MCQ bank · 36 questions · free
Emergency general surgery MCQs with answers
36 single-best-answer questions on the acute abdomen, appendicitis, bowel obstruction, sepsis and peritonitis. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A 26-year-old man has CT-confirmed uncomplicated acute appendicitis (no appendicolith, abscess or perforation). Which statement is correct?
- An appendicolith makes antibiotics alone more likely to succeed
- Open appendicectomy is preferred over laparoscopy
- Antibiotics alone have the same long-term success as surgery
- Surgery must be performed within 2 hours of diagnosis
- Laparoscopic appendicectomy is standard; antibiotics alone are a reasonable alternative, accepting a recurrence of about 4 in 10 within 5 years
Show the answer and explanation
Answer: E. Laparoscopic appendicectomy is standard; antibiotics alone are a reasonable alternative, accepting a recurrence of about 4 in 10 within 5 years. In uncomplicated appendicitis, an antibiotic-first strategy avoids surgery in most patients initially, but about 39% have recurrence within 5 years (APPAC). Laparoscopic appendicectomy remains the standard, and the choice should be shared with the patient.
Why not the others? An appendicolith predicts failure of antibiotic treatment. A short delay of several hours to surgery does not increase perforation.
References
A 70-year-old woman with previous hysterectomy has adhesive small bowel obstruction. She has no fever, tachycardia, peritonism or signs of ischaemia on CT. What is the recommended initial management?
- Discharge with analgesia
- Laparoscopic adhesiolysis within 6 hours
- Oral laxatives
- Nasogastric decompression, fluids, and a water-soluble contrast challenge
- Immediate laparotomy
Show the answer and explanation
Answer: D. Nasogastric decompression, fluids, and a water-soluble contrast challenge. Most adhesive obstructions without signs of strangulation resolve with conservative treatment. Gastrografin given orally both predicts resolution (contrast in the colon within 24 hours) and may speed it. Surgery is indicated for ischaemia, peritonitis or failure after about 72 hours.
Why not the others? Urgent surgery is reserved for signs of strangulation.
References
A 59-year-old diabetic man has rapidly spreading pain in the thigh, out of proportion to a small area of dusky skin, with fever and hypotension. What is the most important step?
- Hyperbaric oxygen as first-line treatment
- Intravenous antibiotics and review in 24 hours
- MRI to confirm the diagnosis before surgery
- Needle aspiration of the area
- Resuscitation, broad-spectrum antibiotics and immediate surgical debridement
Show the answer and explanation
Answer: E. Resuscitation, broad-spectrum antibiotics and immediate surgical debridement. Necrotising soft tissue infection is a surgical emergency. Mortality rises with every hour of delay to debridement, so suspected cases go to theatre without waiting for imaging, and are re-explored within 24 hours.
Why not the others? Imaging and scores such as LRINEC must never delay surgery when the clinical picture is clear.
References
A 67-year-old has faecal peritonitis and septic shock. Within what time should intravenous antibiotics be given?
- After blood cultures have grown an organism
- Within 6 hours
- After the operation
- Within 24 hours
- Within 1 hour of recognition
Show the answer and explanation
Answer: E. Within 1 hour of recognition. In septic shock, antibiotics should be given within 1 hour; each hour of delay increases mortality. Take blood cultures first if this causes no delay, and arrange source control as soon as possible.
Why not the others? Waiting for culture results or theatre delays life-saving treatment.
References
A 78-year-old man in atrial fibrillation has had severe central abdominal pain for 4 hours. His abdomen is soft with little tenderness, and his lactate is 4.1 mmol/L. What is the key investigation?
- Upper GI endoscopy
- Abdominal ultrasound
- Wait for the lactate to rise further
- CT angiography of the abdomen
- Plain abdominal X-ray
Show the answer and explanation
Answer: D. CT angiography of the abdomen. Pain out of proportion to the examination in a patient with atrial fibrillation suggests acute mesenteric ischaemia from an embolus. CT angiography is the diagnostic test and should not be delayed by concerns about kidney function. Treatment is anticoagulation, revascularisation and resection of dead bowel.
Why not the others? A normal lactate does not exclude ischaemia, and waiting increases bowel loss and mortality.
References
A haemodynamically stable 58-year-old has purulent peritonitis from perforated sigmoid diverticulitis (Hinchey III). Which operation is an accepted alternative to Hartmann’s procedure?
- Colonoscopy and stenting
- Total colectomy
- Right hemicolectomy
- Antibiotics without surgery for every patient
- Sigmoid resection with primary anastomosis, with or without a diverting ileostomy
Show the answer and explanation
Answer: E. Sigmoid resection with primary anastomosis, with or without a diverting ileostomy. In stable patients, resection with primary anastomosis (often with a protective ileostomy) has similar safety to Hartmann’s procedure and a much higher chance of ending without a permanent stoma (LADIES, DIVERTI). Hartmann’s remains appropriate for unstable or immunocompromised patients.
Why not the others? Faecal peritonitis or septic shock favours Hartmann’s or damage-control surgery.
References
- Lambrichts DPV et al. Hartmann’s procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES). Lancet Gastroenterol Hepatol 2019
- Sartelli M et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 2020
Four days after a hip replacement, an 80-year-old man has a hugely distended, non-tender abdomen. CT shows a dilated colon (caecum 11 cm) with no obstructing lesion. Electrolytes have been corrected and 48 hours of conservative treatment have failed. What is the next step?
- Intravenous neostigmine with cardiac monitoring and atropine available
- Emergency right hemicolectomy
- Barium enema
- Oral laxatives
- Continue conservative treatment for 2 more weeks
Show the answer and explanation
Answer: A. Intravenous neostigmine with cardiac monitoring and atropine available. This is acute colonic pseudo-obstruction (Ogilvie’s syndrome). If supportive care fails, neostigmine decompresses the colon in most patients; bradycardia is the main side effect. Colonoscopic decompression is next, and surgery is reserved for ischaemia or perforation.
Why not the others? Stimulant laxatives can worsen distension. Surgery without signs of ischaemia or perforation is not indicated.
References
A woman who is 24 weeks pregnant has right-sided abdominal pain, fever and raised white cells. Ultrasound does not show the appendix. What is the next step?
- Antibiotics and discharge
- Diagnostic peritoneal lavage
- CT with intravenous contrast as the first choice
- Observe until delivery
- MRI of the abdomen without gadolinium
Show the answer and explanation
Answer: E. MRI of the abdomen without gadolinium. Ultrasound is the first test in pregnancy. If it is inconclusive, non-contrast MRI is accurate and avoids ionising radiation. Laparoscopic appendicectomy is safe in any trimester; delay increases the risk of perforation, which is the main cause of fetal loss.
Why not the others? CT can be used if MRI is not available, but it is not first choice. Waiting until delivery is dangerous.
References
A 45-year-old man has had right iliac fossa pain for 8 days. He is stable. CT shows an appendiceal phlegmon with a 2-cm abscess. What is the usual management?
- Non-operative treatment with antibiotics (draining the abscess if larger), then colonoscopy and CT later because of his age
- Discharge without antibiotics
- Immediate appendicectomy
- Right hemicolectomy
- Laparotomy and drainage
Show the answer and explanation
Answer: A. Non-operative treatment with antibiotics (draining the abscess if larger), then colonoscopy and CT later because of his age. A delayed presentation with a phlegmon or abscess is usually treated without surgery, because early operation risks a more extensive resection. Larger abscesses are drained percutaneously. In patients over about 40, an underlying tumour must be excluded later with colonoscopy and CT.
Why not the others? Interval appendicectomy is not routine, but is considered for recurrent symptoms.
References
A man with alcohol-related cirrhosis vomits a large amount of blood. His pulse is 118 and his blood pressure 96/60. What is the correct early management?
- Transfuse to a haemoglobin of 120 g/L
- Emergency surgical shunt
- Resuscitation with a restrictive transfusion target, a vasoactive drug (terlipressin), antibiotics, and endoscopy with band ligation within 12 hours
- Fresh frozen plasma to normalise the INR before endoscopy
- Proton pump inhibitor alone and endoscopy in 48 hours
Show the answer and explanation
Answer: C. Resuscitation with a restrictive transfusion target, a vasoactive drug (terlipressin), antibiotics, and endoscopy with band ligation within 12 hours. In suspected variceal bleeding, a vasoactive drug and antibiotic prophylaxis reduce rebleeding and mortality. Transfusion to about 70–80 g/L is safer than liberal transfusion, which raises portal pressure. Endoscopic band ligation follows within 12 hours. TIPS is considered for high-risk or uncontrolled bleeding.
Why not the others? Correcting the INR with plasma does not reduce bleeding and adds volume.
References
After massive resuscitation for a ruptured aneurysm repair, a ventilated patient has a tense abdomen, rising airway pressures and falling urine output. Bladder pressure is 26 mmHg. What is the definitive treatment?
- Increase the ventilator pressures
- Decompressive laparotomy with temporary abdominal closure
- Diuretics
- Observation and repeat pressure in 24 hours
- More intravenous fluid
Show the answer and explanation
Answer: B. Decompressive laparotomy with temporary abdominal closure. Intra-abdominal pressure above 20 mmHg with new organ dysfunction is abdominal compartment syndrome. Medical measures (sedation, decompression, fluid balance) are tried briefly, but persistent compartment syndrome needs a decompressive laparotomy, leaving the abdomen open with temporary closure.
Why not the others? More fluid worsens the oedema that causes the problem.
References
CT in a 45-year-old woman with abdominal distension shows a caecal volvulus without perforation. What is the recommended treatment?
- Surgery: right hemicolectomy (with anastomosis or ileostomy depending on the patient)
- Rectal tube
- Neostigmine
- Observation
- Endoscopic detorsion as definitive treatment
Show the answer and explanation
Answer: A. Surgery: right hemicolectomy (with anastomosis or ileostomy depending on the patient). Unlike sigmoid volvulus, caecal volvulus is rarely reduced endoscopically and has high recurrence, so resection (right hemicolectomy) is recommended. Caecopexy alone has higher recurrence.
Why not the others? Neostigmine is for pseudo-obstruction, never for a mechanical volvulus.
References
An 82-year-old woman has small bowel obstruction. CT shows air in the biliary tree and a 3-cm calcified stone in the terminal ileum. What is the usual operation?
- Right hemicolectomy
- Conservative treatment until the stone passes
- Enterolithotomy, cholecystectomy and fistula repair at the same operation in every patient
- Enterolithotomy (removal of the stone through an enterotomy), checking the rest of the bowel for more stones
- ERCP
Show the answer and explanation
Answer: D. Enterolithotomy (removal of the stone through an enterotomy), checking the rest of the bowel for more stones. Gallstone ileus is caused by a stone passing through a cholecystoenteric fistula. Patients are often frail, so the obstruction is relieved by enterolithotomy alone; the fistula often closes, and cholecystectomy is done later only if needed. The one-stage operation has higher mortality.
Why not the others? Nasogastric decompression alone will not relieve an impacted stone.
References
An 80-year-old man with heart failure and COPD (high surgical risk) has acute calculous cholecystitis. He is stable. According to the CHOCOLATE trial, what is preferred if he can tolerate surgery?
- ERCP
- Antibiotics alone with no follow-up
- Laparoscopic cholecystectomy, which had fewer major complications than percutaneous drainage
- Open cholecystectomy
- Percutaneous cholecystostomy in all high-risk patients
Show the answer and explanation
Answer: C. Laparoscopic cholecystectomy, which had fewer major complications than percutaneous drainage. In high-risk patients with acute calculous cholecystitis, the CHOCOLATE trial found that laparoscopic cholecystectomy had far fewer major complications, reinterventions and recurrences than percutaneous catheter drainage. Drainage remains the option for patients truly unfit for anaesthesia.
Why not the others? Cholecystostomy is a bridge, not a cure, and complications are frequent.
References
A 75-year-old on antibiotics for pneumonia has profuse diarrhoea, a distended abdomen, a white cell count of 35 and a rising lactate. Clostridioides difficile toxin is positive. CT shows a dilated, thick-walled colon. What is required?
- Colonoscopy with biopsies
- Oral metronidazole only
- Urgent surgical review; subtotal colectomy with end ileostomy (or loop ileostomy with colonic lavage) for fulminant colitis
- Continue the antibiotics for pneumonia unchanged
- Loperamide
Show the answer and explanation
Answer: C. Urgent surgical review; subtotal colectomy with end ileostomy (or loop ileostomy with colonic lavage) for fulminant colitis. Fulminant C. difficile colitis (shock, ileus, megacolon or rising lactate) has high mortality without surgery. Early surgical consultation is vital, alongside oral vancomycin. Surgery before the lactate rises above about 5 mmol/L improves survival.
Why not the others? Antidiarrhoeals worsen the risk of megacolon.
References
A 79-year-old has passed large amounts of fresh blood per rectum. His pulse is 120 and his blood pressure is 90/60 after 1 litre of fluid. Upper GI bleeding has been excluded. What is the best next investigation?
- Barium enema
- Exploratory laparotomy straight away
- Capsule endoscopy
- Colonoscopy without bowel preparation in 7 days
- CT angiography to localise active bleeding, followed by targeted embolisation
Show the answer and explanation
Answer: E. CT angiography to localise active bleeding, followed by targeted embolisation. In haemodynamically significant lower GI bleeding, CT angiography quickly confirms and localises active bleeding (for example from a diverticulum) and directs catheter embolisation. Colonoscopy is used in stable patients. Blind segmental colectomy has high rebleeding and mortality.
Why not the others? A brisk upper GI bleed can present with fresh rectal blood and must be excluded first.
References
A patient with adhesive small bowel obstruction has been managed conservatively for 12 hours. A repeat CT shows a closed loop with reduced enhancement of the bowel wall and free fluid. What do you do?
- Continue conservative management for 72 hours
- Discharge home
- Urgent surgery
- Repeat CT in 48 hours
- Water-soluble contrast challenge
Show the answer and explanation
Answer: C. Urgent surgery. CT signs of strangulation, such as a closed loop, reduced wall enhancement, mesenteric oedema or free fluid, mean the bowel is at risk and conservative treatment must stop. Delay increases the need for resection and mortality.
Why not the others? Gastrografin challenge is only for patients without signs of strangulation.
References
At laparotomy for a perforated peptic ulcer, you find a 1-cm perforation in the gastric antrum. What should be added to the omental patch repair?
- Vagotomy
- A biopsy of the ulcer edge to exclude gastric cancer
- No additional step
- Splenectomy
- Total gastrectomy
Show the answer and explanation
Answer: B. A biopsy of the ulcer edge to exclude gastric cancer. A perforated gastric ulcer may be a perforated cancer, so the ulcer edge should be biopsied, or follow-up endoscopy arranged to obtain tissue. Duodenal ulcers are almost never malignant.
Why not the others? Gastrectomy is not indicated without a diagnosis of cancer in an emergency setting.
References
A 70-year-old with sigmoid volvulus has peritonism and a raised lactate. At flexible sigmoidoscopy the mucosa is black and necrotic. What is the management?
- Barium enema
- Abandon decompression; emergency laparotomy with sigmoid resection, usually Hartmann’s procedure
- Repeat endoscopic detorsion
- Neostigmine
- Insert a rectal tube and observe
Show the answer and explanation
Answer: B. Abandon decompression; emergency laparotomy with sigmoid resection, usually Hartmann’s procedure. Endoscopic detorsion is contraindicated when the bowel is ischaemic or perforated. Gangrenous sigmoid volvulus needs emergency resection; Hartmann’s procedure is usual in a sick patient with gangrenous bowel.
Why not the others? Neostigmine is for pseudo-obstruction, not mechanical volvulus.
References
A 72-year-old woman on apixaban had a bout of coughing and now has severe lower abdominal pain and a tender, non-mobile mass in the rectus muscle that does not cross the midline. Her haemoglobin has dropped from 125 to 110 g/L. What is the most likely diagnosis and test?
- Appendicitis; appendicectomy
- Bladder distension; catheter only
- Rectus sheath haematoma; CT, then usually conservative management, with embolisation if bleeding continues
- Ovarian torsion; laparoscopy
- Incarcerated hernia; immediate surgery
Show the answer and explanation
Answer: C. Rectus sheath haematoma; CT, then usually conservative management, with embolisation if bleeding continues. Rectus sheath haematoma occurs after coughing or straining, especially in older, anticoagulated patients. The mass is fixed and does not move when the patient tenses the abdomen (Fothergill’s sign). CT confirms it. Treatment is reversing or holding anticoagulation, fluids and analgesia; embolisation is used for ongoing bleeding.
Why not the others? Mistaking it for an acute abdomen can lead to an unnecessary laparotomy.
References
A 40-year-old woman taking the oral contraceptive pill has 3 days of diffuse abdominal pain. CT shows thrombosis of the superior mesenteric vein with a thickened small bowel but no signs of infarction. What is the main treatment?
- Observation without anticoagulation
- Laparotomy and resection now
- Antibiotics only
- Immediate therapeutic anticoagulation (heparin), with close monitoring and surgery only if bowel infarction develops
- Aspirin
Show the answer and explanation
Answer: D. Immediate therapeutic anticoagulation (heparin), with close monitoring and surgery only if bowel infarction develops. Mesenteric venous thrombosis is treated first with anticoagulation, which prevents propagation and allows recanalisation. Patients are monitored for peritonitis, which signals infarction requiring resection. A thrombophilia and cause should be sought.
Why not the others? Arterial mesenteric ischaemia usually needs revascularisation; venous thrombosis usually does not.
References
A patient with cirrhosis and ascites has abdominal pain and fever. Ascitic fluid shows many neutrophils and Gram stain shows several types of organism; the glucose is very low and the protein is high. What should you suspect?
- Secondary bacterial peritonitis from a perforation or abscess; urgent CT and surgical review
- Spontaneous bacterial peritonitis; antibiotics only
- Hepatorenal syndrome
- Normal ascites
- Tuberculous peritonitis
Show the answer and explanation
Answer: A. Secondary bacterial peritonitis from a perforation or abscess; urgent CT and surgical review. Spontaneous bacterial peritonitis is usually caused by a single organism and treated with antibiotics. Multiple organisms, very low glucose, high protein, high LDH or failure to respond suggest secondary peritonitis from a surgical cause, which needs imaging and source control.
Why not the others? Missing secondary peritonitis in cirrhosis is often fatal.
References
A patient had a laparoscopic washout and appendicectomy for perforated appendicitis with a localised abscess. Source control was adequate. How long should antibiotics be continued?
- 14 days
- About 4 days after adequate source control
- No antibiotics after surgery
- 6 weeks
- Until the white count is completely normal, however long that takes
Show the answer and explanation
Answer: B. About 4 days after adequate source control. The STOP-IT trial showed that in complicated intra-abdominal infection with adequate source control, a fixed course of about 4 days was as effective as longer courses guided by fever and white count. Shorter courses reduce resistance and C. difficile.
Why not the others? Failure to improve should prompt a search for a persistent source rather than prolonged antibiotics.
References
A 78-year-old with a known large para-oesophageal hernia has severe epigastric pain, retching without vomiting, and a nasogastric tube cannot be passed. What is the most likely diagnosis?
- Acute gastric volvulus (Borchardt’s triad); urgent CT and surgery
- Biliary colic
- Peptic ulcer
- Gastroenteritis
- Myocardial infarction only
Show the answer and explanation
Answer: A. Acute gastric volvulus (Borchardt’s triad); urgent CT and surgery. Borchardt’s triad (severe epigastric pain, unproductive retching, inability to pass a nasogastric tube) suggests acute gastric volvulus, often within a para-oesophageal hernia. Strangulation and necrosis can follow, so the stomach is decompressed if possible and repaired urgently.
Why not the others? An ECG should still be done in older patients with epigastric pain.
References
After endoscopic dilatation of an oesophageal stricture, a patient has chest pain. CT shows a small contained leak with a little mediastinal air. He is stable and has no sepsis. What is the usual management?
- Discharge home
- Immediate oesophagectomy
- Thoracotomy for every perforation
- Conservative treatment: nil by mouth, antibiotics, PPI and nutrition, with endoscopic clips or stent if needed and close monitoring
- Oral diet and observe
Show the answer and explanation
Answer: D. Conservative treatment: nil by mouth, antibiotics, PPI and nutrition, with endoscopic clips or stent if needed and close monitoring. Iatrogenic perforations recognised early, small and contained, without sepsis, can often be managed non-operatively or endoscopically. Deterioration, sepsis or uncontained leaks need surgery.
Why not the others? Spontaneous (Boerhaave) perforations are usually larger and more contaminated than iatrogenic ones.
References
During a diagnostic colonoscopy, the endoscopist recognises a small perforation immediately. The bowel was well prepared and the patient is stable. Which management is often possible?
- Endoscopic closure with clips, then antibiotics and close observation, with surgery if the patient deteriorates
- Oral diet the same evening
- Discharge home immediately
- Always an emergency Hartmann’s procedure
- Repeat colonoscopy in 1 week
Show the answer and explanation
Answer: A. Endoscopic closure with clips, then antibiotics and close observation, with surgery if the patient deteriorates. Small perforations recognised during colonoscopy in a well-prepared bowel can often be closed endoscopically. Delayed recognition, large defects, peritonitis or sepsis need surgery.
Why not the others? A clean bowel and immediate recognition make endoscopic closure more successful.
References
A 58-year-old diabetic man has severe perineal and scrotal pain, swelling with crepitus, and fever. The skin is dusky. What is the management?
- Hyperbaric oxygen only
- Resuscitation, broad-spectrum antibiotics and immediate radical surgical debridement (Fournier’s gangrene), with re-look within 24 hours
- Scrotal ultrasound and outpatient follow-up
- Oral antibiotics and review in 2 days
- Orchidectomy alone
Show the answer and explanation
Answer: B. Resuscitation, broad-spectrum antibiotics and immediate radical surgical debridement (Fournier’s gangrene), with re-look within 24 hours. Fournier’s gangrene is a necrotising infection of the perineum and genitalia. As elsewhere, survival depends on early aggressive debridement. A diverting colostomy may be needed for wound management. The testes usually survive because they have a separate blood supply.
Why not the others? Waiting for imaging or antibiotics alone increases mortality.
References
An 83-year-old with a known left-sided colon cancer has sudden generalised peritonitis. CT shows free gas and a perforation at the tumour. What is the usual operation?
- Resection of the tumour-bearing segment, usually with an end colostomy (Hartmann’s procedure) in the presence of peritonitis
- Loop colostomy without resection
- Colonic stent
- Total colectomy in every case
- Antibiotics only
Show the answer and explanation
Answer: A. Resection of the tumour-bearing segment, usually with an end colostomy (Hartmann’s procedure) in the presence of peritonitis. A perforated colon cancer with peritonitis needs source control and removal of the tumour. In a septic patient, Hartmann’s procedure avoids the risk of anastomotic leak. A stent is contraindicated in perforation.
Why not the others? A loop stoma without resection leaves the perforation and tumour in place.
References
A 24-year-old has a laparoscopic appendicectomy for uncomplicated (non-perforated, non-gangrenous) appendicitis. How long should antibiotics continue after surgery?
- 5 days intravenously
- 14 days
- 7 days orally
- No postoperative antibiotics are needed; a single preoperative dose is enough
- Until the white count is normal
Show the answer and explanation
Answer: D. No postoperative antibiotics are needed; a single preoperative dose is enough. In uncomplicated appendicitis, preoperative prophylaxis is sufficient, and postoperative antibiotics do not reduce infection. In complicated appendicitis, a short course (about 3–5 days) after adequate source control is recommended.
Why not the others? Unnecessary antibiotics increase resistance and C. difficile.
References
How can the negative appendicectomy rate be reduced in young adults with suspected appendicitis?
- Operate on every patient with right iliac fossa pain
- Wait 1 week
- Use a clinical score (such as the Alvarado, AIR or Adult Appendicitis Score) together with selective imaging
- Avoid imaging in all women
- Rely on the white count alone
Show the answer and explanation
Answer: C. Use a clinical score (such as the Alvarado, AIR or Adult Appendicitis Score) together with selective imaging. Combining clinical scores with targeted imaging (ultrasound, low-dose CT or MRI in pregnancy) separates low-, intermediate- and high-risk patients. This reduces unnecessary operations, particularly in young women, in whom gynaecological causes are common.
Why not the others? No single blood test reliably confirms or excludes appendicitis.
References
A bleeding posterior duodenal ulcer continues to bleed after endoscopic therapy and embolisation is not available. At laparotomy, what is the key surgical step?
- Omental patch only
- Vagotomy alone
- Closure without addressing the vessel
- Total gastrectomy
- Duodenotomy and under-running of the bleeding vessel (gastroduodenal artery) with sutures above, below and medially
Show the answer and explanation
Answer: E. Duodenotomy and under-running of the bleeding vessel (gastroduodenal artery) with sutures above, below and medially. Posterior duodenal ulcers bleed from the gastroduodenal artery. Under-running it with three-point ligation controls the bleeding while avoiding the common bile duct and pancreas. PPI therapy and H. pylori eradication follow.
Why not the others? An omental patch is for perforation, not bleeding.
References
CT in a 30-year-old with uncomplicated appendicitis shows an appendicolith. He asks about antibiotics instead of surgery. What is true?
- He needs no treatment
- An appendicolith increases the risk of failure and complications with antibiotics, so appendicectomy is preferred
- Antibiotics are always better
- The appendicolith makes antibiotics more effective
- He needs a colonoscopy instead
Show the answer and explanation
Answer: B. An appendicolith increases the risk of failure and complications with antibiotics, so appendicectomy is preferred. In the CODA trial, patients with an appendicolith had a higher risk of needing appendicectomy and of complications when treated with antibiotics. Surgery is generally recommended for these patients.
Why not the others? Antibiotic-first remains an option for some patients without an appendicolith.
References
A 72-year-old has sudden left-sided crampy pain followed by bloody diarrhoea. She is stable with mild tenderness. CT shows segmental thickening of the splenic flexure without free gas. What is the most likely diagnosis and management?
- Ischaemic colitis; supportive care (fluids, bowel rest, antibiotics in moderate/severe cases) and surgery only for peritonitis, gangrene or perforation
- Immediate left hemicolectomy
- Haemorrhoids; banding
- Diverticular bleed; embolisation
- Sigmoid volvulus; detorsion
Show the answer and explanation
Answer: A. Ischaemic colitis; supportive care (fluids, bowel rest, antibiotics in moderate/severe cases) and surgery only for peritonitis, gangrene or perforation. Ischaemic colitis often affects watershed areas such as the splenic flexure and usually resolves with supportive care. Colonoscopy confirms it once the patient is stable. Signs of transmural necrosis (peritonitis, rising lactate, gas in the bowel wall) need surgery.
Why not the others? Right-sided ischaemic colitis has a worse prognosis and may reflect mesenteric arterial disease.
References
A 70-year-old has generalised faecal peritonitis from a perforated sigmoid diverticulum (Hinchey IV) and is in septic shock. What is the operation?
- Laparoscopic lavage alone
- Primary anastomosis without a stoma
- Antibiotics only
- Percutaneous drainage only
- Hartmann’s procedure (sigmoid resection with end colostomy), or damage control surgery if unstable
Show the answer and explanation
Answer: E. Hartmann’s procedure (sigmoid resection with end colostomy), or damage control surgery if unstable. Faecal peritonitis with septic shock calls for resection without anastomosis. In very unstable patients, damage control (resection, temporary closure, re-look) is an option. Primary anastomosis is reserved for stable patients with purulent peritonitis.
Why not the others? Laparoscopic lavage is not appropriate for faecal peritonitis.
References
Seven days after a laparoscopic appendicectomy for perforated appendicitis, a patient has fever and pelvic pain. CT shows a 5-cm pelvic abscess. What is the treatment?
- Immediate laparotomy
- Colonoscopy
- Antibiotics and image-guided percutaneous (or transrectal) drainage
- Oral antibiotics alone at home
- Observation
Show the answer and explanation
Answer: C. Antibiotics and image-guided percutaneous (or transrectal) drainage. Postoperative intra-abdominal abscesses are best treated with antibiotics and percutaneous drainage when accessible. Surgery is for collections that cannot be drained, failure of drainage, or generalised peritonitis.
Why not the others? Small abscesses (under about 3 cm) may resolve with antibiotics alone.
References
An 80-year-old is admitted with suspected perforated bowel and sepsis. Which pathway elements improve survival after emergency laparotomy?
- Postponing antibiotics until after surgery
- Waiting overnight for the morning list
- Avoiding CT in the elderly
- Routine ward care for all after surgery
- Early CT, antibiotics within 1 hour for sepsis, timely surgery with consultant involvement, risk assessment and critical care for high-risk patients, and frailty-informed geriatric input
Show the answer and explanation
Answer: E. Early CT, antibiotics within 1 hour for sepsis, timely surgery with consultant involvement, risk assessment and critical care for high-risk patients, and frailty-informed geriatric input. National audit data (NELA) show that early diagnosis, prompt antibiotics, timely surgery for sepsis, consultant-led care, documented risk scores, planned critical care and geriatric assessment improve outcomes in emergency laparotomy, especially in older patients.
Why not the others? Delay is a leading avoidable cause of death.
References