MCCQE Acute Surgical Presentations 3

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?

Accepted Answer

Ascending cholangitis — IV antibiotics, urgent biliary decompression via ERCP

Answer

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?

Accepted Answer

CT-guided percutaneous drainage and IV antibiotics, with interval resection

Answer

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?

Accepted Answer

Laparoscopic cholecystectomy regardless of trimester for acute cholecystitis

Answer

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?

Accepted Answer

CT angiography followed by interventional radiology embolization

Answer

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?

Accepted Answer

Lumbar puncture to look for xanthochromia

Answer

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.

(MCCQE) Medical Council of Canada Qualifying Examination Practice Test

(MCCQE) Medical Council of Canada Qualifying Examination Practice Test

MCCQE Acute Surgical Presentations 3