A 28-year-old professional weightlifter presents with a 4-week history of a painless lump in his right groin that becomes prominent during training. Examination reveals a reducible swelling that emerges above and medial to the pubic tubercle when performing a Valsalva manoeuvre. He has an important competition in 3 weeks and wishes to continue training at full intensity until then. What is the most appropriate management advice?
Q162
A 62-year-old man presents with iron deficiency anaemia and weight loss. Colonoscopy identifies a circumferential tumour in the descending colon 25 cm from the anal verge. CT staging shows no distant metastases but reveals bilateral external iliac lymphadenopathy with nodes measuring up to 15 mm. He undergoes a left hemicolectomy. The histology report describes a moderately differentiated adenocarcinoma invading through the bowel wall into surrounding adipose tissue but not reaching the peritoneal surface, with 4 out of 18 lymph nodes positive for metastatic disease. What is the correct TNM stage?
Q163
A 37-year-old woman undergoes emergency appendicectomy for acute appendicitis. Intraoperatively, a 4 cm firm mass is noted at the tip of the appendix. The caecum and terminal ileum appear normal. Histology reports a well-differentiated neuroendocrine tumour (carcinoid tumour) measuring 2.2 cm in maximum diameter, invading the muscularis propria, with Ki-67 index of 1%. The resection margins are clear. What is the most appropriate further management?
Q164
A 75-year-old man presents to the emergency department with a 4-day history of progressive left iliac fossa pain, fever, and constipation. CT abdomen demonstrates an 8 cm pelvic collection adjacent to the sigmoid colon with surrounding fat stranding and sigmoid diverticulosis. There is localised pneumoperitoneum. His observations show: temperature 38.6°C, heart rate 105 bpm, blood pressure 128/78 mmHg, respiratory rate 20/min, oxygen saturation 96% on air. Blood tests show: WCC 17.2 × 10⁹/L, CRP 285 mg/L, creatinine 98 μmol/L. What is the most appropriate initial management according to modified Hinchey classification?
Q165
A 48-year-old man undergoes colonoscopy for altered bowel habit. A 12 mm sessile polyp is identified in the sigmoid colon and removed by endoscopic mucosal resection. Histology shows a tubulovillous adenoma with a 3 mm focus of adenocarcinoma invading into the submucosa. The resection margin is clear by 2 mm and there is no lymphovascular invasion. What is the most appropriate management?
Q166
A 42-year-old woman presents to the emergency department with a 30-hour history of right lower quadrant pain, fever of 38.3°C, and vomiting. She has a past history of recurrent urinary tract infections and takes no regular medications. Her last menstrual period was 3 weeks ago. Examination reveals tenderness and guarding in the right iliac fossa. Urinalysis shows 3+ leucocytes and 2+ blood. White cell count is 16.8 × 10⁹/L. What is the most appropriate next investigation?
Q167
A 64-year-old woman undergoes a left hemicolectomy for a T3N1M0 adenocarcinoma located in the splenic flexure. The operation is uncomplicated. She has no significant comorbidities and her performance status is ECOG 0. What is the most appropriate adjuvant treatment according to current UK guidelines?
Q168
A 56-year-old man presents to the surgical outpatient clinic with a 6-month history of a painless right groin lump that increases in size with coughing and disappears when lying down. On examination, there is a reducible lump that emerges above and medial to the pubic tubercle. The examining finger can be placed over the deep inguinal ring, and the lump still emerges on coughing. What is the most likely diagnosis?
Q169
A 33-year-old man presents to the emergency department with a 14-hour history of right iliac fossa pain, nausea, and fever of 37.9°C. His white cell count is 14.2 × 10⁹/L and CRP is 45 mg/L. He is haemodynamically stable. CT abdomen confirms acute appendicitis with no perforation or collection. What is the most appropriate initial management?
Q170
A 71-year-old man with a history of chronic constipation undergoes colonoscopy which reveals multiple diverticula throughout the sigmoid colon and a 2.5 cm polyp in the descending colon. Histology confirms a tubular adenoma with low-grade dysplasia. What is the most appropriate surveillance interval for this patient according to current UK guidelines?
General Surgery UK Medical PG Practice Questions and MCQs
Question 161: A 28-year-old professional weightlifter presents with a 4-week history of a painless lump in his right groin that becomes prominent during training. Examination reveals a reducible swelling that emerges above and medial to the pubic tubercle when performing a Valsalva manoeuvre. He has an important competition in 3 weeks and wishes to continue training at full intensity until then. What is the most appropriate management advice?
A. Continue training until after the competition, then proceed with elective hernia repair
B. Immediate elective hernia repair with mesh, allowing return to full training in 2 weeks
C. Cease all heavy lifting immediately and proceed with urgent hernia repair within 1 week (Correct Answer)
D. Prescribe a supportive truss and allow continued training with regular review
E. Advise modification of training to avoid heavy lifting and Valsalva manoeuvres until after competition, followed by elective repair
Explanation: ***Cease all heavy lifting immediately and proceed with urgent hernia repair within 1 week***- The patient's profession involves high-intensity **Valsalva manoeuvres**, which significantly increase intra-abdominal pressure and the risk of **strangulation or incarceration**.- Continuing heavy weightlifting with an active **inguinal hernia** is medically unsafe, as the potential for emergency complications outweighs the benefits of completing a single competition.*Continue training until after the competition, then proceed with elective hernia repair*- High-intensity weightlifting provides a massive mechanical force that can lead to **acute incarceration** or **strangulation**, making delayed elective repair a dangerous strategy.- **Patient safety** must be prioritized over professional commitments when there is a significant risk of requiring **emergency surgery** due to a potentially life-threatening complication.*Immediate elective hernia repair with mesh, allowing return to full training in 2 weeks*- While surgery is necessary, a **2-week recovery** is insufficient for the mesh to incorporate and the fascia to heal enough to withstand the extreme pressures of weightlifting.- Returning to maximum lifting too early risks **postoperative recurrence** and chronic groin pain due to displacement or damage to the repair site.*Prescribe a supportive truss and allow continued training with regular review*- A **hernia truss** is considered an outdated management strategy that does not reliably prevent herniation or strangulation during extreme physical exertion.- Trusses can lead to **pressure necrosis** of the skin or underlying tissue and provide a false sense of security that may result in delayed presentation of complications.*Advise modification of training to avoid heavy lifting and Valsalva manoeuvres until after competition, followed by elective repair*- For a professional weightlifter, modifying training to avoid heavy lifting effectively prevents them from preparing for a **competition**, making this advice impractical and clinically non-definitive.- Even minor training activities can trigger **hernia protrusion**, so complete cessation and prompt surgical intervention is the only definitive way to manage the risk and return the athlete to their sport safely.
Question 162: A 62-year-old man presents with iron deficiency anaemia and weight loss. Colonoscopy identifies a circumferential tumour in the descending colon 25 cm from the anal verge. CT staging shows no distant metastases but reveals bilateral external iliac lymphadenopathy with nodes measuring up to 15 mm. He undergoes a left hemicolectomy. The histology report describes a moderately differentiated adenocarcinoma invading through the bowel wall into surrounding adipose tissue but not reaching the peritoneal surface, with 4 out of 18 lymph nodes positive for metastatic disease. What is the correct TNM stage?
A. T2 N2a M0 (Stage IIIB)
B. T3 N1b M0 (Stage IIIB)
C. T3 N2a M0 (Stage IIIC) (Correct Answer)
D. T4a N2a M0 (Stage IIIC)
E. T3 N2b M1a (Stage IVA)
Explanation: ***T3 N2a M0 (Stage IIIC)***- The tumor invades through the muscularis propria into the **subserosal adipose tissue** but does not reach the peritoneal surface, which correctly classifies it as **T3**.- With **4 positive regional lymph nodes** out of 18, the nodal status is classified as **N2a** (4–6 positive nodes). CT confirmed **no distant metastases**, making it **M0**.*T2 N2a M0 (Stage IIIB)*- **T2** stage would imply the tumor is confined to the **muscularis propria**, whereas the histology indicates invasion *through* it into the surrounding adipose tissue.- While the N2a and M0 components are consistent with the findings, the incorrect T-stage makes this option unsuitable.*T3 N1b M0 (Stage IIIB)*- The histology report clearly states **4 positive lymph nodes**, which corresponds to **N2a**.- **N1b** refers to metastases in **2 to 3 regional lymph nodes**, which is an underestimation of the nodal burden in this case.*T4a N2a M0 (Stage IIIC)*- **T4a** is defined by tumor invasion penetrating the **visceral peritoneum (serosa)**, which the report explicitly states the tumor did *not* reach.- Therefore, the T-stage is incorrectly upgraded to T4a, despite the N2a and M0 being consistent with the findings.*T3 N2b M1a (Stage IVA)*- **N2b** signifies metastases in **7 or more regional lymph nodes**, which contradicts the finding of only 4 positive nodes.- **M1a** denotes distant metastasis, but the CT staging explicitly reported **no distant metastases**, ruling out M1a.
Question 163: A 37-year-old woman undergoes emergency appendicectomy for acute appendicitis. Intraoperatively, a 4 cm firm mass is noted at the tip of the appendix. The caecum and terminal ileum appear normal. Histology reports a well-differentiated neuroendocrine tumour (carcinoid tumour) measuring 2.2 cm in maximum diameter, invading the muscularis propria, with Ki-67 index of 1%. The resection margins are clear. What is the most appropriate further management?
A. No further treatment required; routine surveillance
B. Right hemicolectomy with lymph node dissection (Correct Answer)
C. Adjuvant chemotherapy with platinum-based regimen
D. Measurement of 24-hour urinary 5-HIAA and octreotide scan, followed by observation
E. Completion right hemicolectomy only if lymph node metastases detected on CT imaging
Explanation: ***Right hemicolectomy with lymph node dissection*** - A **right hemicolectomy** is indicated for appendiceal **neuroendocrine tumours (NETs)** that are **greater than 2 cm** in size due to a significant risk (30-40%) of nodal metastasis. - This procedure provides adequate **lymphadenectomy** and oncological clearance, which an appendicectomy alone cannot achieve for larger tumours.*No further treatment required; routine surveillance* - **Appendicectomy alone** is only sufficient for small tumours **less than 1 cm** or 1-2 cm tumours without high-risk features. - Surveillance without definitive surgery for a **2.2 cm tumour** results in an unacceptably high risk of leaving behind **regional lymph node** disease.*Adjuvant chemotherapy with platinum-based regimen* - Well-differentiated (Grade 1) NETs with a low **Ki-67 index (<3%)** are relatively chemo-resistant and are primarily managed surgically. - **Adjuvant chemotherapy** is not a standard treatment for localized or regional appendiceal carcinoids; it is reserved for **high-grade** small cell neuroendocrine carcinomas.*Measurement of 24-hour urinary 5-HIAA and octreotide scan, followed by observation* - Biochemical markers and functional imaging can assist in staging but do not change the surgical requirement for a tumour **larger than 2 cm**. - Carcinoid syndrome and elevated **5-HIAA** are rare in appendiceal NETs unless there is extensive **liver metastasis**.*Completion right hemicolectomy only if lymph node metastases detected on CT imaging* - **CT imaging** has low sensitivity for detecting micrometastases in regional lymph nodes for neuroendocrine tumours. - The decision for surgery is based on **histopathological size** (2.2 cm) rather than radiographic findings, as size is the strongest predictor of **nodal involvement**.
Question 164: A 75-year-old man presents to the emergency department with a 4-day history of progressive left iliac fossa pain, fever, and constipation. CT abdomen demonstrates an 8 cm pelvic collection adjacent to the sigmoid colon with surrounding fat stranding and sigmoid diverticulosis. There is localised pneumoperitoneum. His observations show: temperature 38.6°C, heart rate 105 bpm, blood pressure 128/78 mmHg, respiratory rate 20/min, oxygen saturation 96% on air. Blood tests show: WCC 17.2 × 10⁹/L, CRP 285 mg/L, creatinine 98 μmol/L. What is the most appropriate initial management according to modified Hinchey classification?
A. Emergency laparotomy with sigmoid colectomy and end colostomy (Hartmann's procedure)
B. Emergency laparoscopic peritoneal lavage and drainage
C. Intravenous antibiotics and CT-guided percutaneous drainage of the collection (Correct Answer)
D. Intravenous antibiotics alone with interval sigmoid colectomy at 6-8 weeks
E. Emergency laparotomy with sigmoid colectomy and primary anastomosis with defunctioning ileostomy
Explanation: ***Intravenous antibiotics and CT-guided percutaneous drainage of the collection***
- This patient presents with a **Hinchey Stage II** (or modified Hinchey Stage II) diverticulitis characterized by a large **(>4-5 cm) pelvic abscess** and localized air, while remaining **hemodynamically stable**.
- Guidelines recommend **percutaneous drainage** for abscesses larger than 3-5 cm to control the source of infection and avoid the morbidity of emergency surgery in stable patients.
*Emergency laparotomy with sigmoid colectomy and end colostomy (Hartmann's procedure)*
- **Hartmann’s procedure** is reserved for **Hinchey Stage III or IV** (purulent or fecal peritonitis) where the patient is unstable or source control cannot be achieved non-operatively.
- Performing an emergency resection in a stable patient with a drainable abscess increases the risk of **stoma formation** and perioperative complications.
*Emergency laparoscopic peritoneal lavage and drainage*
- **Laparoscopic lavage** was previously an option for **Hinchey III** disease, but recent large trials (e.g., LOLA) have shown it may be inferior to resection due to higher rates of re-intervention.
- It is not indicated for a **localized collection** that can be accessed safely via a **CT-guided percutaneous** route.
*Intravenous antibiotics alone with interval sigmoid colectomy at 6-8 weeks*
- While antibiotics are essential, **antibiotics alone** are often insufficient for collections larger than **3-5 cm**, which have a high failure rate without drainage.
- Conservative management without drainage for an **8 cm collection** significantly increases the risk of treatment failure and progression to free perforation.
*Emergency laparotomy with sigmoid colectomy and primary anastomosis with defunctioning ileostomy*
- This is an alternative to Hartmann's for **Hinchey III** in stable patients, but it still represents **major surgery** that is premature in this scenario.
- The priority for a localized **Hinchey II** abscess in a hemodynamically stable patient is **source control** via the least invasive method possible (percutaneous drainage).
Question 165: A 48-year-old man undergoes colonoscopy for altered bowel habit. A 12 mm sessile polyp is identified in the sigmoid colon and removed by endoscopic mucosal resection. Histology shows a tubulovillous adenoma with a 3 mm focus of adenocarcinoma invading into the submucosa. The resection margin is clear by 2 mm and there is no lymphovascular invasion. What is the most appropriate management?
A. No further treatment; routine surveillance colonoscopy in 3 years (Correct Answer)
B. Completion segmental colectomy with lymph node resection
C. Adjuvant chemotherapy followed by surveillance colonoscopy in 1 year
D. Repeat colonoscopy in 3 months to assess the resection site and tattoo for future reference
E. Radiotherapy to the polyp site followed by surveillance
Explanation: ***No further treatment; routine surveillance colonoscopy in 3 years***- The presence of a **pT1 adenocarcinoma** (invasion into the submucosa) with **favorable features** (clear resection margin >1mm, no lymphovascular invasion, well/moderately differentiated) indicates complete endoscopic cure.- For such **low-risk malignant polyps**, the risk of residual disease or lymph node metastasis is very low, making further aggressive treatment unnecessary. Routine surveillance colonoscopy at 3 years is standard.*Completion segmental colectomy with lymph node resection*- This more aggressive surgical approach is reserved for **high-risk features** in a malignant polyp, such as a **positive or very close resection margin** (<1mm), **lymphovascular invasion**, poor differentiation, or deep submucosal invasion (Sm3).- In this patient, the **2 mm clear margin** and absence of lymphovascular invasion categorize it as a low-risk lesion, thus segmental colectomy would represent overtreatment.*Adjuvant chemotherapy followed by surveillance colonoscopy in 1 year*- **Adjuvant chemotherapy** is generally indicated for **Stage III colorectal cancer** (lymph node involvement) or high-risk Stage II disease, following surgical resection.- A **pT1 lesion** with favorable features and no evidence of nodal involvement does not warrant systemic chemotherapy, which carries significant side effects.*Repeat colonoscopy in 3 months to assess the resection site and tattoo for future reference*- A very early repeat colonoscopy (e.g., at 3-6 months) is usually recommended for **piecemeal resections** of large, flat lesions or when there is concern for **incomplete resection** or residual adenoma.- Since this polyp was fully excised with a **clear margin** of 2 mm, there is no immediate need to re-evaluate the site so soon; routine surveillance is preferred.*Radiotherapy to the polyp site followed by surveillance*- **Radiotherapy** is a key treatment modality for **rectal cancer**, often used neoadjuvantly or adjuvantly, particularly for locally advanced stages.- It is generally **not used for colon cancers**, especially for a localized pT1 lesion in the sigmoid colon, as the colon is a mobile organ and radiation carries risks of damage to surrounding structures without clear oncological benefit in this scenario.
Question 166: A 42-year-old woman presents to the emergency department with a 30-hour history of right lower quadrant pain, fever of 38.3°C, and vomiting. She has a past history of recurrent urinary tract infections and takes no regular medications. Her last menstrual period was 3 weeks ago. Examination reveals tenderness and guarding in the right iliac fossa. Urinalysis shows 3+ leucocytes and 2+ blood. White cell count is 16.8 × 10⁹/L. What is the most appropriate next investigation?
A. Urine microscopy, culture and sensitivity
B. Serum β-hCG followed by transvaginal ultrasound (Correct Answer)
C. CT abdomen and pelvis with intravenous contrast
D. Diagnostic laparoscopy
E. MRI pelvis without contrast
Explanation: ***Serum β-hCG followed by transvaginal ultrasound***
- In any woman of **reproductive age** presenting with acute lower abdominal pain, a **pregnancy test** (β-hCG) is the mandatory first step to exclude a potentially life-threatening **ectopic pregnancy**.
- Transvaginal ultrasound is the imaging modality of choice to differentiate between **gynaecological emergencies** (like ectopic pregnancy or ovarian torsion) and other abdominal causes like **appendicitis**.
*Urine microscopy, culture and sensitivity*
- While **leucocytes and blood** are present in the urinalysis, these can be secondary to an **inflamed appendix** irritating the ureter or bladder wall.
- This test takes 24-48 hours for results and is not appropriate for the acute management of a patient with **peritoneal signs** and fever.
*CT abdomen and pelvis with intravenous contrast*
- CT is highly sensitive for **appendicitis**, but it must not be performed until **pregnancy is ruled out** due to the risks of **ionising radiation** to a fetus.
- A serum β-hCG test must always precede radiological investigations involving radiation in a female patient of this age group.
*Diagnostic laparoscopy*
- This is an **invasive surgical procedure** that should only be performed after non-invasive imaging has been conducted or if the patient is clinically unstable.
- Jumping directly to surgery without excluding **ectopic pregnancy** via β-hCG and imaging increases the risk of unnecessary operative morbidity.
*MRI pelvis without contrast*
- MRI is a useful second-line tool in **pregnant patients** when ultrasound is inconclusive, as it avoids radiation exposure.
- However, it is not the most appropriate immediate next step before a **serum β-hCG** has even confirmed whether the patient is pregnant.
Question 167: A 64-year-old woman undergoes a left hemicolectomy for a T3N1M0 adenocarcinoma located in the splenic flexure. The operation is uncomplicated. She has no significant comorbidities and her performance status is ECOG 0. What is the most appropriate adjuvant treatment according to current UK guidelines?
A. No adjuvant treatment required
B. Radiotherapy alone
C. Adjuvant chemotherapy with single-agent 5-fluorouracil for 6 months
D. Adjuvant chemotherapy with oxaliplatin-based regimen (FOLFOX or CAPOX) for 6 months (Correct Answer)
E. Concurrent chemoradiotherapy followed by maintenance chemotherapy
Explanation: ***Adjuvant chemotherapy with oxaliplatin-based regimen (FOLFOX or CAPOX) for 6 months***- For **Stage III colon cancer (T3N1M0)**, current UK (NICE) guidelines recommend **oxaliplatin-based chemotherapy** to reduce the risk of recurrence.- The addition of **oxaliplatin** to a fluoropyrimidine backbone provides superior disease-free survival in patients with a good performance status like **ECOG 0**.*No adjuvant treatment required*- This is incorrect because the patient has **node-positive (Stage III)** disease, which carries a high risk of micrometastases.- Observation without chemotherapy is typically reserved for low-risk **Stage II (node-negative)** disease.*Radiotherapy alone*- **Radiotherapy** is not a standard adjuvant treatment for colon cancer because the colon is a mobile organ, making it difficult to target.- It is primarily used in **rectal cancer** to prevent local recurrence rather than in colon cancer management.*Adjuvant chemotherapy with single-agent 5-fluorouracil for 6 months*- **Single-agent fluoropyrimidine** is no longer the gold standard for **Stage III** disease when the patient is fit enough for dual agents.- It is generally reserved for patients who cannot tolerate **oxaliplatin** due to comorbidities or existing neuropathy.*Concurrent chemoradiotherapy followed by maintenance chemotherapy*- **Concurrent chemoradiotherapy** is a treatment modality used for **rectal cancer** or occasionally for locally advanced, non-resectable colon tumors.- It is not indicated as standard adjuvant therapy for post-operative **Stage III colon cancer**.
Question 168: A 56-year-old man presents to the surgical outpatient clinic with a 6-month history of a painless right groin lump that increases in size with coughing and disappears when lying down. On examination, there is a reducible lump that emerges above and medial to the pubic tubercle. The examining finger can be placed over the deep inguinal ring, and the lump still emerges on coughing. What is the most likely diagnosis?
A. Direct inguinal hernia (Correct Answer)
B. Indirect inguinal hernia
C. Femoral hernia
D. Saphena varix
E. Inguinal lymphadenopathy
Explanation: ***Direct inguinal hernia***- A **direct inguinal hernia** occurs through a weakness in the **Hesselbach's triangle** and protrudes **medial** to the **inferior epigastric artery**.- During the **internal ring occlusion test**, the lump still emerges on coughing, indicating it is not coming through the deep inguinal ring. *Indirect inguinal hernia*- Unlike the direct type, an **indirect hernia** enters the **deep inguinal ring** and would be controlled (not emerge) when pressure is applied over the deep inguinal ring during coughing.- It is located **lateral** to the inferior epigastric vessels and often descends into the **scrotum** in males. *Femoral hernia*- A **femoral hernia** typically presents as a lump **below and lateral** to the **pubic tubercle**, whereas this lump is above and medial.- These hernias have a **narrow neck** and carry a much higher risk of **strangulation** compared to inguinal hernias. *Saphena varix*- A **saphena varix** is a dilation of the great saphenous vein that may demonstrate a distinctive **cough thrill** and often disappears immediately on **lying down** or leg elevation.- It is usually associated with other signs of **varicose veins** and is located at the **saphenofemoral junction** below the inguinal ligament. *Inguinal lymphadenopathy*- **Inguinal lymphadenopathy** typically presents as **firm**, discrete, or matted nodes that are **non-reducible** and do not change with **intra-abdominal pressure**.- These nodes would not exhibit a **cough impulse** or disappear when the patient lies in a supine position.
Question 169: A 33-year-old man presents to the emergency department with a 14-hour history of right iliac fossa pain, nausea, and fever of 37.9°C. His white cell count is 14.2 × 10⁹/L and CRP is 45 mg/L. He is haemodynamically stable. CT abdomen confirms acute appendicitis with no perforation or collection. What is the most appropriate initial management?
A. Emergency appendicectomy within 4 hours
B. Urgent appendicectomy within 24 hours and intravenous antibiotics (Correct Answer)
C. Conservative management with intravenous antibiotics for 48 hours followed by interval appendicectomy at 6 weeks
D. Conservative management with intravenous antibiotics alone with no planned surgery
E. Observation for 24 hours with regular clinical assessment before deciding on surgery
Explanation: ***Urgent appendicectomy within 24 hours and intravenous antibiotics***
- For **haemodynamically stable** patients with **uncomplicated appendicitis** (no perforation or collection on CT), surgery within 24 hours is the standard of care.
- This timeframe allows for adequate **rehydration** and administration of **intravenous antibiotics** to reduce surgical site infections and intra-abdominal abscesses.
*Emergency appendicectomy within 4 hours*
- Surgery within 4 hours is typically reserved for patients with **sepsis**, **generalized peritonitis**, or clinical signs of **haemodynamic instability**.
- In stable patients, there is no clinical benefit to rushing to the operating theatre before establishing **fluid resuscitation** and antibiotic coverage.
*Conservative management with intravenous antibiotics for 48 hours followed by interval appendicectomy at 6 weeks*
- This approach is generally reserved for patients presenting with an **appendix mass** or **phlegmon**, where immediate surgery is technically difficult.
- The CT in this patient confirmed **simple appendicitis** without a mass or collection, making immediate definitive surgery the preferred choice.
*Conservative management with intravenous antibiotics alone with no planned surgery*
- Antibiotics alone may be considered in specific circumstances, but there is a **high recurrence rate** (approx. 30% within a year) compared to surgery.
- **Laparoscopic appendicectomy** remains the gold standard in the UK for providing a definitive cure and preventing future complications.
*Observation for 24 hours with regular clinical assessment before deciding on surgery*
- Observation is indicated when the diagnosis is **uncertain**; however, this patient has a **CT-confirmed** diagnosis of acute appendicitis.
- Delaying surgery for observation in a confirmed case increases the risk of **perforation** and unnecessary morbidity.
Question 170: A 71-year-old man with a history of chronic constipation undergoes colonoscopy which reveals multiple diverticula throughout the sigmoid colon and a 2.5 cm polyp in the descending colon. Histology confirms a tubular adenoma with low-grade dysplasia. What is the most appropriate surveillance interval for this patient according to current UK guidelines?
A. No surveillance required
B. 1 year
C. 3 years (Correct Answer)
D. 5 years
E. 10 years
Explanation: ***3 years***- According to the **BSG (British Society of Gastroenterology)** guidelines, a surveillance interval of **3 years** is indicated for patients categorized as "high-risk" after a baseline colonoscopy.- This patient qualifies as high-risk because he has at least **one adenoma ">"=10mm** (his is 2.5 cm), which necessitates closer monitoring than low-risk findings.*No surveillance required*- This option is only appropriate for patients with **no adenomas** or those with very low-risk features like distal small **rectal hyperplastic polyps**.- Since a **2.5 cm tubular adenoma** was found, the patient must remain in a surveillance program to prevent colorectal cancer.*1 year*- A **1-year** follow-up is generally reserved for patients with very high-risk findings, such as the removal of **">"=5 adenomas** or a very large **sessile polyp** removed piecemeal.- The current case involves a single polyp, so a 1-year interval would be unnecessarily frequent.*5 years*- A **5-year** interval is typically considered for patients who are **low-risk**, defined as having only **1-2 small adenomas ("<"10mm)** with low-grade dysplasia.- Because the polyp size exceeds **10mm**, this patient requires the more frequent **3-year** surveillance instead.*10 years*- **10 years** is a common interval for general population screening using **colonoscopy**, but it is not used for post-polypectomy surveillance of high-risk adenomas.- Following the detection of a **significant adenoma**, the interval must be shortened to assess for recurrence or metachronous lesions.
