Examkin

Question

Difficulty: HardGastrointestinal and Abdominal Surgery

Match each clinical presentation of an acute surgical abdomen to the most appropriate next step in management.

  • A 35-year-old man presents with 5 days of right lower quadrant pain, fever, and leukocytosis. Computed tomography (CT) reveals a 6.5-cm periappendiceal abscess without generalized peritonitis.CT-guided percutaneous drainage and intravenous antibiotics
  • A 71-year-old woman is admitted with sudden-onset, severe generalized abdominal pain, confusion, and a systolic blood pressure of 85 mm Hg. CT imaging demonstrates sigmoid diverticulitis with diffuse pneumoperitoneum.Emergent exploratory laparotomy, bowel resection, and end colostomy
  • A 52-year-old man presents with left lower quadrant pain and low-grade fever. CT reveals sigmoid diverticulitis complicated by a localized 1.5-cm pericolic fluid collection.Intravenous antibiotics and bowel rest alone
  • A 58-year-old man with a history of open appendectomy presents with obstipation, abdominal distension, and bilious vomiting. CT reveals a small bowel transition point with normal wall enhancement.Nasogastric tube decompression and intravenous fluid resuscitation

Answer

The 6.5-cm abscess matches with percutaneous drainage; the perforated diverticulitis with shock matches with emergent laparotomy; the 1.5-cm microabscess matches with IV antibiotics alone; and the uncomplicated small bowel obstruction matches with nasogastric tube decompression.
Appropriate triage relies on established surgical indications. Uncomplicated small bowel obstruction and small (<3 cm) abscesses are managed conservatively. Large abscesses (>4 cm) require percutaneous drainage to allow inflammation to subside prior to any definitive operation. Free perforation with hemodynamic instability requires emergent operative source control.

Step-by-Step Solution

1
Evaluate the 6.5-cm periappendiceal abscess.
Determine that the abscess is large enough to warrant drainage rather than immediate surgery.
Operating on a large, acute abscess risks iatrogenic bowel injury and necessitates more extensive resection.
2
Assess the hemodynamically unstable patient with diffuse pneumoperitoneum.
Identify Hinchey IV diverticulitis requiring emergent laparotomy.
Free fecal or purulent peritonitis with shock is life-threatening and demands immediate operative source control (Hartmann procedure).
3
Analyze the 1.5-cm pericolic fluid collection.
Classify as a microabscess suitable for medical management.
Collections smaller than 3-4 cm have excellent resolution rates with antibiotics alone and are technically difficult to drain percutaneously.
4
Review the small bowel obstruction presentation.
Recognize an uncomplicated obstruction due to normal bowel wall enhancement.
Without signs of ischemia or closed-loop physiology, conservative management is the standard first-line approach.

Key Concept

Surgical triage of the acute abdomen based on complication severity, imaging findings, and hemodynamic stability
Rate this question

Topics

Gastrointestinal and Abdominal Surgery

More questions from this topic