General Surgery and Gastrointestinal Surgery
Core Concepts
Candidates must master the evaluation of acute abdominal pain, including the differentiation of surgical from nonsurgical causes. Key topics include appendicitis (Alvarado score, imaging choices), biliary colic and cholecystitis, bowel obstruction (small vs. large, adhesive vs. neoplastic), and perforated viscus. Understand the pathophysiology of sepsis from abdominal sources and the principles of source control.
Traps in Questions
Questions often test the next best step in management. For suspected appendicitis in a young male with classic symptoms, clinical diagnosis may suffice; in women of childbearing age, ultrasound or CT is often needed to exclude gynecologic causes. Another trap is the use of antibiotics alone for uncomplicated diverticulitis-current guidelines recommend antibiotics only for complicated cases or immunocompromised patients. Also, beware of the “unstable patient” scenario: resuscitation before imaging.
Worked Example
A 45-year-old man presents with 2 days of periumbilical pain migrating to the right lower quadrant, anorexia, and low-grade fever. On exam, McBurney’s point tenderness with rebound. What is the most appropriate management? Answer: Early laparoscopic appendectomy after appropriate antibiotics. If a fecalith is seen on imaging, it does not change the indication for surgery.
Rule of Thumb
In adhesive small bowel obstruction, a trial of nonoperative management (NG tube, IV fluids) is appropriate for 24–48 hours if there are no signs of strangulation (fever, tachycardia, peritoneal signs, leukocytosis, or metabolic acidosis).