Acute Surgical Presentations Flashcards

A 65-year-old diabetic man presents with a perianal abscess. After incision and drainage, a fistula-in-ano is suspected. Which classification system is used to guide surgical management?

Answer: Parks classification

The Parks classification categorizes fistulas-in-ano as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric, guiding surgical strategy to preserve continence.

A 78-year-old woman presents with acute onset confusion, abdominal distension, and obstipation. AXR shows a grossly dilated sigmoid colon in an inverted U-shape pointing to the right upper quadrant. What is the diagnosis and first-line treatment?

Answer: Sigmoid volvulus — endoscopic detorsion via flexible sigmoidoscopy

The 'coffee bean sign' on AXR is pathognomonic of sigmoid volvulus, and endoscopic decompression is the initial treatment of choice unless there are signs of ischemia or perforation.

A 42-year-old woman undergoes laparoscopic cholecystectomy. On POD 1 she has right upper quadrant pain, rising bilirubin, and bile drain output. HIDA scan shows biliary leak. What is the most common bile duct injury in laparoscopic cholecystectomy?

Answer: Injury to the cystic duct—CBD junction

The most common bile duct injury in laparoscopic cholecystectomy is a cystic duct stump leak or clip misplacement at the cystic duct–CBD junction due to misidentification of structures.

A 58-year-old man presents with hematemesis and melena. He is hemodynamically stable after resuscitation. Upper endoscopy reveals a duodenal ulcer with a visible vessel (Forrest Ia). What is the endoscopic treatment of choice?

Answer: Combination therapy: epinephrine injection plus thermal coagulation or hemoclip

High-risk peptic ulcer stigmata (Forrest Ia/Ib/IIa) require combination endoscopic therapy—epinephrine injection plus a second modality (thermal coagulation or mechanical clips)—to reduce rebleeding risk.

A 33-year-old man presents with testicular pain and swelling that began 4 hours ago. The testis is high-riding with a horizontal lie. Doppler ultrasound shows absent blood flow. What is the time window for salvage with surgical detorsion?

Answer: Within 6 hours — approximately 90–100% salvage

Testicular salvage rates approach 90–100% if surgical detorsion is performed within 6 hours of onset; rates drop to ~50% at 12 hours and <10% at 24 hours.

A 50-year-old woman presents with right iliac fossa pain, fever, and a palpable mass. CT shows a perforated appendicitis with a 4 cm periappendiceal abscess and no free perforation. What is the preferred management in a stable patient?

Answer: IV antibiotics and CT-guided percutaneous drainage, followed by interval appendectomy

A well-contained periappendiceal abscess in a stable patient is best managed with percutaneous drainage and antibiotics, followed by interval appendectomy at 6–8 weeks to rule out underlying malignancy.

A 55-year-old man presents post-thyroidectomy with stridor, voice hoarseness, and respiratory distress 2 hours after surgery. Neck is swelling. What is the immediate bedside intervention?

Answer: Bedside wound opening to evacuate hematoma

Post-thyroidectomy neck hematoma causing airway compromise requires immediate bedside wound opening to decompress the hematoma before definitive airway management or return to OR.