MCCQE Acute Surgical Presentations 2 — Questions and Answers
Question 1: A 45-year-old man presents with sudden onset severe epigastric pain radiating to the back, nausea, and vomiting after a heavy meal. Serum lipase is 1200 U/L. CT shows peripancreatic fat stranding but no necrosis. What is the Ranson criterion at admission that most strongly predicts severity?
- Serum glucose > 11 mmol/L (Correct answer)
- Age > 55 years
- WBC > 16 x10⁹/L
- LDH > 350 IU/L
Correct answer: Serum glucose > 11 mmol/L
Serum glucose > 11 mmol/L (200 mg/dL) at admission is one of the five Ranson criteria assessed on presentation and is a key predictor of severe pancreatitis.
Question 2: A 68-year-old woman with atrial fibrillation presents with sudden severe periumbilical pain out of proportion to physical exam findings, followed by bloody diarrhea 6 hours later. CT angiography shows filling defect in the superior mesenteric artery. What is the priority management?
- Immediate exploratory laparotomy
- IV heparin anticoagulation and urgent surgical or endovascular revascularization (Correct answer)
- Broad-spectrum antibiotics and bowel rest
- Vasopressin infusion via angiography catheter
Correct answer: IV heparin anticoagulation and urgent surgical or endovascular revascularization
Acute mesenteric ischemia from embolic occlusion requires immediate anticoagulation with heparin and urgent revascularization (surgical embolectomy or endovascular therapy) to prevent bowel infarction.
Question 3: A 55-year-old man undergoes elective right hemicolectomy. On post-operative day 3 he develops fever, tachycardia, and worsening abdominal pain with peritoneal signs. CT shows free air and fluid. What is the most likely diagnosis and appropriate next step?
- Ileus — nasogastric decompression
- Anastomotic leak — return to OR for washout and stoma creation (Correct answer)
- Wound infection — open wound and antibiotics
- C. difficile colitis — oral vancomycin
Correct answer: Anastomotic leak — return to OR for washout and stoma creation
Post-operative peritonitis with free air on POD 3 after bowel resection is anastomotic leak until proven otherwise, requiring urgent surgical re-exploration, washout, and fecal diversion.
Question 4: A 30-year-old woman presents with right lower quadrant pain, low-grade fever, and elevated WBC. Ultrasound is non-diagnostic. CT with contrast shows a 9 mm appendix with periappendiceal fat stranding. She has no perforation or abscess. What is standard of care?
- IV antibiotics alone with outpatient follow-up
- Laparoscopic appendectomy (Correct answer)
- Open appendectomy via McBurney incision
- Interval appendectomy in 6 weeks
Correct answer: Laparoscopic appendectomy
Uncomplicated acute appendicitis confirmed on CT is treated with laparoscopic appendectomy, which is the current standard of care offering lower morbidity and faster recovery than open surgery.
Question 5: A 72-year-old man with a known 5.5 cm abdominal aortic aneurysm presents with sudden onset severe back and flank pain, hypotension, and a pulsatile abdominal mass. BP is 80/50. What is the immediate management priority?
- CT angiography to confirm rupture
- Permissive hypotension targeting SBP 50-70 mmHg and emergent surgical repair (Correct answer)
- IV fluid resuscitation to normalize blood pressure before surgery
- Endovascular aortic repair (EVAR) as first-line
Correct answer: Permissive hypotension targeting SBP 50-70 mmHg and emergent surgical repair
Ruptured AAA is a surgical emergency; permissive hypotension (SBP 50–70 mmHg) is maintained to reduce further hemorrhage while rushing the patient to the OR for open or endovascular repair.
Question 6: A 40-year-old man presents with a painful, irreducible bulge in the right groin below and lateral to the pubic tubercle that appeared during heavy lifting. He has nausea but no vomiting. What type of hernia is most likely and what is the next step?
- Indirect inguinal hernia — elective repair
- Femoral hernia — urgent surgical repair due to high strangulation risk (Correct answer)
- Direct inguinal hernia — conservative management with truss
- Spigelian hernia — CT confirmation then repair
Correct answer: Femoral hernia — urgent surgical repair due to high strangulation risk
A femoral hernia presents below and lateral to the pubic tubercle and carries a high risk of incarceration and strangulation, warranting urgent operative repair.
Question 7: A 25-year-old man sustains a stab wound to the left chest at the 5th intercostal space, midclavicular line. He is hypotensive with distended neck veins and muffled heart sounds. Trachea is midline. What is the immediate intervention?
- Emergency chest X-ray
- Needle decompression at 2nd ICS midclavicular line
- Pericardiocentesis or emergency thoracotomy for cardiac tamponade (Correct answer)
- Bilateral chest tubes
Correct answer: Pericardiocentesis or emergency thoracotomy for cardiac tamponade
Beck's triad (hypotension, JVD, muffled heart sounds) with a penetrating chest wound indicates cardiac tamponade, treated emergently with pericardiocentesis or left anterolateral thoracotomy.
MCCQE Acute Surgical Presentations 2
A 45-year-old man presents with sudden onset severe epigastric pain radiating to the back, nausea, and vomiting after a heavy meal.
Serum lipase is 1200 U/L.
CT shows peripancreatic fat stranding but no necrosis.
What is the Ranson criterion at admission that most strongly predicts severity?