General Surgery Board Review Case Studies & Practical Application 2 — Questions and Answers
Question 1: A 55-year-old male presents with sudden-onset severe epigastric pain radiating to the back, nausea, and vomiting after a heavy meal. Serum lipase is 1,200 U/L. CT scan shows peripancreatic fat stranding without necrosis. What is the most appropriate initial management?
- Emergent laparotomy
- NPO, IV fluids, and analgesics (Correct answer)
- Immediate ERCP
- Nasogastric decompression and TPN
Correct answer: NPO, IV fluids, and analgesics
Mild acute pancreatitis is managed conservatively with bowel rest, aggressive IV fluid resuscitation, and pain control.
Question 2: A 68-year-old woman undergoes elective sigmoid colectomy. On postoperative day 5, she develops fever, abdominal distension, and CT shows a 4 cm pelvic fluid collection with air-fluid level. What is the best next step?
- Immediate return to OR for washout
- CT-guided percutaneous drainage (Correct answer)
- IV antibiotics alone
- Colonoscopy to assess the anastomosis
Correct answer: CT-guided percutaneous drainage
A well-defined postoperative pelvic abscess is best managed with CT-guided percutaneous drainage combined with antibiotics.
Question 3: A 42-year-old male with a BMI of 38 undergoes laparoscopic Roux-en-Y gastric bypass. On postoperative day 2, his heart rate rises to 118 bpm and he complains of left shoulder pain. What complication must be ruled out first?
- Pulmonary embolism
- Anastomotic leak (Correct answer)
- Internal hernia
- Marginal ulcer
Correct answer: Anastomotic leak
Tachycardia with left shoulder pain (referred from diaphragmatic irritation) after gastric bypass is a red flag for anastomotic leak until proven otherwise.
Question 4: A 70-year-old man presents with a pulsatile abdominal mass. CT angiography reveals a 6.2 cm infrarenal AAA with no symptoms. He is an active smoker with well-controlled hypertension. What is the recommended management?
- Medical management and surveillance every 6 months
- Open surgical repair
- Endovascular aneurysm repair (EVAR) (Correct answer)
- Urgent repair only if symptomatic
Correct answer: Endovascular aneurysm repair (EVAR)
EVAR is preferred over open repair for anatomically suitable infrarenal AAAs ≥5.5 cm due to lower perioperative morbidity.
Question 5: A 35-year-old woman presents with right lower quadrant pain, fever, and leukocytosis. CT scan shows a 10 mm appendix with periappendiceal fat stranding and a 3 cm periappendiceal abscess. What is the best initial management?
- Emergent appendectomy
- IV antibiotics and interval appendectomy in 6-8 weeks
- CT-guided drainage plus IV antibiotics (Correct answer)
- Colonoscopy to rule out malignancy
Correct answer: CT-guided drainage plus IV antibiotics
A periappendiceal abscess is optimally treated with CT-guided drainage and IV antibiotics, followed by interval appendectomy after resolution.
Question 6: A 60-year-old male undergoes right hemicolectomy for ascending colon cancer. Pathology shows T3N1M0 (Stage IIIB) disease with 2/18 lymph nodes positive and clear margins. What is the next recommended step?
- Surveillance colonoscopy only
- Radiation therapy to the abdomen
- Adjuvant chemotherapy with FOLFOX or CAPOX (Correct answer)
- Repeat resection for wider margins
Correct answer: Adjuvant chemotherapy with FOLFOX or CAPOX
Stage III colon cancer with nodal involvement requires adjuvant chemotherapy; FOLFOX or CAPOX is the standard of care.
Question 7: A 50-year-old woman with known gallstones develops jaundice, fever, and RUQ pain. Labs show total bilirubin 4.2, ALP 380, and WBC 16,000. She is hemodynamically stable. What is the most appropriate next step?
- Emergent cholecystectomy
- MRCP to confirm choledocholithiasis
- ERCP with sphincterotomy and stone extraction (Correct answer)
- Percutaneous cholecystostomy
Correct answer: ERCP with sphincterotomy and stone extraction
Ascending cholangitis with choledocholithiasis in a stable patient is treated with ERCP for biliary decompression and stone extraction followed by elective cholecystectomy.
General Surgery Board Review Case Studies & Practical Application 2
A 55-year-old male presents with sudden-onset severe epigastric pain radiating to the back, nausea, and vomiting after a heavy meal.
Serum lipase is 1,200 U/L.
CT scan shows peripancreatic fat stranding without necrosis.
What is the most appropriate initial management?