General Surgery — MCQs

A 65-year-old man undergoes an emergency appendicectomy for perforated appendicitis with localised peritonitis. Intraoperatively, a hard mass is palpated at the appendix base. Histopathology confirms a 1.8 cm appendiceal adenocarcinoma with invasion into the muscularis propria but no lymphovascular invasion. Three lymph nodes examined are negative. What is the most appropriate definitive management?

Q262

A 28-year-old woman presents to the emergency department with a 12-hour history of right iliac fossa pain that initially started periumbilically. She has had two episodes of vomiting and reports anorexia. On examination, her temperature is 38.1°C, pulse 95 bpm, and blood pressure 120/75 mmHg. There is tenderness and guarding in the right iliac fossa with rebound tenderness. What is the most appropriate initial imaging investigation?

General Surgery UK Medical PG Practice Questions and MCQs

Question 261: A 65-year-old man undergoes an emergency appendicectomy for perforated appendicitis with localised peritonitis. Intraoperatively, a hard mass is palpated at the appendix base. Histopathology confirms a 1.8 cm appendiceal adenocarcinoma with invasion into the muscularis propria but no lymphovascular invasion. Three lymph nodes examined are negative. What is the most appropriate definitive management?

A. No further treatment required
B. Right hemicolectomy (Correct Answer)
C. Adjuvant chemotherapy only
D. Right hemicolectomy followed by adjuvant chemotherapy
E. Completion appendicectomy with wider margins

Explanation: ***Right hemicolectomy*** - **Appendiceal adenocarcinoma**, especially when larger than 1 cm or involving the muscularis propria, requires a **formal oncological resection** similar to colonic cancer to ensure clear margins and adequate **lymphadenectomy**. - The initial appendicectomy harvested only three lymph nodes, which is **insufficient for accurate staging** (a minimum of 12 nodes is generally required for colorectal cancer staging). A **right hemicolectomy** provides the necessary extensive lymph node sampling. *No further treatment required* - This option is incorrect because **appendiceal adenocarcinoma** is a malignant tumor with a notable risk of regional lymph node metastasis, necessitating definitive oncological management. - The initial emergency appendicectomy was not a planned oncological resection, and the **inadequate lymph node harvest** means the patient is not definitively staged or treated. *Adjuvant chemotherapy only* - **Adjuvant chemotherapy** is not a standalone treatment for localized adenocarcinoma; **surgical resection** with wide margins and lymphadenectomy is the primary definitive therapy. - The decision for adjuvant chemotherapy typically relies on **post-operative pathological staging** (e.g., node-positive or high-risk Stage II disease), which cannot be determined without a proper oncological resection. *Right hemicolectomy followed by adjuvant chemotherapy* - While **right hemicolectomy** is the correct surgical approach, the need for **adjuvant chemotherapy** cannot be determined until the **final pathological staging** of the hemicolectomy specimen is complete. - If the subsequent pathology (with adequate lymph nodes) confirms **Stage II (T2N0)** disease without high-risk features, adjuvant chemotherapy may not be indicated. *Completion appendicectomy with wider margins* - A **completion appendicectomy** is insufficient for **appendiceal adenocarcinoma** because it does not provide the necessary **regional lymph node dissection** of the ileocolic lymphatic basin. - This procedure would result in **suboptimal oncological clearance** and an unacceptably high risk of locoregional recurrence, failing to meet standards for definitive cancer surgery.

Question 262: A 28-year-old woman presents to the emergency department with a 12-hour history of right iliac fossa pain that initially started periumbilically. She has had two episodes of vomiting and reports anorexia. On examination, her temperature is 38.1°C, pulse 95 bpm, and blood pressure 120/75 mmHg. There is tenderness and guarding in the right iliac fossa with rebound tenderness. What is the most appropriate initial imaging investigation?

A. Abdominal ultrasound (Correct Answer)
B. CT abdomen and pelvis with intravenous contrast
C. MRI abdomen and pelvis
D. Plain abdominal radiograph
E. No imaging required, proceed directly to theatre

Explanation: ***Abdominal ultrasound***- In a young woman of childbearing age, **abdominal ultrasound** is the preferred first-line imaging to avoid exposing the patient to **ionising radiation**.- It is highly effective at identifying **appendicitis** and can simultaneously evaluate for alternative **gynecological pathologies**, such as ovarian cysts or pelvic inflammatory disease.*CT abdomen and pelvis with intravenous contrast*- Although this provides higher sensitivity and specificity than ultrasound, it is avoided as the **initial** test in young women due to the risk of **radiation exposure** to the ovaries.- It is typically reserved for cases where the **ultrasound is inconclusive** or the clinical picture is complex.*MRI abdomen and pelvis*- MRI is a safe alternative to CT for diagnosing appendicitis specifically in **pregnant patients** to avoid radiation.- It is not used as the initial investigation because it is **expensive**, less readily available in the acute setting, and takes significantly longer to perform than ultrasound.*Plain abdominal radiograph*- This modality has **low sensitivity** and specificity for diagnosing appendicitis and rarely changes management.- Its primary use in acute abdominal pain is to rule out **bowel perforation** (pneumoperitoneum) or **mechanical obstruction**, neither of which are the primary suspicion here.*No imaging required, proceed directly to theatre*- While appendicitis is a clinical diagnosis, modern surgical practice favors **pre-operative imaging** to reduce the rate of **negative appendicectomies**.- Proceeding directly to theatre is generally reserved for patients with clear clinical **peritonitis** or hemodynamic instability.

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