MCCQE Acute Surgical Presentations 3 — Questions and Answers
Question 1: A 60-year-old woman with known gallstones presents with fever, right upper quadrant pain, and jaundice (Charcot's triad). She then develops hypotension and altered consciousness (Reynolds' pentad). What is the diagnosis and priority management?
- Acute cholecystitis — laparoscopic cholecystectomy within 24 hours
- Ascending cholangitis — IV antibiotics, urgent biliary decompression via ERCP (Correct answer)
- Choledocholithiasis — elective ERCP as outpatient
- Mirizzi syndrome — hepaticojejunostomy
Correct answer: Ascending cholangitis — IV antibiotics, urgent biliary decompression via ERCP
Reynolds' pentad (Charcot's triad plus shock and confusion) indicates acute suppurative cholangitis requiring urgent biliary decompression via ERCP and IV broad-spectrum antibiotics.
Question 2: A 50-year-old man with Crohn's disease presents with severe right lower quadrant pain, fever, and a palpable mass. CT reveals a 5 cm phlegmon/abscess in the right iliac fossa with no free perforation. What is the preferred initial management?
- Immediate surgical resection of terminal ileum
- CT-guided percutaneous drainage and IV antibiotics, with interval resection (Correct answer)
- Colonoscopy and mucosal biopsy
- High-dose systemic corticosteroids
Correct answer: CT-guided percutaneous drainage and IV antibiotics, with interval resection
A Crohn's-related abscess without free perforation is best managed initially with CT-guided percutaneous drainage and antibiotics, followed by elective bowel resection after inflammation resolves.
Question 3: A 35-year-old pregnant woman (32 weeks) presents with right upper quadrant pain and elevated liver enzymes. WBC is 14. Ultrasound shows gallbladder wall thickening and pericholecystic fluid. What is the management?
- Conservative management until delivery, then cholecystectomy
- Laparoscopic cholecystectomy during the second trimester only
- Laparoscopic cholecystectomy regardless of trimester for acute cholecystitis (Correct answer)
- Percutaneous cholecystostomy tube only
Correct answer: Laparoscopic cholecystectomy regardless of trimester for acute cholecystitis
Acute cholecystitis in pregnancy is treated with laparoscopic cholecystectomy regardless of trimester, as conservative management has high recurrence and risk of preterm labor.
Question 4: A 70-year-old man presents with sudden onset painless bright red rectal bleeding causing hemodynamic instability. He has no abdominal pain. Nasogastric aspirate is bile-stained without blood. What is the most appropriate next diagnostic and therapeutic step?
- Upper GI endoscopy
- Colonoscopy after rapid bowel prep
- CT angiography followed by interventional radiology embolization (Correct answer)
- Emergent sigmoidoscopy
Correct answer: CT angiography followed by interventional radiology embolization
Hemodynamically significant lower GI bleeding in an elderly patient warrants CT angiography (if actively bleeding at ≥0.3 mL/min) to localize the source, followed by angioembolization.
Question 5: A 55-year-old woman develops sudden severe headache ('thunderclap'), neck stiffness, and photophobia. Non-contrast CT head is negative for hemorrhage. What is the next critical step?
- Start empiric acyclovir for herpes encephalitis
- MRI brain with gadolinium
- Lumbar puncture to look for xanthochromia (Correct answer)
- CT angiography for aneurysm
Correct answer: Lumbar puncture to look for xanthochromia
A negative CT does not exclude subarachnoid hemorrhage; lumbar puncture must be performed to detect xanthochromia or elevated RBCs, as CT sensitivity drops significantly after 6–12 hours.
Question 6: A 48-year-old man presents with a painful erythematous and edematous right lower leg with rapidly spreading erythema, crepitus on palpation, and systemic sepsis. Blood glucose is 22 mmol/L. What is the diagnosis and immediate treatment?
- Cellulitis — IV penicillin
- Deep vein thrombosis — anticoagulation
- Necrotizing fasciitis — emergent surgical debridement and broad-spectrum antibiotics (Correct answer)
- Gas gangrene (myonecrosis) — hyperbaric oxygen first
Correct answer: Necrotizing fasciitis — emergent surgical debridement and broad-spectrum antibiotics
Crepitus, rapidly advancing erythema, and sepsis in a diabetic patient indicate necrotizing fasciitis requiring immediate aggressive surgical debridement, which is life-saving and cannot be delayed.
Question 7: A 20-year-old male presents after a motor vehicle collision with hypotension, tachycardia, and abdominal distension. FAST ultrasound shows free fluid in Morrison's pouch and the splenorenal space. He remains hypotensive despite 2 L IV crystalloid. What is the next step?
- CT abdomen with contrast for injury characterization
- Diagnostic peritoneal lavage
- Emergent exploratory laparotomy (Correct answer)
- Angioembolization of splenic artery
Correct answer: Emergent exploratory laparotomy
A hemodynamically unstable trauma patient with FAST-positive free fluid requires emergent exploratory laparotomy; CT is contraindicated in the unstable patient.
MCCQE Acute Surgical Presentations 3
A 60-year-old woman with known gallstones presents with fever, right upper quadrant pain, and jaundice (Charcot's triad).
She then develops hypotension and altered consciousness (Reynolds' pentad).
What is the diagnosis and priority management?