LE6 (older) Flashcards

Question

Q: A 65-year-old institutionalized patient presents with a 2-day history of abdominal distention, nausea, and obstipation. Physical examination reveals marked distention with mild tenderness. WBC count is 10,000 cells/uL. Plain films show a massively dilated, inverted U-shaped (omega sign) loop of bowel. What is the best management? A: A. Endoscopic detorsion and insertion of a rectal tube B. Endoscopic detorsion followed by elective sigmoid colectomy C. Endoscopic detorsion followed by elective sigmoid colectomy in case of recurrence D. Exploratory laparotomy with sigmoid colectomy, on-table lavage, and primary anastomosis

Answer 1

**B. Endoscopic detorsion followed by elective sigmoid colectomy** **Rationale:** - The patient presents with **sigmoid volvulus**, as indicated by the **massively dilated, inverted U-shaped (omega sign) loop of bowel**. - **First-line management** for non-perforated, non-ischemic sigmoid volvulus is **endoscopic detorsion** using either a rigid sigmoidoscope or a flexible endoscope. - However, recurrence rates are **high (up to 40%)**, so after successful detorsion, an **elective sigmoid colectomy** is recommended to prevent recurrence. ### **Why not the other options?** - **A. Endoscopic detorsion alone** → Not sufficient because of the high recurrence rate; definitive surgical management is needed. - **C. Endoscopic detorsion followed by elective colectomy in case of recurrence** → Delaying surgery until recurrence increases the risk of complications. Prophylactic surgery is preferred. - **D. Exploratory laparotomy with sigmoid colectomy, lavage, and primary anastomosis** → This is needed **only if there is bowel ischemia, perforation, or peritonitis** (not present in this patient). Thus, the best approach is **endoscopic detorsion followed by elective sigmoid colectomy** to prevent future volvulus episodes.

Answer 2

D. Colonic malignancy has the same prognosis as sporadic cancer Rationale: Lynch syndrome follows an autosomal dominant inheritance pattern and carries an increased risk of colorectal and other cancers, but the prognosis is similar to sporadic cases when matched for stage.

Answer 3

A. Argon plasma coagulation Rationale: Argon plasma coagulation is a safe and effective endoscopic treatment for chronic radiation proctitis with bleeding.

Answer 4

C. Mucosa, submucosa, longitudinal muscle layer, and circular muscle layer** **High-Yield Rationale:** - The **wall of the rectum** consists of **five layers**: 1. **Mucosa** 2. **Submucosa** 3. **Circular muscle layer** 4. **Longitudinal muscle layer** 5. **Serosa** (only present in the **proximal rectum** but **absent in the mid and lower rectum**) - **Why C is Correct?** - The **mid and lower rectum lack serosa** (as highlighted in the reference). - In a **low anterior resection**, the **distal portion of the resected specimen** is from the **mid or lower rectum**, where **serosa is absent**. - This means the staple line **only includes the mucosa, submucosa, circular muscle, and longitudinal muscle layers**. **Why Not the Other Options?** - **A, B, and D include serosa**, which is incorrect because the mid and lower rectum **lack serosa**. - **B has the incorrect order of muscle layers**. **Bottom Line:** For **low anterior resection of the rectum**, **stapling through the mid or lower rectum does not include serosa**, making **C the correct answer**.

Answer 5

C. Puborectalis muscle Rationale: The external anal sphincter is formed by the puborectalis muscle, which plays a key role in maintaining continence.

Answer 6

C. Broad-spectrum IV antibiotics and rectal examination under anesthesia Rationale: The patient likely has perineal sepsis, a rare but life-threatening complication of hemorrhoidal banding. Prompt surgical evaluation and IV antibiotics are critical.

Answer 7

C. Suture ligation Rationale: Persistent post-hemorrhoidectomy bleeding suggests an arterial source, which requires direct visualization and suture ligation.

Answer 8

D. Elliptical excision of skin and drainage with the patient under local anesthesia in the ED Rationale: This presentation is consistent with a thrombosed external hemorrhoid. The best treatment is elliptical excision with drainage.

Answer 9

A. Injury to the puborectalis Rationale: The puborectalis muscle forms a sling around the rectum and plays a critical role in maintaining continence. Injury can lead to fecal incontinence.

Answer 10

D. Colonoscopic evaluation **High-Yield Rationale:** - **Fecal Immunochemical Test (FIT) detects human hemoglobin**, making it **more specific** for lower GI bleeding than guaiac-based Fecal Occult Blood Test (FOBT). - **Any positive FIT requires a follow-up colonoscopy**, as it may indicate: - **Colorectal cancer (CRC)** - **Adenomatous polyps** - **Inflammatory conditions (e.g., colitis, diverticulosis)** **Why Not Other Options?** - **A. No, vitamin C can produce a false-positive result** → **Incorrect** - Vitamin C can **interfere with FOBT**, but **FIT is not affected** by diet. - **B. No, all positive FIT requires further investigation with FOB** → **Incorrect** - A positive FIT does **not require another stool test**; it **directly warrants colonoscopy**. - **C. Yes, all positive FIT requires further investigation with FIT in 1 year** → **Incorrect** - **Delaying evaluation is inappropriate** when FIT is positive; **colonoscopy should be done immediately**. **Key Takeaway:** - **FIT is a more accurate screening tool for colorectal cancer**. - **A positive FIT result should always be followed by colonoscopy** to identify the source of bleeding.

Answer 11

D. Whole abdominal CT scan Rationale: Diarrhea evaluation should start with stool analysis, culture, and colonoscopy if needed. A CT scan is not typically required for infectious diarrhea.

Answer 12

D. Sigmoidectomy and Hartmann’s procedure Rationale: In an unstable patient with perforation, Hartmann’s procedure is preferred to avoid anastomotic leakage.

Answer 13

E. All of the above Rationale: Pouchitis, increased stool frequency, nocturnal incontinence, and small bowel obstruction are common complications following J-pouch reconstruction.

Answer 14

E. Contrast study of the distal segment Rationale: A contrast enema or distal contrast study is needed to ensure no anastomotic stricture before ileostomy reversal.

Answer 15

D. CT scan of the chest and abdomen Rationale: Staging with a CT scan is crucial to assess for metastasis before definitive surgery.

Answer 16

B. Right hemicolectomy and primary anastomosis Rationale: Right-sided colon cancers are best treated with right hemicolectomy and anastomosis unless contraindications exist.

Answer 17

B. Bacterial or viral infection, undiagnosed Crohn’s disease, and pouchitis Rationale: Pouchitis is a common complication of ileal pouch-anal anastomosis, often presenting with diarrhea, abdominal pain, and malaise. Crohn’s disease must also be considered.

Answer 18

C. Parenteral antibiotic prophylaxis at the time of surgery before the skin incision is made Rationale: Prophylactic antibiotics should be administered before the skin incision to reduce surgical site infections.

Answer 19

C. 10-30% Rationale: Crohn’s disease has a strong genetic component, with 10-30% of patients having a family history of the disease.

Answer 20

B. Mucosal ulcerations, noncaseating granulomas, fibrosis strictures, and fistulas in the colon with deep serpiginous ulcers** **High-Yield Rationale:** - **Crohn’s disease (CD) is a transmural inflammatory condition** that affects any part of the **GI tract from mouth to anus**, most commonly the **terminal ileum and colon**. - **Hallmark diagnostic findings of Crohn’s disease include:** - **Skip lesions (discontinuous involvement)** - **Transmural inflammation** (extends through all layers of the bowel wall) - **Noncaseating granulomas** (on histology) - **Deep serpiginous ulcers** and a **cobblestone appearance** (on endoscopy) - **Strictures, fibrosis, and fistula formation** (complications from chronic inflammation) **Why Not the Other Options?** - **A. (Atrophic mucosa, crypt abscesses, inflammatory pseudopolyps, continuous involvement)** - **Describes Ulcerative Colitis (UC), not Crohn’s disease**. UC has **continuous** involvement, starting from the **rectum**. - **C. (Atrophic mucosa, noncaseating granulomas, cobblestone appearance)** - Close, but **atrophic mucosa is more characteristic of UC**. - **D. (Mucosal ulcerations, crypt abscesses, continuous involvement)** - **Crypt abscesses and continuous involvement are hallmarks of UC, not Crohn’s**. **Key Takeaway:** - **Crohn’s disease = Skip lesions, transmural inflammation, deep ulcers, fistulas, and strictures**. - **Ulcerative colitis = Continuous inflammation, limited to mucosa/submucosa, crypt abscesses, and pseudopolyps**. - **Endoscopic appearance of Crohn’s disease = Deep serpiginous ulcers + Cobblestone pattern**.

Answer 21

A. Liver, biliary tree, joints, skin, eyes Rationale: IBD is associated with primary sclerosing cholangitis, arthritis, erythema nodosum, uveitis, and pyoderma gangrenosum.

Answer 22

A. Salicylates, such as sulfasalazine and 5-acetyl salicylic acid Rationale: Sulfasalazine and mesalamine (5-ASA) are first-line treatments for mild-to-moderate IBD.

Answer 23

A. Long-standing history of ulcerative colitis with multiple colon polyps** **High-Yield Rationale:** - **Primary anastomosis vs. Stoma Creation** - In patients with **ulcerative colitis (UC) undergoing colectomy**, primary anastomosis is **only feasible if the patient is stable, well-nourished, and has no sepsis or perforation**. - If the patient is **severely malnourished, has ongoing inflammation, or has been on corticosteroids**, a **stoma (ileostomy) is preferred** to allow for healing before anastomosis. **Why is A Incorrect?** - **A long-standing history of UC with multiple colon polyps is an indication for colectomy, but NOT for stoma creation instead of anastomosis.** - The presence of **multiple colon polyps** raises concern for **dysplasia or malignancy**, making **surgery necessary**, but **it does not indicate poor healing or require delaying anastomosis**. - If the patient is otherwise **nutritionally stable**, **a primary anastomosis can be performed (e.g., IPAA).** **Why Are the Other Options Correct Indicators for Stoma Creation?** - **B. Low Albumin (22.0 g/L) in a Patient on Corticosteroids → Correct Indicator** - **Severe hypoalbuminemia (<30 g/L) suggests malnutrition and poor wound healing.** - **Corticosteroids impair anastomotic healing**, making primary anastomosis risky. - **Stoma creation allows time for nutritional optimization before reversal.** - **C. Blood Glucose 300 mg/dL After Recent Corticosteroid Course → Correct Indicator** - **Hyperglycemia impairs wound healing** and **increases infection risk**. - This patient likely has **steroid-induced hyperglycemia or diabetes**, making **anastomotic leakage more likely**. - **D. BMI of 14 → Correct Indicator** - **BMI <16 indicates severe malnutrition**, increasing the risk of **poor wound healing and anastomotic failure**. - **Patients with extreme malnutrition often require a staged approach with stoma first.** **Key Takeaway:** - **Stoma is preferred in unstable, malnourished, or immunosuppressed patients.** - **UC with multiple polyps is an indication for colectomy but NOT necessarily for stoma over primary anastomosis.** - **Correct Answer = A (EXCEPT option).**

Answer 24

D. Cecum measured at 8 cm in diameter on CT scan Rationale: Toxic megacolon is diagnosed when cecal dilation is ≥9 cm. A cecum measuring 8 cm is not yet an absolute indication for surgery.

Answer 25

E. Abdominal pain Rationale: Surgery is reserved for complications such as obstruction, strictures, fistulas, abscesses, and toxic megacolon, but not for isolated abdominal pain.

Answer 26

C. Deep and narrow ulcer located in the lateral position Rationale: Anal fissures in Crohn’s disease are atypically located (lateral) and may be deep or multiple. Most benign fissures occur in the posterior midline.

Answer 27

B. NPO, IV hydration, and IV antibiotics Rationale: Uncomplicated diverticulitis without large abscesses or peritonitis is best managed conservatively with bowel rest, IV fluids, and antibiotics.

Answer 28

B. A single episode of diverticulitis in an immunosuppressed patient** **High-Yield Rationale:** - **Elective colectomy for diverticulitis is NOT always necessary** after multiple episodes unless specific risk factors are present. - **Immunosuppressed patients are an exception** → They are **advised to undergo colectomy after a single episode** because they: - Have a **higher risk of complications** (e.g., perforation, abscess, sepsis). - Often have **blunted inflammatory responses**, delaying diagnosis and worsening outcomes. **Why Not the Other Options?** - **A. Three episodes requiring hospitalization in an asymptomatic patient → Incorrect** - Surgery is **not required just based on the number of episodes** unless symptoms persist or complications occur. - **C. A current episode of complicated diverticulitis resulting in frequent peritonitis → Incorrect** - **Urgent or emergency surgery (not elective) is needed** for **perforation, abscess, or peritonitis**. - **D. Inability to exclude malignancy → Incorrect** - **Colonoscopy should be performed first** (4-6 weeks after recovery). Surgery is indicated **only if malignancy is confirmed**. **Key Takeaway:** - **Immunosuppressed patients should undergo colectomy after a single episode of diverticulitis** due to their **high risk of severe disease progression**. - **Elective colectomy is otherwise considered selectively based on complications, recurrence, and quality of life.**

Answer 29

A. Stage I Rationale: Stage I is characterized by a localized pericolic or mesenteric abscess. Management: IV antibiotics, bowel rest, and percutaneous drainage if the abscess is >2 cm. No generalized peritonitis, so no urgent surgery is required unless there is no improvement.

Answer 30

B. Stage II Rationale: Stage II involves a larger, more distant abscess, such as pelvic, retroperitoneal, or intra-abdominal abscess. Management: IV antibiotics and CT-guided percutaneous drainage if the abscess is large (>3 cm). Surgery is reserved for worsening symptoms or recurrence.

Answer 31

D. Stage IV Rationale: Stage IV = Fecal peritonitis, which is the most severe stage. Signs: Free air and free fluid on CT Peritoneal signs (rigid abdomen, severe pain, rebound tenderness) Fecal contamination intraoperatively Management: Emergency laparotomy with sigmoid colectomy and colostomy (Hartmann's procedure).

Answer 32

D. Colovesicular fistula Rationale: Colovesicular fistula is the most common fistula in complicated diverticulitis, presenting with pneumaturia or fecaluria.

Answer 33

B. Bacteroides Rationale: Bacteroides spp. are the most common anaerobic bacteria in the gut and a major cause of intraabdominal infections.

Answer 34

D. Will affect squeeze pressure Rationale: The external sphincter is responsible for voluntary control of defecation. Damage results in reduced squeeze pressure and potential incontinence.

Answer 35

A. Symptomatic Rationale: Hemorrhoids should only be treated if symptomatic, causing pain, bleeding, or prolapse.

Answer 36

B. Rubber band ligation Rationale: Rubber band ligation is preferred for Grade 2 internal hemorrhoids that do not respond to conservative treatment.

Answer 37

B. Peri-rectal Explanation: * Peri-rectal lymph node involvement (N1) indicates early-stage nodal spread, which still allows for curative treatment, leading to a better prognosis. * Rectal cancer follows a stepwise lymphatic spread: 1. Peri-rectal nodes (N1) 2. Inferior mesenteric nodes (N2) 3. Para-aortic nodes (N3, distant metastasis - worse prognosis) * When cancer is confined to the peri-rectal nodes, prognosis is still favorable compared to involvement of higher-tier nodes.

Answer 38

D. Combined radiotherapy, chemotherapy, and immunotherapy Rationale: Anal melanoma has a very poor prognosis, and multimodal therapy (radiation, chemotherapy, and immunotherapy) is often used for palliation in advanced cases.

Answer 39

C. Left colic and left branch of middle colic artery

Answer 40

C. Parastomal hernia Rationale: Parastomal hernia is a common long-term complication of end colostomies due to increased intraabdominal pressure.

Answer 41

E. Chest and abdominal CT scan Rationale: Rising CEA levels suggest possible recurrence or metastasis, and CT imaging is needed for staging.

Answer 42

C. Sigmoid Rationale: The sigmoid colon is the most commonly affected site due to its high intraluminal pressure.

Answer 43

A. MRI** **Updated High-Yield Rationale:** - **MRI is the preferred imaging modality for evaluating the depth of invasion of malignant rectal tumors (T-staging).** - **MRI with an endorectal coil** significantly improves accuracy in assessing: - **Tumor penetration through the rectal wall (T-staging)** - **Involvement of the mesorectal fascia (circumferential resection margin, CRM)** - **Lymph node involvement** **Why Not the Other Options?** - **B. CT scan → Less sensitive for local invasion** - Used mainly for **detecting distant metastases (liver, lungs)** rather than local rectal tumor staging. - Cannot reliably differentiate between rectal wall layers. - **C. Endorectal ultrasound (ERUS) → Best for early-stage rectal cancer (T1-T2)** - **ERUS is more accurate for early rectal tumors (T1-T2)** but **less reliable for advanced (T3-T4) tumors**. - Cannot assess **extramural spread or mesorectal lymph nodes well**. - **D. Colonoscopy → Detects tumors but does not assess depth of invasion** - Essential for **biopsy and visualization** but does not provide **T-staging** information. **Bottom Line:** ✅ **MRI is the best imaging modality for rectal cancer staging, especially for T3-T4 tumors and assessing CRM.** ✅ **ERUS is useful for early-stage tumors but less effective for deeper invasion.** ✅ **CT scan is primarily for metastatic workup, not local staging.**

Answer 44

D. NOTA (None of the above) Rationale: Gardner’s syndrome is associated with colonic polyps, osteomas, and epidermal cysts.

Answer 45

C. Lecithin Rationale: Gut bacteria play roles in bile acid metabolism, cholesterol breakdown, and vitamin K synthesis but do not metabolize lecithin.

Answer 46

C. Will affect resting pressure Rationale: The internal sphincter is responsible for resting tone, and its injury reduces resting anal pressure, potentially leading to incontinence.

Answer 47

C. The omentum and peritoneal cavity are less efficient in localizing the disease in these age groups. Rationale: In elderly patients and children, the omentum is less effective at walling off infection, leading to delayed presentation and increased risk of perforation.

Answer 48

E. Innervation of the appendix is derived from the somatic nervous system. Rationale: The appendix is innervated by the autonomic nervous system (not somatic), specifically the sympathetic and parasympathetic nervous system (T10). This is why early appendicitis presents with vague, visceral pain at the umbilicus before localizing to the RLQ.

Answer 49

A. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks. Rationale: Initial management: Broad-spectrum antibiotics + percutaneous drainage. Follow-up: Colonoscopy to rule out underlying malignancy (especially in elderly patients). Interval appendectomy in 6-8 weeks is often recommended if the patient is high risk for recurrent appendicitis.

Answer 50

B. Perforated bowel and advanced Crohn’s disease with obstruction should be resected. Rationale: If the appendix is inflamed but not perforated, do not remove it, as this could cause a fistula in Crohn’s patients. If there is perforation or obstruction, segmental resection of diseased bowel is required.

Answer 51

D. Abdominal MRI scan. Rationale: MRI is the preferred imaging modality in pregnant patients when ultrasound is inconclusive.

Answer 52

D. Perform a limited cecal resection using a stapling device. Rationale: A necrotic perforation at the base requires resection of the involved cecum to prevent stump blowout.

Answer 53

C. Right hemicolectomy. Rationale: Indications for right hemicolectomy in appendiceal cancer: Tumor size >2 cm Extension into mesoappendix ✅ Lymphovascular invasion or positive margins Simple appendectomy is only sufficient if the tumor is ≤2 cm and confined to the appendix.

Answer 54

D. Appendectomy. Rationale: Simple appendectomy is appropriate unless: Malignancy is suspected → Right hemicolectomy. Perforation or pseudomyxoma peritonei is present → More extensive resection needed.

Answer 55

E. Perforation has an associated mortality rate of 50%. Rationale: Perforated appendicitis has a higher mortality in elderly patients (~10-20%) but NOT 50%. Other statements are true: Elderly patients present later → Higher perforation rates. Symptoms can mimic bowel obstruction. Appendicitis + anemia → Suspect cecal malignancy.

Answer 56

E. Referred pain in the right side with pressure on the left (Rovsing’s sign). Rationale: Rovsing’s sign: Pressing on the left lower quadrant (LLQ) causes RLQ pain, indicating peritoneal irritation. Other signs of appendicitis: Psoas sign: Pain with right thigh extension (retrocecal appendix). Obturator sign: Pain with internal rotation of the thigh (pelvic appendix). Dunphy’s sign: RLQ pain worsens with coughing.

Answer 57

E. Unusual infections such as those caused by mycobacteria, protozoa, and fungi do not usually mimic appendicitis. Rationale: Immunocompromised patients can have atypical infections (e.g., mycobacteria, fungi, protozoa) that mimic appendicitis. Typhlitis (neutropenic enterocolitis) presents similarly to appendicitis. CMV infections and Kaposi sarcoma can cause appendiceal obstruction, leading to appendicitis.

Answer 58

D. Obtain an MRI and proceed with appendectomy if positive. Rationale: MRI is the preferred imaging modality for appendicitis in pregnancy if ultrasound is inconclusive. CT is avoided due to radiation risks. Early surgical intervention is preferred over observation if appendicitis is suspected.

Answer 59

D. The base of the appendix can always be found at the confluence of the cecal taeniae. Rationale: The appendix is attached to the cecum at the point where the three taenia coli converge. The position of the tip varies (retrocecal, pelvic, subcecal, preileal, postileal). Retrocecal position is most common (60-65%).

Answer 60

B. An ultrasound showing a compressible appendix <5 mm in diameter. Rationale: A normal appendix should be compressible and ≤5 mm in diameter; a noncompressible appendix suggests appendicitis.

Answer 61

E. For tumors >2 cm, a formal right hemicolectomy is indicated. Rationale: Tumors >2 cm or with mesoappendiceal invasion require right hemicolectomy due to increased metastatic risk.

Answer 62

**A. Synchronous treatment with right hemicolectomy and radiofrequency ablation of liver metastases is appropriate.** **Explanation:** 1. **Right hemicolectomy is the preferred surgical approach** for appendiceal carcinoid tumors located at the base and >2 cm in size, as it ensures complete resection with appropriate lymphadenectomy. 2. **Liver metastases from neuroendocrine tumors (NETs) can be managed with hepatic resection or radiofrequency ablation (RFA)**, especially when limited to the liver, to prolong survival and control symptoms. 3. **Octreotide (a somatostatin analog) helps in symptom control** and reduces hormone secretion but is not the primary treatment for metastatic disease. 4. **Carcinoid syndrome is typically associated with hepatic metastases** rather than tumor size alone. 5. **Appendiceal carcinoid tumors with liver metastases have a relatively favorable prognosis**, with a 5-year survival rate of **20–40% after resection**, contrary to the 10% survival stated in option E.

Answer 63

A. Right hemicolectomy. Rationale: Tumors >1 cm at the base of the appendix require right hemicolectomy due to higher risk of lymph node metastasis.

Answer 64

C. Exploration and ileal resection if the terminal ileum appears inflamed. Rationale: If the terminal ileum appears inflamed, it may indicate Crohn’s disease or Meckel’s diverticulitis, warranting resection.

Answer 65

E. Retrocecal over the psoas muscle. Rationale: The psoas sign (pain with thigh extension) suggests a retrocecal appendix causing irritation of the psoas muscle.

Answer 66

D. No difference in perforation rates, surgical-site infection, abscess, conversion rate, or operative time. Rationale: Studies show that a short delay (<12 hours) in surgery for uncomplicated appendicitis does not increase complications.

Answer 67

D. Ulcerative colitis Rationale: An inverse association exists between appendectomy and ulcerative colitis, though routine resection for prevention is not recommended.

Answer 68

A. Administer ceftriaxone and metronidazole (Flagyl) and proceed with surgery. Rationale: Ceftriaxone and metronidazole provide broad-spectrum coverage against Bacteroides fragilis and Gram-negative bacteria, which are common in appendicitis.

Answer 69

A. Fecaliths are commonly responsible for appendicitis in children. Rationale: Lymphoid hyperplasia, rather than fecaliths, is the most common cause of appendicitis in children.

Answer 70

E. A point between the outer one-third and inner two-thirds of a line from the umbilicus to the anterior superior iliac spine. Rationale: The classic site of maximal tenderness in acute appendicitis is McBurney’s point, which is located at the junction of the outer one-third and inner two-thirds of a line drawn from the umbilicus to the anterior superior iliac spine (ASIS). This corresponds to the location of the base of the appendix, where inflammation causes the most significant localized pain.

Answer 71

B. In the umbilical region and then moves to the RLQ Rationale: Appendicitis pain starts in the periumbilical region due to visceral innervation, later localizing to the RLQ with peritoneal involvement.

Answer 72

A. 4–5% after rupture

Answer 73

C. Longer post-hospital recovery. Rationale: Laparoscopic appendectomy has shorter recovery times and less postoperative pain compared to open appendectomy.

Answer 74

A. It can be performed safely with minimal morbidity compared to open surgery. Rationale: Laparoscopic appendectomy is associated with lower wound infection rates and faster recovery.

Answer 75

B. Remove the appendix. Rationale: A normal appendix should be removed to prevent future diagnostic confusion and appendicitis.

Answer 76

D. Diagnostic laparoscopy 💡 Rationale: Pneumoperitoneum in a symptomatic patient usually requires emergency surgery (exploratory laparotomy) due to visceral perforation. Colonoscopy, particularly with insufflation, can cause benign pneumoperitoneum from microperforations or transmural passage of air. Patients without abdominal pain, fever, or leukocytosis can be managed conservatively with IV antibiotics, bowel rest, and observation. However, diagnostic laparoscopy is preferred in this case to confirm whether a microperforation requires intervention.

Answer 77

D. Chronic obstructive pulmonary disease (COPD) is the strongest risk factor. 💡 Rationale: Parastomal hernias occur in up to 50% of stoma patients, with end colostomy having the highest risk and loop ileostomy the lowest risk. Risk factors include: older age, obesity, malnutrition, immunosuppression, inflammatory bowel disease (IBD), and COPD (the strongest risk factor). Prophylactic mesh placement at initial surgery reduces recurrence rates (from 55% to 7.8% in studies). Supportive treatment (hernia belts, weight loss) can help in asymptomatic cases, but symptomatic cases require surgical repair with mesh reinforcement.

Answer 78

E. Re-exploration in the OR, resection of ischemic colon, and stoma relocation Rationale: Dusky mucosa suggests ischemia, requiring urgent re-exploration to prevent necrosis.

Answer 79

B. Immediate colonoscopy with random biopsies Rationale: PSC is associated with an increased risk of colorectal cancer in UC patients, warranting immediate surveillance.

Answer 80

A. Female gender Rationale: Male gender is associated with a higher anastomotic leak risk due to a narrower pelvis and more difficult dissection.

Answer 81

D. Upper endoscopy should be performed every 1-3 years. Rationale: FAP patients are at risk for duodenal and periampullary carcinoma, necessitating regular upper endoscopy.

Answer 82

E. Restorative proctocolectomy with ileal pouch–anal anastomosis 💡 Rationale: High-grade dysplasia in UC patients is an indication for surgery, as it is associated with an increased risk of colorectal cancer. Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the preferred surgical treatment to preserve bowel function. Repeat colonoscopy (A) is not appropriate, as high-grade dysplasia warrants definitive treatment. Segmental resection (B) and total colectomy with ileorectal anastomosis (C) are not recommended because they leave residual colonic mucosa at risk for cancer. Total proctocolectomy with ileostomy (D) is an option, but IPAA is preferred for functional outcomes unless contraindicated.

Answer 83

B. CT-guided drainage followed by colonoscopy and sigmoid colectomy in 6 weeks Rationale: Large abscesses (>3 cm) should be drained percutaneously, followed by interval colectomy.

Answer 84

B. The polyps are hamartomas. Rationale: Juvenile polyps are hamartomas and have a variable risk of malignancy, necessitating surveillance.

Answer 85

B. Some hyperplastic polyps are premalignant Rationale: While most hyperplastic polyps are benign, those in the proximal colon (sessile serrated adenomas) have premalignant potential and are associated with the serrated pathway to colorectal cancer. Tubulovillous adenomas have a higher malignancy risk than tubular adenomas. The polyps in Peutz-Jeghers syndrome are hamartomas, not hyperplastic. Pseudopolyps are more commonly found in ulcerative colitis rather than FAP.

Answer 86

D. Colonoscopy Rationale: The CT findings suggest ischemic colitis, which often presents with mild thickening of the colonic wall and pericolic fat stranding. The next step should be colonoscopy, as it allows direct visualization of the mucosa and confirms ischemia. Mesenteric angiography is used for acute mesenteric ischemia, which typically presents with severe pain and metabolic acidosis. Surgery (laparoscopy/laparotomy) is indicated only for peritonitis or clinical deterioration.

Answer 87

A. Oral metronidazole is the treatment of choice 💡 Rationale: Pseudomembranous colitis is predominantly caused by Clostridium difficile. First-line treatment for an initial episode is oral metronidazole for 10–14 days. A first recurrence is also treated with a repeat course of metronidazole. Oral vancomycin (B) is reserved for second recurrences or complicated cases (e.g., severe disease or toxic megacolon). IV vancomycin (C) is not used for C. difficile infections as it does not achieve effective colonic levels. Sigmoidoscopy (D) is not routinely required for diagnosis; PCR testing for C. difficile toxins is preferred.

Answer 88

E. Right hemicolectomy with primary anastomosis ✅ 💡 Rationale: Cecal volvulus occurs when the cecum rotates over itself (axial ileocolic volvulus) or flips upward and anteriorly (cecal bascule). Key imaging finding → Dilated "kidney-shaped" loop of bowel with haustral markings projecting from RLQ to LUQ. Unlike sigmoid volvulus, endoscopic decompression is difficult. Best treatment: Right hemicolectomy with primary anastomosis (E) even without bowel prep. Cecopexy (B) has a high recurrence rate. If ischemic/gangrenous bowel is present, a right hemicolectomy with ileostomy and mucus fistula (C) may be necessary.

Answer 89

D. Sigmoid resection should be preceded by mechanical bowel prep with oral and IV antibiotics. Rationale: Sigmoid diverticulosis is the most common form, and elective resection is best performed with preoperative bowel prep and perioperative antibiotics.

Answer 90

C. Resection of sigmoid colon with primary anastomosis. Rationale: Colonic perforation post-polypectomy requires urgent surgery, typically with segmental colectomy and anastomosis unless peritonitis mandates colostomy.

Answer 91

B. 5-fluorouracil and leucovorin prolong survival in stage III colon cancer. Rationale: Adjuvant chemotherapy with 5-FU and leucovorin reduces recurrence and improves survival in stage III colon cancer.

Answer 92

C. CT scan Rationale: CT scan is the gold standard for diagnosing acute diverticulitis and evaluating for complications like abscess or perforation.

Answer 93

B. Propionate Rationale: Short-chain fatty acids (SCFAs), particularly butyrate and propionate, are crucial for colonic mucosal health, especially in conditions like diversion colitis.

Answer 94

C. Restorative proctocolectomy with ileal-pouch anal anastomosis. Rationale: FAP requires prophylactic colectomy due to near 100% risk of colon cancer. Ileal-pouch anal anastomosis is preferred for continence preservation.

Answer 95

A. Obstetric injury Rationale: Obstetric trauma (e.g., prolonged labor, perineal tears, or forceps delivery) is the most frequent cause of rectovaginal fistulas.

Answer 96

A. Sigmoid colectomy with proximal margin at an area without hypertrophy of the muscularis propria and distal margin where the taenia splay out. Rationale: Elective sigmoid colectomy is the procedure of choice for patients with recurrent diverticulitis, especially when multiple hospitalizations have occurred . The resection should always be extended to the rectum distally to minimize the risk of recurrence. The proximal extent of the resection should include all thickened or inflamed bowel but does not need to remove all diverticula . Laparoscopy is commonly used in elective cases, but the fundamental principle remains proper resection margins.

Answer 97

B. Amyand** **Rationale:** An **Amyand hernia** is a rare type of inguinal hernia that contains the **appendix**, which may be normal, inflamed, or even perforated. This condition is named after **Claudius Amyand**, the surgeon who first described it in the 18th century. **Why not the other options?** - **A. Petit hernia** → A type of **lumbar hernia** that occurs through the **inferior lumbar triangle**. - **C. Littre hernia** → A hernia containing a **Meckel’s diverticulum** (not the appendix). - **D. Spigelian hernia** → A rare **ventral hernia** that occurs along the **semilunar line** (Spigelian fascia), often at the lateral edge of the rectus abdominis. Thus, the correct answer is **B. Amyand hernia**.

Answer 98

C. Close wound without further intervention Rationale: This presentation is consistent with regional enteritis (Crohn’s disease). Appendectomy should be avoided if the cecum is inflamed, as this increases the risk of enterocutaneous fistula formation.

Answer 99

A. Colonoscopy Rationale: • Presentation is nearly identical to the first case. • Since BP stabilized after resuscitation, she is now a candidate for colonoscopy, which is the preferred diagnostic and therapeutic tool for lower GI bleeding. • Colonoscopy allows localization of the bleeding site and possible intervention (e.g., coagulation or clipping of bleeding lesions).

Answer 100

**B. Endoscopic detorsion followed by elective sigmoid colectomy** **Rationale:** - The patient presents with **sigmoid volvulus**, as indicated by the **massively dilated, inverted U-shaped (omega sign) loop of bowel**. - **First-line management** for non-perforated, non-ischemic sigmoid volvulus is **endoscopic detorsion** using either a rigid sigmoidoscope or a flexible endoscope. - However, recurrence rates are **high (up to 40%)**, so after successful detorsion, an **elective sigmoid colectomy** is recommended to prevent recurrence. ### **Why not the other options?** - **A. Endoscopic detorsion alone** → Not sufficient because of the high recurrence rate; definitive surgical management is needed. - **C. Endoscopic detorsion followed by elective colectomy in case of recurrence** → Delaying surgery until recurrence increases the risk of complications. Prophylactic surgery is preferred. - **D. Exploratory laparotomy with sigmoid colectomy, lavage, and primary anastomosis** → This is needed **only if there is bowel ischemia, perforation, or peritonitis** (not present in this patient). Thus, the best approach is **endoscopic detorsion followed by elective sigmoid colectomy** to prevent future volvulus episodes.

Answer 101

D. Colonic malignancy has the same prognosis as sporadic cancer Rationale: HNPCC is an autosomal dominant condition. Although it causes early-onset colorectal cancer, the prognosis is similar to sporadic cases if detected early.

Answer 102

C. Sodium is absorbed actively via Na⁺/K⁺ ATPase Rationale: Water absorption occurs mainly in the small intestine (jejunum). The colon actively absorbs sodium, with water following passively.

Answer 103

C. Mucosa, submucosa, longitudinal muscle layer, and circular muscle layer Rationale: The rectum lacks serosa, so the stapler only passes through the mucosa, submucosa, and muscle layers.

Answer 104

**D. Circular muscle layer** **Rationale:** - The **inner circular muscle layer** of the rectum coalesces to form the **internal anal sphincter**. - This sphincter is **involuntary** and plays a crucial role in maintaining continence at rest. - The **external anal sphincter**, on the other hand, is composed of **skeletal muscle** and is under **voluntary control**. **Why not the other options?** - **A. Circumferential muscle layer** → This is not a specific term used in anatomy; the correct term is **circular muscle layer**. - **B. Longitudinal muscle layer** → This contributes to the **rectal wall structure** but does not form the internal anal sphincter. - **C. Puborectalis muscle** → This is part of the **external anal sphincter complex**, providing voluntary control over defecation. Thus, the **inner circular muscle layer** forms the **internal anal sphincter**, making **D. Circular muscle layer** the correct answer.

Answer 105

**A. The presacral fascia separates the rectum from the presacral venous plexus and the pelvic nerves; Waldeyer fascia extends forward and downward and attaches to the fascia propria at the anorectal junction. Denonvilliers fascia separates the rectum from the prostate and seminal vesicles in men and from the vagina in women.** **Rationale:** - The **inferior mesenteric vein (IMV)** is typically ligated during a **total colectomy** at the **inferior border of the pancreas** before it drains into the **splenic vein**. - Understanding the anatomical relationships of **fasciae in the pelvic region** is crucial for safe dissection and avoiding injury to nearby structures. - **Presacral fascia**: Separates the **rectum** from the **presacral venous plexus** and **pelvic nerves**, which is key for identifying safe ligation planes. - **Waldeyer fascia**: Extends **forward and downward** and **attaches to the fascia propria** at the anorectal junction. - **Denonvilliers fascia**: Separates the **rectum from the prostate and seminal vesicles in men** and from the **vagina in women**. Thus, **A** is the best answer as it correctly describes the key anatomic landmarks used during a total colectomy for ulcerative colitis.

Answer 106

D. At 6 weeks gestation, the midgut herniates through the abdominal cavity, rotates 270° counterclockwise around the SMA, and returns to the abdomen by week 10. Rationale: Intestinal malrotation results from failure of 270° counterclockwise rotation around the SMA. It typically presents with bilious vomiting due to volvulus.

Answer 107

A. Butyric and propionic acid Rationale: Short-chain fatty acids (SCFAs), such as butyric and propionic acid, are the primary energy source for colonic epithelial cells. Lack of colonic exposure to SCFAs in diversion colitis leads to inflammation and mucosal atrophy.

Answer 108

A. Injury to the puborectalis Rationale: The puborectalis muscle forms a sling around the distal rectum and is essential for maintaining continence. Injury during childbirth is a common cause of fecal incontinence.

Answer 109

B. Yes, all positive FOB results require colonoscopy. Rationale: Any positive FOB requires further investigation with colonoscopy, as it does not differentiate between benign and malignant causes.

Answer 110

D. All of the above Rationale: Chronic diarrhea in a young patient requires evaluation for infectious, inflammatory, and malabsorption causes. Testing includes stool cultures, microscopic stool analysis, and endoscopy (if needed).

Answer 111

C. Below the beltline, within the rectus abdominis muscle, away from the costal margin. Rationale: Placing the colostomy within the rectus abdominis muscle prevents herniation and provides better appliance fitting.

Answer 112

E. All of the above Rationale: Pouchitis, increased stool frequency, nocturnal incontinence, and small bowel obstruction are common complications following J-pouch reconstruction.

Answer 113

C. Flexible sigmoidoscopy or contrast enema to check patency. Rationale: Before ileostomy reversal, an endoscopic or radiographic study is required to ensure the anastomosis is intact and functional.

Answer 114

C. Stoma necrosis below the level of the fascia Rationale: Stomal necrosis below the level of the fascia requires revision, as it may indicate ischemia of the bowel segment.

Answer 115

E. All of the above Rationale: Pouchitis, increased stool frequency, nocturnal incontinence, and small bowel obstruction are common complications following J-pouch reconstruction.

Answer 116

C. Parenteral antibiotic prophylaxis at the time of surgery before the skin incision is made Rationale: Antibiotic prophylaxis should be administered before skin incision, as studies show this significantly reduces surgical site infections (SSI). Redosing is required for prolonged procedures (>4 hrs) or excessive blood loss (>1.5L). Oral antibiotics may be used preoperatively but not postoperatively.

Answer 117

B. Bacterial or viral infection, undiagnosed Crohn’s disease, and pouchitis Rationale: Pouchitis is the most common long-term complication of ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. Symptoms include diarrhea, abdominal pain, urgency, and malaise, and it responds well to antibiotics (ciprofloxacin or metronidazole).

Answer 118

C. 10-30% Rationale: Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, has a genetic component. About 10-30% of patients have a family history of IBD.

Answer 119

B. Mucosal ulcerations, noncaseating granulomas, fibrosis, strictures, and fistulas in the colon with deep serpiginous ulcers Rationale: Crohn’s disease is a transmural inflammatory process that can affect any part of the GI tract. Key features include: Skip lesions (non-continuous inflammation) Cobblestone appearance Strictures and fistulas Noncaseating granulomas Deep serpiginous ulcers on colonoscopy

Answer 120

A. Liver, biliary tree, joints, skin, eyes Rationale: IBD has multiple extracolonic manifestations, including: PSC (Primary Sclerosing Cholangitis) → Liver & Biliary Tree Uveitis → Eyes Erythema nodosum, pyoderma gangrenosum → Skin Arthritis → Joints

Answer 121

A. Salicylates such as sulfasalazine and 5-aminosalicylic acid (5-ASA) Rationale: 5-ASA drugs (such as mesalamine) are first-line therapy for mild to moderate IBD. They reduce inflammation without systemic immunosuppression.

Answer 122

B. Albumin of 2.2 in a patient who has been on corticosteroids Rationale: A low albumin level (malnutrition) and prolonged corticosteroid use increase the risk of anastomotic failure. In these cases, a stoma is preferred over primary anastomosis.

Answer 123

D. Cecum measuring 11 cm in diameter on CT scan Rationale: Toxic megacolon (cecum >9 cm) is an emergency requiring surgical intervention.

Answer 124

A. Internal fistula or abscess Explanation: • The most common indications for surgery in Crohn’s disease include: • Symptomatic strictures causing obstruction. • Internal fistulas (e.g., enteroenteric, enterocutaneous, enterovesical, enterovaginal). • Intra-abdominal abscesses that do not respond to drainage and antibiotics. • Perforation leading to peritonitis. • Dysplasia or cancer arising from long-standing disease. • In this patient, the presence of fluctuance, foul-smelling drainage, and a history of Crohn’s disease suggests a fistula or abscess formation, making surgical intervention necessary

Answer 125

A. Deep and broad ulcer in the lateral position Rationale: Fissures in Crohn’s disease tend to be deep, broad, and located laterally, whereas benign fissures occur in the posterior midline.

Answer 126

D. AOTA (All of the Above) Rationale: Diverticulosis occurs due to a combination of factors: Low-fiber diet → Smaller stool volume → Higher intraluminal pressure Chronic contraction → Muscular hypertrophy → Segmented colon movement Herniation of mucosa/muscularis mucosa → Diverticulum formation

Answer 127

A. Three episodes of diverticulitis requiring hospitalization in an otherwise asymptomatic patient Rationale: Elective sigmoid colectomy is recommended for recurrent, severe, or complicated diverticulitis. Immunosuppressed patients and those with complicated diverticulitis (peritonitis, fistula, obstruction) may need early surgical intervention.

Answer 128

A. Stage I Rationale: Hinchey staging system for diverticulitis: Stage I – Pericolic or mesenteric abscess Stage II – Pelvic, retroperitoneal, or distant intra-abdominal abscess Stage III – Purulent peritonitis (no fecal contamination) Stage IV – Fecal peritonitis

Answer 129

B. Stage II Rationale: Stage II diverticulitis involves a distant abscess (e.g., retroperitoneal, pelvic).

Answer 130

D. Stage IV Rationale: Feculent peritonitis = Stage IV, requiring emergency surgery.

Answer 131

D. Colovesical fistula Rationale: Colovesical fistulas (65%) are the most common, followed by colovaginal fistulas (25%).

Answer 132

B. Bacteroides Rationale: Bacteroides fragilis is the most abundant anaerobe in feces.

Answer 133

D. Will affect squeeze pressure Rationale: The external anal sphincter contributes to voluntary control. Cutting it decreases squeeze pressure, leading to incontinence.

Answer 134

A. Symptomatic Rationale: Only symptomatic hemorrhoids require treatment (bleeding, pain, prolapse, thrombosis).

Answer 135

B. Rubber band ligation Rationale: Grade 1 Hemorrhoids → Medical therapy (fiber, sitz baths, topical agents) Grade 2 Hemorrhoids → Rubber band ligation Grade 3 Hemorrhoids → Rubber band ligation or surgical hemorrhoidectomy Grade 4 Hemorrhoids → Hemorrhoidectomy

Answer 136

D. Para-aortic Explanation: * Para-aortic lymph node involvement represents distant metastasis (M1 disease), which significantly worsens prognosis. * Higher-stage nodal spread (N3) is associated with lower survival rates, as it often indicates widespread disease. * The stepwise spread of rectal cancer follows this order: 1. Peri-rectal nodes (N1) → Best prognosis 2. Inferior mesenteric nodes (N2) - Intermediate prognosis 3. Para-aortic nodes (N3/M1) → Poorest prognosis Why Not the Other Options? * A. Inguinal nodes → More common in anal cancer rather than rectal cancer. * B. Peri-rectal nodes → First level of nodal spread and still resectable, leading to a better prognosis. * C. Inferior mesenteric nodes → Worse than peri-rectal involvement but better than para-aortic metastasis.

Answer 137

C. Wide excision with free margins Rationale: Wide local excision (WLE) is preferred due to high morbidity associated with APR. Adjuvant therapy is usually ineffective in improving survival. Melanoma has poor outcomes overall, but local control is best with WLE.

Answer 138

B. Ileocolic, right colic, right branch of middle colic artery Rationale: A right hemicolectomy involves removing the cecum, ascending colon, and proximal transverse colon, requiring ligation of the following vessels: Ileocolic artery (a branch of the SMA) Right colic artery (if present, from the SMA) Right branch of the middle colic artery (from the SMA)

Answer 139

C. Parastomal hernia Rationale: Parastomal hernias occur in up to 50% of colostomies, due to weakness in the abdominal wall fascia. Skin breakdown is also common but less severe than herniation.

Answer 140

B. Complete workup for metastasis Rationale: CEA (Carcinoembryonic Antigen) is a tumor marker for colorectal cancer recurrence. Elevated CEA post-treatment → Requires full metastatic workup (CT chest/abdomen, PET scan). Surgery is not first-line without evidence of resectable disease.

Answer 141

C. Sigmoid colon Rationale: Sigmoid colon is the most common site because of high intraluminal pressure and narrow diameter. Right-sided (ascending) diverticulosis is more common in Asian populations.

Answer 142

D. Mucosal pigmentation Explanation: Gardner’s syndrome is a variant of familial adenomatous polyposis (FAP) and is associated with: Colorectal polyps (by age 20) Osteomas of the skull and mandible Epidermoid cysts of the skin Desmoid tumors Mucosal pigmentation is NOT a feature of Gardner’s syndrome. Instead, Peutz-Jeghers syndrome (another polyposis syndrome) is associated with mucocutaneous pigmentation.

Answer 143

B. Lecithin Rationale: Gut bacteria help metabolize bilirubin, vitamin K, bile acids, and cholesterol. Lecithin is not significantly metabolized by gut flora.

Answer 144

D. Will affect squeeze pressure Rationale: External anal sphincter provides voluntary control over defecation. Damage leads to decreased squeeze pressure and incontinence.

Answer 145

D. AOTA (All of the Above) Rationale: Low-fiber diet → Smaller stool volume → Higher pressure Chronic contraction → Muscular hypertrophy Mucosa/muscularis herniation → Diverticulum formation

Answer 146

A. IgA Rationale: The appendix contains lymphoid tissue that contributes to mucosal immunity. It secretes IgA, which plays a role in gut-associated lymphoid tissue (GALT) and mucosal defense.

Answer 147

D. Reginald Fitz Rationale: Reginald Fitz first described appendicitis and recommended surgical intervention in 1886. Charles McBurney later refined the surgical approach.

Answer 148

C. Obstruction of lumen Rationale: Fecaliths (most common), lymphoid hyperplasia, parasites, and tumors can obstruct the appendiceal lumen, leading to increased intraluminal pressure, bacterial overgrowth, ischemia, and inflammation.

Answer 149

D. Anorexia, abdominal pain, vomiting Rationale: McBurney's triad: Anorexia (earliest sign) Abdominal pain (initially periumbilical, then migrates to RLQ) Vomiting (late sign)

Answer 150

C. Lie supine Rationale: Patients avoid movement and prefer lying still, as movement exacerbates peritoneal irritation.

Answer 151

A. Pelvic inflammatory disease (PID) Rationale: PID occurs in females. Testicular torsion, gastroenteritis, and UTIs can mimic appendicitis in males.

Answer 152

B. Early operative intervention (Appendectomy) Rationale: Surgery is the standard treatment to prevent perforation. Antibiotics alone may be used in selected cases but have higher recurrence rates.

Answer 153

C. Right hemicolectomy Rationale: >2 cm carcinoid tumors, involving the base of the appendix, or with lymphovascular invasion require right hemicolectomy. Smaller (<2 cm, confined to the tip) can be treated with appendectomy.

Answer 154

D. Appendectomy Rationale: Early surgery prevents perforation and complications like peritonitis or abscess formation.

Answer 155

A. Inspection, auscultation, palpation Rationale: Inspection is done first to observe for distension, scars, or visible peristalsis. Auscultation follows to assess bowel sounds before palpation, as palpation can alter bowel sounds. Palpation is done last to evaluate tenderness, rigidity, rebound, and masses.

Answer 156

C. Rovsing’s sign Explanation: Rovsing’s sign is positive when pressure applied to the left lower quadrant (LLQ) causes pain in the right lower quadrant (RLQ). It indicates peritoneal irritation and is commonly seen in acute appendicitis. Why Not the Other Options? A. Murphy’s sign → Associated with acute cholecystitis (pain upon deep inspiration while palpating the RUQ). B. Obturator sign → Pain with internal rotation of the flexed thigh, indicating a pelvic appendix. D. Psoas sign → Pain with hip extension, suggesting a retrocecal appendix.

Answer 157

C. History and physical examination Explanation: The most important and initial steps in evaluating abdominal pain are history-taking and physical examination. History helps determine location, onset, nature, radiation, aggravating/relieving factors, associated symptoms. Physical examination provides key clinical signs that guide further imaging and management.

Answer 158

D. Anorexia, abdominal pain, and RLQ tenderness Rationale: Classic appendicitis triad: Anorexia + RLQ pain + Tenderness. High fever (≥40°C) and WBC > 20,000 → Suggest perforation or sepsis. Diarrhea is rare in appendicitis unless pelvic appendix is inflamed.

Answer 159

D. All of the above Rationale: Pain history guides differential diagnosis. Sudden onset → Perforation, ischemia. Colicky → Obstruction, stones. Sharp/localized → Peritoneal irritation.

Answer 160

D. Localized RLQ tenderness Rationale: McBurney’s point tenderness is the most sensitive sign of appendicitis. Psoas sign suggests retrocecal appendix. Rectal tenderness → May indicate pelvic appendix involvement.

Answer 161

D. Vomiting usually precedes pain Rationale: Pain first, then vomiting is the classic sequence. Diarrhea can occur if the inflamed appendix is near the rectum.

Answer 162

B: Acute appendicitis

Answer 163

B. Appendectomy Explanation: Since the patient in Q87 is most likely suffering from acute appendicitis, the definitive treatment is surgical removal of the appendix (appendectomy). Management of Acute Appendicitis: Immediate appendectomy (Gold standard treatment) Reduces risk of perforation and peritonitis. Can be performed laparoscopically (preferred) or open. If perforation with abscess is present, some cases may require initial antibiotics and percutaneous drainage, followed by interval appendectomy after 6-8 weeks. Supportive Care (Preoperative and Postoperative) IV fluids for hydration. IV antibiotics (ceftriaxone + metronidazole) to prevent postoperative infections. Pain management (opioids sparingly, NSAIDs). Early ambulation to prevent complications.

Answer 164

A. Acute mesenteric adenitis, gastroenteritis, acute appendicitis Rationale: Ovarian and fallopian tube pathologies are NOT applicable to male patients. Mesenteric adenitis and gastroenteritis can mimic appendicitis.

Answer 165

B. McBurney’s point Rationale: McBurney’s point = One-third distance from ASIS to umbilicus. Most reliable landmark for appendicitis tenderness.

Answer 166

B. Ruptured ectopic pregnancy Rationale: Most common gynecologic cause of hemoperitoneum → Ruptured ectopic pregnancy. Other causes: Ruptured ovarian cyst, uterine rupture, endometriosis.

Answer 167

C. Acute appendicitis Rationale: Acute appendicitis is a surgical emergency. Other surgical causes: Perforated ulcer, intestinal obstruction, volvulus.

Answer 168

C. Acute gastroenteritis Rationale: Acute appendicitis and perforation cases require surgery. Acute gastroenteritis is managed medically.

Answer 169

A. Internal or external rotation of the flexed hip causes pain Rationale: Suggests pelvic appendicitis due to irritation of the obturator internus muscle.

Answer 170

B. Passively extending the hip or actively flexing the hip against resistance causes pain Rationale: Suggests retrocecal appendicitis due to irritation of the psoas muscle.

Answer 171

D. Sudden withdrawal of the hand after pressing the abdomen causes increased tenderness Rationale: Indicates peritoneal irritation (classic for peritonitis/appendicitis).

Answer 172

C. Detection of increased abdominal muscle tone during palpation Rationale: Involuntary contraction of abdominal muscles due to peritoneal inflammation.

Answer 173

D. 35-year-old female Rationale: Reproductive-aged women require pregnancy and menstrual cycle assessment to rule out ectopic pregnancy, ovarian cysts, or PID.

Answer 174

B. False Rationale: Mesenteric lymphadenitis is more common in children, adolescents, and young adults.

Answer 175

B. False Rationale: The first successful appendectomy was performed in 1759 in Bordeaux.

LE6 (older) Flashcards

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