the appendix is found to be normal, but there is a 2 cm perforation in the terminal ileum 60 cm from the ileocaecal valve with surrounding healthy bowel. Multiple enlarged mesenteric lymph nodes are noted, and the perforation site shows a clean punched-out appearance. What is the most likely underlying diagnosis?
- A. Meckel's diverticulum perforation
- B. Terminal ileal perforation from typhoid fever (Correct Answer)
- C. Crohn's disease with perforation
- D. Small bowel lymphoma with perforation
- E. Perforated ileal carcinoid tumor
Explanation: ***Terminal ileal perforation from typhoid fever*** - The classic presentation of a **clean punched-out perforation** in the anti-mesenteric border of the **terminal ileum** with relatively healthy surrounding bowel is pathognomonic for **Typhoid (Enteric) Fever**. - Perforation typically occurs in the third week of illness due to necrosis and ulceration of **Peyer’s patches** caused by Salmonella typhi infection. *Meckel's diverticulum perforation* - While it occurs at a similar location (within 60 cm of the **ileocaecal valve**), it would involve a distinct **diverticular pouch** rather than a hole in the native ileal wall. - Perforation of a Meckel's is usually caused by **ectopic gastric mucosa** leading to peptic ulceration, not linear punched-out ulcers. *Crohn's disease with perforation* - Crohn's disease typically presents with **transmural inflammation**, "creeping fat," and a **thickened, leather-like bowel wall**, which contradicts the finding of healthy surrounding bowel. - Free perforation is rare in Crohn's; it more commonly leads to **fistula formation** or localized abscesses due to the chronic fibrotic nature of the disease. *Small bowel lymphoma with perforation* - Lymphoma typically presents as a **fleshy, irregular mass** or a bulky tumor that leads to a much more ragged and necrotic perforation site. - It is often associated with **hepatosplenomegaly** or systemic B-symptoms rather than a localized "punched-out" ileal ulcer. *Perforated ileal carcinoid tumor* - Carcinoid tumors generally cause a significant **desmoplastic reaction** leading to intense mesenteric fibrosis and kinking of the bowel. - These tumors are usually **small, firm, and yellow**-colored nodules rather than simple ulcers localized to the lymphoid tissue.
Question 77: A 56-year-old man with a history of alcohol excess presents with sudden onset severe epigastric pain radiating to his back. He is vomiting and appears unwell. Examination shows epigastric tenderness with guarding. Serum amylase is 1450 U/L (normal <100). Erect chest X-ray shows no free air under the diaphragm but does show a dilated loop of small bowel in the left upper quadrant. What is the most likely explanation for the radiological finding?
- A. Perforated duodenal ulcer with localized ileus
- B. Small bowel obstruction secondary to adhesions
- C. Sentinel loop from acute pancreatitis (Correct Answer)
- D. Paralytic ileus from generalized peritonitis
- E. Early gallstone ileus
Explanation: ***Sentinel loop from acute pancreatitis***- The patient presents with classic **acute pancreatitis**, indicated by severe epigastric pain, alcohol history, and a **serum amylase** level (>3x normal).- A **sentinel loop** is a localized segment of dilated small bowel (focal ileus) typically found in the left upper quadrant due to inflammation of the adjacent pancreas.*Perforated duodenal ulcer with localized ileus*- While it causes severe pain, the **erect chest X-ray** shows no **pneumoperitoneum** (free air), which is typically present in peritonitis from a perforation.- The highly elevated **amylase** levels are much more characteristic of primary pancreatic inflammation than a perforated ulcer.*Small bowel obstruction secondary to adhesions*- Adhesional obstruction typically presents with **multiple dilated loops** and prominent **air-fluid levels** rather than a single localized loop.- The clinical context of back-radiating pain and high amylase point strongly toward a **pancreatic etiology** rather than mechanical obstruction.*Paralytic ileus from generalized peritonitis*- Generalized ileus would manifest as **diffuse dilatation** of both the small and large intestines throughout the abdomen.- This patient exhibits a localized finding in the **left upper quadrant**, suggesting a focal inflammatory process rather than widespread peritonitis.*Early gallstone ileus*- **Gallstone ileus** usually presents with signs of mechanical obstruction and often **pneumobilia** (air in the biliary tree) on imaging.- While alcohol is a common cause of pancreatitis, the localized sentinel loop in the LUQ is the classic radiological hallmark of **acute pancreatitis** inflammation.
Question 78: A 72-year-old woman with a history of sigmoid diverticular disease presents with a 5-day history of left lower quadrant pain and fever. CT abdomen shows inflamed sigmoid colon with multiple diverticula, thickened bowel wall, and pericolic fat stranding. There is a 3 cm × 2 cm pericolic fluid collection. She is haemodynamically stable with temperature 37.9°C, HR 88 bpm, BP 135/80 mmHg. Blood tests show WBC 13.2 × 10⁹/L, CRP 145 mg/L. According to the Hinchey classification, what stage is this patient's diverticulitis?
- A. Uncomplicated diverticulitis
- B. Hinchey I - pericolic abscess or phlegmon (Correct Answer)
- C. Hinchey II - pelvic or distant abscess
- D. Hinchey III - purulent peritonitis
- E. Hinchey IV - faecal peritonitis
Explanation: ***Hinchey I - pericolic abscess or phlegmon*** - The presence of a **small (3 cm x 2 cm) pericolic fluid collection** localized near the inflamed sigmoid colon confirms **Hinchey Stage I**. - This stage defines cases where inflammation or an **abscess is confined** to the mesentery or the immediate **pericolic space**.*Uncomplicated diverticulitis* - This refers to simple **colonic wall thickening** and fat stranding without any evidence of localized **pus or fluid collections**. - Since this patient has a 3 cm fluid collection, it is categorized as a **complicated** diverticulitis case.*Hinchey II - pelvic or distant abscess* - This stage is characterized by a **distant abscess**, usually located in the **pelvis** or retroperitoneum, far from the primary pericolic site. - The patient's abscess is described as **pericolic**, meaning it has not yet migrated or developed in a remote anatomical location.*Hinchey III - purulent peritonitis* - Stage III involves **generalized peritonitis** caused by the rupture of an abscess, spreading **non-fecal pus** throughout the peritoneal cavity. - This patient is **haemodynamically stable** and lacks signs of diffuse peritonitis, having only a localized collection.*Hinchey IV - faecal peritonitis* - This is the most severe stage, caused by **free perforation** of the bowel resulting in **faecal contamination** of the abdomen. - It typically presents with **surgical emergency** symptoms and systemic shock, which are inconsistent with this patient's stability and CT findings.
Question 79: What is the primary pathophysiological mechanism by which gallstone ileus causes small bowel obstruction?
- A. Mechanical obstruction from a large gallstone impacting at the terminal ileum (Correct Answer)
- B. Chemical peritonitis from bile leak causing adhesions
- C. Inflammatory stricture formation in the small bowel
- D. Paralytic ileus secondary to cholecystitis
- E. Extrinsic compression from an inflamed gallbladder
Explanation: ***Mechanical obstruction from a large gallstone impacting at the terminal ileum***- **Gallstone ileus** is a form of mechanical **small bowel obstruction** caused by a large gallstone (typically >2.5 cm) that has eroded through a **cholecystoenteric fistula** into the intestinal lumen.- The stone then travels distally until it becomes impacted, most commonly in the **terminal ileum** due to its narrower lumen, leading to acute obstruction.*Chemical peritonitis from bile leak causing adhesions*- While **bile leakage** can occur from a perforated gallbladder, it primarily causes **chemical peritonitis** or abscess formation, not a primary intraluminal mechanical obstruction.- Adhesions, if they form from peritonitis, typically lead to **extrinsic compression** or kinking of the bowel, which is a different mechanism from a free-floating obstructing stone.*Inflammatory stricture formation in the small bowel*- **Inflammatory strictures** are chronic, fibrotic narrowing of the bowel wall, often seen in conditions like **Crohn's disease** or chronic ischemia.- **Gallstone ileus** is an acute event where a physical object (the stone) blocks the lumen, rather than a gradual scarring and narrowing of the bowel wall.*Paralytic ileus secondary to cholecystitis*- **Paralytic ileus** (or adynamic ileus) is a functional disorder where there is a lack of peristalsis without a physical obstruction, often triggered by inflammation or surgery.- In **gallstone ileus**, despite the name, the obstruction is explicitly **mechanical** due to the physical presence of a gallstone within the lumen, completely different from a functional ileus.*Extrinsic compression from an inflamed gallbladder*- **Extrinsic compression** refers to pressure on the bowel from an external source, such as a severely inflamed gallbladder (e.g., in **Mirizzi syndrome** or **Bouveret syndrome** affecting the duodenum).- **Gallstone ileus** involves the **internal migration** of a gallstone *into* the bowel lumen, where it then causes obstruction from within, not external pressure.
Question 80: A 45-year-old man with Crohn's disease maintained on adalimumab presents with a 12-hour history of right iliac fossa pain and fever. CT abdomen shows a thick-walled terminal ileum with a 6 cm × 4 cm rim-enhancing fluid collection in the right iliac fossa. His inflammatory markers show WBC 15.8 × 10⁹/L and CRP 185 mg/L. He is clinically stable with normal observations. What is the most appropriate initial management?
- A. Emergency surgical drainage and right hemicolectomy
- B. IV antibiotics and percutaneous CT-guided drainage of the abscess (Correct Answer)
- C. IV antibiotics alone with monitoring
- D. Increase adalimumab dosing frequency and add IV steroids
- E. Conservative management with bowel rest and enteral nutrition
Explanation: ***IV antibiotics and percutaneous CT-guided drainage of the abscess***- In a clinically stable patient with a large (6 cm x 4 cm) **intra-abdominal abscess**, **percutaneous drainage** combined with **intravenous antibiotics** is the most appropriate initial management.- This approach offers effective **source control** and resolution of infection, reducing the need for emergency surgery and minimizing risks associated with operating on an active inflammatory process in an immunocompromised patient.*Emergency surgical drainage and right hemicolectomy*- **Emergency surgery** is generally reserved for patients with **hemodynamic instability**, generalized **peritonitis**, or those who fail percutaneous drainage.- Performing **primary anastomosis** in the setting of active infection and **immunosuppression** (due to adalimumab) significantly increases the risk of **anastomotic leak** and other complications.*IV antibiotics alone with monitoring*- While very small abscesses might resolve with **antibiotics** alone, a 6 cm collection is unlikely to clear without **source control** (drainage).- Relying solely on **antibiotics** for a large abscess in an immunocompromised patient increases the risk of septic deterioration and treatment failure.*Increase adalimumab dosing frequency and add IV steroids*- Escalating **immunosuppression** with adalimumab or adding **corticosteroids** is strictly contraindicated in the presence of an untreated **active infection** or abscess.- These medications would further impair the immune response, mask clinical symptoms, and can lead to the spread or worsening of the **bacterial collection**.*Conservative management with bowel rest and enteral nutrition*- While **bowel rest** and **enteral nutrition** are supportive therapies in Crohn's disease, they do not address the need for **mechanical drainage** of a large fluid collection.- Delaying **abscess drainage** by focusing solely on conservative measures can lead to worsening infection, systemic sepsis, and potential perforation.
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