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EBSQ General Surgery - independent subject foundations study materials
EBSQ General Surgery - independent subject foundations study resources

EBSQ General Surgery - independent subject foundations practice questions

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Question 1Surgical assessment, trauma and anatomical complications

A 68-year-old presents with sudden severe abdominal pain, guarding, hypotension, and tachycardia. What is the best initial management?

  1. Withhold analgesia until a definitive diagnosis is made because it prevents reliable examination
  2. Send the patient for outpatient ultrasound because most acute abdominal pain is benign
  3. Start oral laxatives and observe because guarding is common in constipation
  4. Resuscitate immediately with an ABCDE approach, obtain senior surgical review, give analgesia and antibiotics if sepsis or perforation is suspected, and arrange urgent imaging or operation as appropriate Correct answer.

Explanation

An unstable acute abdomen requires simultaneous resuscitation, analgesia, senior review, early antibiotics when indicated, and urgent diagnostic or operative planning.

Question 2Surgical assessment, trauma and anatomical complications

A patient with previous laparotomy presents with colicky abdominal pain, vomiting, distension, and no flatus. They are dehydrated but have no peritonitis. What is the best initial management bundle?

  1. Give oral bowel preparation and discharge if pain improves
  2. Keep nil by mouth, give IV isotonic fluids with electrolyte correction, insert a nasogastric tube if vomiting or distended, provide analgesia, catheterize if needed, and obtain CT with surgical review Correct answer.
  3. Start loperamide and high-fiber diet because adhesive obstruction is functional
  4. Avoid imaging because adhesions cannot be seen directly

Explanation

Suspected small bowel obstruction is initially managed with bowel rest, fluid and electrolyte correction, decompression when indicated, analgesia, monitoring, CT, and surgical assessment.

Question 3Surgical assessment, trauma and anatomical complications

A patient with acute abdominal pain has pain out of proportion to examination, atrial fibrillation, metabolic acidosis, and elevated lactate. What diagnosis and action should be prioritized?

  1. Treat as uncomplicated gastroenteritis and discharge with oral fluids
  2. Suspect acute mesenteric ischemia and arrange urgent resuscitation, contrast CT angiography if feasible, broad-spectrum antibiotics, and senior surgical or vascular involvement Correct answer.
  3. Assume renal colic and delay review until hematuria is confirmed
  4. Give antispasmodics only because the abdomen is soft

Explanation

Pain out of proportion, atrial fibrillation, acidosis, and lactate elevation are red flags for mesenteric ischemia, requiring urgent imaging, resuscitation, antibiotics, and specialist intervention.

Question 4Surgical assessment, trauma and anatomical complications

Two hours after total thyroidectomy, a patient develops neck swelling, stridor and increasing respiratory distress on the ward. What is the correct immediate action?

  1. Open the cervical wound at the bedside to decompress the haematoma while calling for airway and theatre support Correct answer.
  2. Wait for a CT neck before intervening
  3. Give oral antibiotics and review in the morning
  4. Place the patient flat and apply a tight pressure dressing

Explanation

Post-thyroidectomy haematoma can rapidly obstruct the airway. If respiratory compromise is present, immediate bedside wound opening and clot evacuation can be lifesaving, followed by definitive airway control and operative haemostasis.

Question 5Surgical assessment, trauma and anatomical complications

A patient develops perioral tingling, carpopedal spasm and a prolonged QT interval the morning after total thyroidectomy with central neck dissection. Corrected calcium is 1.78 mmol/L. What is the best immediate treatment?

  1. Restrict dietary calcium and observe
  2. High-dose loop diuretic therapy
  3. Urgent reoperation to remove all parathyroid tissue
  4. Intravenous calcium gluconate with cardiac monitoring, followed by oral calcium and active vitamin D replacement as needed Correct answer.

Explanation

Symptomatic acute hypocalcaemia after thyroid surgery requires intravenous calcium. Ongoing treatment usually includes oral calcium and calcitriol while parathyroid function recovers or permanent hypoparathyroidism is assessed.

Question 6Surgical assessment, trauma and anatomical complications

A diabetic patient presents with severe thigh pain, fever, tachycardia, mild erythema, and tenderness extending beyond the visible skin changes. Serum lactate is elevated. What is the most appropriate initial management?

  1. Discharge with oral antibiotics because the skin changes are mild
  2. Urgent broad-spectrum antibiotics, resuscitation, and immediate surgical exploration and debridement Correct answer.
  3. Wait for MRI confirmation before contacting the operating theatre
  4. Aspirate the area and proceed only if pus is obtained

Explanation

Necrotizing soft tissue infection is a clinical emergency. Early resuscitation, broad antimicrobial cover, and prompt surgical debridement are key to survival.

Question 7Surgical assessment, trauma and anatomical complications

During attempted internal jugular central venous catheter placement, pulsatile bright red blood is aspirated after dilator passage and arterial placement is suspected. The patient is stable. What is the safest immediate action?

  1. Leave the catheter in place, stop using it, and obtain urgent vascular or interventional radiology advice Correct answer.
  2. Remove the catheter immediately and apply pressure for 2 minutes
  3. Flush the catheter and use it for vasopressors if it draws back well
  4. Advance a larger venous catheter through the same tract

Explanation

Large-bore arterial cannulation during central venous access should not be blindly removed. Leaving it in place allows controlled repair or endovascular management.

Question 8Surgical assessment, trauma and anatomical complications

A patient develops severe hand pain, pallor, coolness, and paraesthesia shortly after creation of a brachiocephalic arteriovenous fistula for dialysis. The radial pulse is weak and symptoms improve when the fistula is compressed. What is the most likely diagnosis requiring urgent vascular review?

  1. Normal postoperative swelling after fistula surgery
  2. Superficial thrombophlebitis of the forearm
  3. Dialysis access-associated steal syndrome Correct answer.
  4. Complex regional pain syndrome diagnosed by exclusion after 6 months

Explanation

Hand ischemia relieved by fistula compression suggests access-associated steal. Severe pain or neurologic symptoms after access creation need urgent vascular assessment.

Question 9Surgical assessment, trauma and anatomical complications

A 74-year-old man presents with sudden back and abdominal pain, hypotension, and a pulsatile abdominal mass. What is the priority management approach?

  1. Give full-volume crystalloid resuscitation to normalize blood pressure before calling vascular surgery
  2. Discharge after analgesia if the pain improves
  3. Immediate vascular surgery activation with permissive resuscitation and transfer for emergency repair Correct answer.
  4. Arrange outpatient ultrasound within 2 weeks

Explanation

This presentation is classic for ruptured abdominal aortic aneurysm. Survival depends on rapid vascular control, balanced resuscitation, and emergency open or endovascular repair where appropriate.

Question 10Surgical assessment, trauma and anatomical complications

A patient with atrial fibrillation develops sudden severe leg pain, pallor, paraesthesia, and reduced motor power. The foot is cold and no Doppler arterial signal is heard. What is the best immediate action?

  1. Start therapeutic anticoagulation if not contraindicated and obtain urgent vascular surgery assessment Correct answer.
  2. Prescribe compression stockings and review the next day
  3. Wait for a routine outpatient duplex scan before treating
  4. Give oral antibiotics for presumed cellulitis

Explanation

Threatened acute limb ischemia requires immediate heparin if safe and urgent vascular assessment for revascularization. Motor deficit and absent Doppler signals indicate a time-critical limb.

Question 11Surgical assessment, trauma and anatomical complications

A motorcyclist arrives after blunt trauma with hypotension and an unstable pelvic ring injury. There is no external bleeding. What early intervention directly addresses a likely source of hemorrhage?

  1. Place the binder around the abdomen above the iliac crests
  2. Delay hemorrhage control until a formal pelvic radiograph is reported
  3. Give analgesia only because pelvic bleeding is usually self-limiting
  4. Apply a pelvic binder at the level of the greater trochanters and activate major hemorrhage management Correct answer.

Explanation

Unstable pelvic fractures can cause life-threatening hemorrhage. A correctly positioned binder reduces pelvic volume and supports early hemorrhage control while definitive management is organized.

Question 12Surgical assessment, trauma and anatomical complications

A hypotensive patient has blunt abdominal trauma. FAST examination shows free intraperitoneal fluid and the patient remains unstable despite initial resuscitation. What is the most appropriate next step?

  1. Immediate contrast CT scan to define all injuries before treatment
  2. Emergency operative control of hemorrhage, usually laparotomy Correct answer.
  3. Observation in the emergency department with serial hemoglobin measurements only
  4. Diagnostic colonoscopy to exclude bowel injury

Explanation

In hemodynamically unstable blunt trauma with a positive FAST, operative hemorrhage control should not be delayed for CT.

Question 13Surgical assessment, trauma and anatomical complications

A 67-year-old man presents with sudden severe generalized abdominal pain, rigid abdomen, tachycardia, and free air under the diaphragm on erect chest radiograph. What is the best initial management?

  1. Oral proton pump inhibitor and outpatient endoscopy
  2. Nil by mouth, intravenous fluids, broad-spectrum antibiotics, analgesia, and urgent surgical assessment for source control Correct answer.
  3. High-dose laxatives and repeat radiograph in 24 hours
  4. Immediate colonoscopy to decompress the abdomen

Explanation

Pneumoperitoneum with peritonitis indicates perforated viscus until proven otherwise. Resuscitation, antibiotics, and urgent source control are the priorities.

Question 14Visceral surgery: inflammatory, obstructive and biliary disease

A 68-year-old man presents with haematemesis, melaena, confusion and a systolic blood pressure of 78 mmHg. He has a history of ischaemic heart disease and takes aspirin. What is the best immediate management priority?

  1. Urgent diagnostic endoscopy before any transfusion to identify the bleeding point
  2. High-dose oral proton pump inhibitor and discharge if haemoglobin is above 100 g/L
  3. Immediate CT angiography as the first investigation in all suspected upper gastrointestinal bleeds
  4. Two large-bore intravenous lines, blood tests including group and crossmatch, haemodynamic resuscitation and early senior/endoscopy involvement Correct answer.

Explanation

In major upper gastrointestinal bleeding, airway assessment and circulatory resuscitation come before definitive endoscopy. Endoscopy should follow once the patient is appropriately stabilised, with transfusion and reversal decisions individualised.

Question 15Visceral surgery: inflammatory, obstructive and biliary disease

A 52-year-old woman has sudden severe epigastric pain, generalised peritonitis and free intraperitoneal air on erect chest radiograph. She has taken ibuprofen daily for osteoarthritis. What is the most appropriate definitive management after initial resuscitation?

  1. Urgent operative management with peritoneal lavage and closure of the perforation, usually with an omental patch if suitable Correct answer.
  2. Outpatient Helicobacter pylori eradication and repeat review in 6 weeks
  3. Immediate oral contrast follow-through to confirm a duodenal leak before treatment
  4. Endoscopic clipping as first-line therapy for all perforated peptic ulcers with peritonitis

Explanation

A perforated peptic ulcer with diffuse peritonitis requires prompt surgery after resuscitation, antibiotics and acid suppression. Non-operative treatment is reserved for carefully selected stable patients with sealed perforation and no generalised peritonitis.

Question 16Visceral surgery: inflammatory, obstructive and biliary disease

A 76-year-old man has a spurting posterior duodenal ulcer bleed. Endoscopic injection and clipping fail to control bleeding, and he remains transfusion-dependent. Interventional radiology is immediately available. What is the best next step?

  1. Repeat oral proton pump inhibitor therapy and observe for 24 hours
  2. Emergency total gastrectomy
  3. Catheter angiography with embolisation of the gastroduodenal arterial supply Correct answer.
  4. Elective vagotomy and pyloroplasty after discharge

Explanation

Persistent bleeding after endoscopic therapy should prompt escalation. Where available, transcatheter arterial embolisation is often preferred before surgery in high-risk patients, particularly for gastroduodenal artery bleeding from posterior duodenal ulcers.

Question 17Visceral surgery: inflammatory, obstructive and biliary disease

A 59-year-old man has recurrent non-bilious vomiting, early satiety and weight loss. He has a long history of duodenal ulcer disease. Examination shows dehydration and a succussion splash. What is the most appropriate initial management?

  1. Immediate oral refeeding to stimulate gastric emptying
  2. Empirical pyloric dilatation without endoscopic assessment
  3. Nasogastric decompression, intravenous fluid and electrolyte correction, then upper endoscopy with biopsy to exclude malignancy Correct answer.
  4. Long-term antibiotics alone because this is diagnostic of Helicobacter pylori infection

Explanation

Gastric outlet obstruction needs decompression and correction of hypochloraemic, hypokalaemic metabolic alkalosis before definitive treatment. Endoscopy is essential to define the cause and exclude gastric cancer.

Question 18Visceral surgery: inflammatory, obstructive and biliary disease

A 44-year-old woman presents with acute pancreatitis, fever, jaundice, rigors and right upper quadrant pain. Ultrasound shows gallstones and a dilated common bile duct. What is the best management of the biliary obstruction?

  1. Urgent ERCP with biliary decompression after initial resuscitation Correct answer.
  2. Delay all biliary intervention for 6 weeks until pancreatic inflammation has completely resolved
  3. Immediate open common bile duct exploration without imaging
  4. Treat with analgesia only because ERCP is contraindicated in acute pancreatitis

Explanation

Gallstone pancreatitis with cholangitis or persistent biliary obstruction requires urgent ERCP for drainage. In uncomplicated gallstone pancreatitis, ERCP is not routine and cholecystectomy is planned during the index admission when feasible.

Question 19Visceral surgery: inflammatory, obstructive and biliary disease

A 38-year-old man has acute pancreatitis confirmed by typical pain and lipase more than three times the upper limit of normal. He is haemodynamically stable, has no cholangitis and presents within 12 hours of symptom onset. Which management strategy is most appropriate?

  1. Routine prophylactic broad-spectrum antibiotics to prevent sterile necrosis becoming infected
  2. Immediate contrast-enhanced CT in every case to grade severity on admission
  3. Total parenteral nutrition and nil by mouth for at least 7 days
  4. Early supportive care with intravenous fluids, opioid analgesia, monitoring for organ failure and early enteral/oral feeding as tolerated Correct answer.

Explanation

Initial pancreatitis care is supportive and severity is driven by organ failure. Prophylactic antibiotics are not indicated for sterile pancreatitis, early CT is reserved for diagnostic uncertainty or deterioration, and enteral nutrition is preferred when feeding is needed.

Question 20Visceral surgery: inflammatory, obstructive and biliary disease

A patient with severe necrotising pancreatitis deteriorates 3 weeks after admission with fever, rising inflammatory markers and gas in a peripancreatic collection on CT. What is the preferred approach if the patient can be stabilised?

  1. Immediate open pancreatic necrosectomy for all infected necrosis
  2. A step-up strategy with antibiotics and image-guided or endoscopic drainage, delaying necrosectomy until the collection is walled off if possible Correct answer.
  3. No intervention because gas in a collection is expected in sterile necrosis
  4. Elective distal pancreatectomy as the standard treatment

Explanation

Infected pancreatic necrosis is managed with antibiotics and source control. A minimally invasive step-up approach, preferably after maturation into walled-off necrosis, reduces morbidity compared with early open necrosectomy when the patient can be temporised.

Question 21Visceral surgery: inflammatory, obstructive and biliary disease

A 70-year-old man presents with painless jaundice, weight loss, pale stools and a palpable non-tender gallbladder. He has no fever or abdominal pain. What is the most appropriate next investigation to assess likely pancreatic head malignancy?

  1. Immediate laparotomy without cross-sectional imaging
  2. Pancreatic protocol contrast-enhanced CT to stage disease and assess vascular involvement Correct answer.
  3. Plain abdominal radiograph
  4. Diagnostic ERCP as the first test solely to visualise the papilla

Explanation

Painless obstructive jaundice with Courvoisier sign suggests malignant distal biliary obstruction. Pancreatic protocol CT is central to diagnosis, staging and resectability assessment; ERCP is mainly used for tissue acquisition or biliary drainage when indicated.

Question 22Visceral surgery: inflammatory, obstructive and biliary disease

A 61-year-old woman with biliary colic has bilirubin 86 micromol/L, alkaline phosphatase 420 IU/L and ultrasound showing gallstones, a 9 mm common bile duct and a visible distal duct stone. What is the best next management step?

  1. Proceed directly to laparoscopic cholecystectomy without addressing the duct stone
  2. Discharge with ursodeoxycholic acid
  3. Percutaneous liver biopsy to explain the cholestatic liver tests
  4. ERCP for common bile duct stone clearance, followed by cholecystectomy during the same admission if fit Correct answer.

Explanation

A duct stone seen on imaging with cholestatic jaundice is high-probability choledocholithiasis. ERCP clears the duct, and cholecystectomy should follow to prevent recurrent biliary events in suitable patients.

Question 23Visceral surgery: inflammatory, obstructive and biliary disease

During assessment of a jaundiced patient with gallstones, MRCP shows a large stone impacted in the cystic duct compressing the common hepatic duct. Which statement best describes the surgical significance?

  1. This is Mirizzi syndrome and it increases the risk of bile duct injury, so careful operative planning and cholangiographic assessment are important Correct answer.
  2. This is gallstone ileus and treatment is always colonoscopy
  3. This finding excludes the need for cholecystectomy
  4. This is diagnostic of primary sclerosing cholangitis

Explanation

Mirizzi syndrome is extrinsic common hepatic duct obstruction by an impacted cystic duct or Hartmann pouch stone. Distorted anatomy and possible cholecystocholedochal fistula make bile duct injury more likely.

Question 24Visceral surgery: inflammatory, obstructive and biliary disease

A 49-year-old otherwise fit woman has 24 hours of right upper quadrant pain, fever, Murphy sign and ultrasound-confirmed gallbladder wall thickening with stones. What is the preferred treatment plan?

  1. Antibiotics and interval cholecystectomy only if symptoms recur
  2. Endoscopic sphincterotomy alone as definitive treatment for acute cholecystitis
  3. Early laparoscopic cholecystectomy during the index admission with antibiotics and supportive care Correct answer.
  4. Observation without antibiotics because gallbladder inflammation is self-limiting

Explanation

For most fit patients with acute calculous cholecystitis, early laparoscopic cholecystectomy during the index admission reduces recurrent events and total hospital stay. Percutaneous cholecystostomy is reserved mainly for high-risk or septic unfit patients.

Question 25Visceral surgery: inflammatory, obstructive and biliary disease

A 46-year-old man has incidental gallstones found on ultrasound performed for renal colic. He has never had biliary pain, jaundice, pancreatitis or cholecystitis. What is the most appropriate advice?

  1. Routine prophylactic cholecystectomy is indicated for all asymptomatic gallstones
  2. Annual ERCP is needed to prevent common bile duct stones
  3. No cholecystectomy is required unless symptoms or selected high-risk features develop Correct answer.
  4. Long-term broad-spectrum antibiotics prevent future acute cholecystitis

Explanation

Most asymptomatic gallstones remain asymptomatic and do not require surgery. Cholecystectomy is considered if typical biliary symptoms occur or in selected special circumstances with higher complication risk.

Question 26Visceral surgery: inflammatory, obstructive and biliary disease

A 35-year-old woman has an incidental 4 cm liver lesion. MRI shows peripheral nodular discontinuous enhancement with progressive centripetal fill-in and very high T2 signal. Liver tests are normal and she is asymptomatic. What is the best management?

  1. Reassurance without treatment if imaging is diagnostic and there are no concerning features Correct answer.
  2. Percutaneous biopsy because all vascular liver lesions require histology
  3. Emergency hepatic resection because rupture is common
  4. Empirical chemotherapy

Explanation

These imaging features are typical of cavernous haemangioma. Biopsy is avoided because of bleeding risk and poor necessity when imaging is diagnostic; asymptomatic haemangiomas usually need no treatment.

Question 27Visceral surgery: inflammatory, obstructive and biliary disease

A 63-year-old man with compensated cirrhosis has a new 2.3 cm liver lesion. Dynamic MRI shows arterial phase hyperenhancement with portal venous washout and capsule appearance. Alpha-fetoprotein is mildly elevated. What is the best interpretation?

  1. The lesion is most likely a simple cyst and can be ignored
  2. Percutaneous biopsy is mandatory before any treatment can be considered
  3. The finding is diagnostic of colorectal liver metastasis
  4. The lesion is radiologically characteristic of hepatocellular carcinoma in a cirrhotic liver and should be managed through a liver multidisciplinary pathway Correct answer.

Explanation

In a cirrhotic liver, a lesion with arterial enhancement and washout on appropriate dynamic imaging can establish non-invasive HCC diagnosis. Treatment choice depends on liver function, portal hypertension, performance status and tumour burden.

Question 28Visceral surgery: inflammatory, obstructive and biliary disease

A patient with sigmoid cancer has four bilobar colorectal liver metastases and no extrahepatic disease. The hepatobiliary team believes all disease could be cleared with staged resection and portal vein embolisation to ensure an adequate future liver remnant. Which principle best defines resectability?

  1. More than three liver metastases are an absolute contraindication to liver surgery
  2. Resectability depends on the ability to remove or ablate all disease with negative margins while preserving adequate functional liver remnant Correct answer.
  3. Bilobar disease is always palliative
  4. Synchronous colorectal liver metastases must never be treated surgically

Explanation

Modern colorectal liver metastasis resectability is based on complete disease clearance and sufficient future liver remnant, not simply the number or bilobar distribution of lesions. Staged strategies can convert selected patients to resectability.

Question 29Visceral surgery: inflammatory, obstructive and biliary disease

A 42-year-old woman presents 5 days after sleeve gastrectomy with tachycardia, fever and left shoulder-tip pain. She looks septic. What complication must be assumed until proven otherwise?

  1. Normal postoperative pain that should be treated with discharge analgesia
  2. Staple-line leak requiring urgent resuscitation, broad-spectrum antibiotics, imaging and source control planning Correct answer.
  3. Chronic marginal ulcer, best managed with outpatient antacids
  4. Vitamin B12 deficiency as the immediate cause of sepsis

Explanation

Tachycardia and sepsis after sleeve gastrectomy are classic warning signs of a staple-line leak. Management requires early recognition, resuscitation, antibiotics, imaging and drainage, endoscopic or operative source control depending on stability and anatomy.

Question 30Visceral surgery: inflammatory, obstructive and biliary disease

A 37-year-old woman presents 18 months after Roux-en-Y gastric bypass with intermittent severe crampy abdominal pain and vomiting. CT is equivocal but shows subtle mesenteric swirl. Between episodes she appears well. What is the best management principle?

  1. Exclude internal hernia because CT is not definitive
  2. Treat with pancreatic enzymes only
  3. Advise permanent liquid diet and no surgical review
  4. Maintain a low threshold for urgent diagnostic laparoscopy because internal hernia can be intermittent and lead to closed-loop obstruction Correct answer.

Explanation

Internal hernia after Roux-en-Y gastric bypass may present intermittently and CT can be falsely reassuring. Because strangulation can occur, persistent concerning symptoms warrant urgent bariatric surgical assessment and often diagnostic laparoscopy.

Question 31Visceral surgery: inflammatory, obstructive and biliary disease

A 50-year-old man who smokes and takes NSAIDs develops epigastric pain and occult bleeding 8 months after Roux-en-Y gastric bypass. Endoscopy shows an ulcer at the gastrojejunal anastomosis. What is the most appropriate initial management?

  1. High-dose proton pump inhibitor, stop NSAIDs, smoking cessation and assess for Helicobacter pylori where appropriate Correct answer.
  2. Immediate total gastrectomy in all cases
  3. No treatment because marginal ulcers always heal spontaneously
  4. Oral iron only, with no need to address ulcer risk factors

Explanation

Marginal ulceration after gastric bypass is associated with acid exposure, smoking, NSAIDs and sometimes H. pylori. Initial therapy is risk-factor modification and acid suppression; surgery is reserved for refractory or complicated cases.

Question 32Visceral surgery: inflammatory, obstructive and biliary disease

A 72-year-old man with a previous open colectomy presents with colicky abdominal pain, vomiting, distension, fever and continuous pain. CT shows a small bowel obstruction with a single transition point, mesenteric oedema, reduced mural enhancement and a small volume of free fluid. What is the best next step?

  1. Immediate operative exploration after resuscitation and antibiotics Correct answer.
  2. Nasogastric decompression and observation for 72 hours
  3. Oral water-soluble contrast challenge as definitive treatment
  4. Colonoscopy to decompress the obstructed segment

Explanation

Continuous pain, fever and CT signs of impaired enhancement/free fluid suggest strangulation or ischaemia. Resuscitation should not delay urgent operative exploration.

Question 33Visceral surgery: inflammatory, obstructive and biliary disease

A stable 58-year-old woman has adhesive small bowel obstruction without peritonitis, leucocytosis, acidosis or CT signs of ischaemia. After nasogastric decompression and fluids, a water-soluble contrast study shows contrast in the colon at 8 hours. What is the most appropriate management?

  1. Proceed directly to laparotomy because adhesive obstruction rarely resolves
  2. Administer stimulant laxatives to accelerate resolution
  3. Continue non-operative management with close clinical review Correct answer.
  4. Book elective adhesiolysis before discharge

Explanation

In uncomplicated adhesive obstruction, early passage of water-soluble contrast to the colon predicts likely resolution. Continued conservative care is appropriate while monitoring for deterioration.

Question 34Visceral surgery: inflammatory, obstructive and biliary disease

A 79-year-old woman presents with vomiting, abdominal distension and a tender irreducible groin swelling below and lateral to the pubic tubercle. She is tachycardic and has localized erythema over the swelling. What is the best management?

  1. Attempt forceful taxis under sedation and discharge if reduced
  2. Outpatient ultrasound and elective hernia repair
  3. Urgent operation for suspected strangulated femoral hernia Correct answer.
  4. Intravenous antibiotics alone until the erythema resolves

Explanation

A tender irreducible femoral hernia with obstruction and skin change should be treated as strangulated. Taxis is inappropriate when strangulation is suspected.

Question 35Visceral surgery: inflammatory, obstructive and biliary disease

A 27-year-old man has CT-proven uncomplicated acute appendicitis with a visible appendicolith. He is haemodynamically stable and fit for surgery. Which option is the best recommendation?

  1. Laparoscopic appendicectomy with peri-operative antibiotics Correct answer.
  2. Antibiotics alone because an appendicolith predicts durable non-operative success
  3. Right hemicolectomy to exclude occult malignancy
  4. Interval appendicectomy after 6 to 8 weeks of antibiotics

Explanation

Antibiotic-first management can be considered in selected uncomplicated appendicitis, but an appendicolith increases failure and perforation risk. Fit patients are usually best managed with appendicectomy.

Question 36Visceral surgery: inflammatory, obstructive and biliary disease

A 46-year-old man presents after 7 days of right iliac fossa pain and fever. CT shows a 6 cm periappendiceal abscess without diffuse peritonitis. He is stable after fluids. What is the best initial treatment?

  1. Immediate right hemicolectomy
  2. Discharge on oral analgesia and review if symptoms persist
  3. Colonoscopy during the acute admission to drain the abscess
  4. Antibiotics plus image-guided percutaneous drainage where feasible Correct answer.

Explanation

A stable patient with a sizeable appendiceal abscess is usually managed initially with antibiotics and percutaneous drainage when technically possible. Emergency surgery is reserved for generalized peritonitis or failure of source control.

Question 37Visceral surgery: inflammatory, obstructive and biliary disease

A 61-year-old immunocompetent patient has CT-confirmed uncomplicated sigmoid diverticulitis, normal observations after analgesia, no abscess, no free air and no significant comorbidity. Which management is most appropriate?

  1. Emergency Hartmann procedure
  2. Outpatient supportive care with safety-netting, without routine antibiotics Correct answer.
  3. Percutaneous drainage followed by elective colectomy
  4. Urgent colonoscopy to confirm the diagnosis

Explanation

Selected stable immunocompetent patients with uncomplicated diverticulitis can be managed without routine antibiotics, provided they have clear return advice and follow-up.

Question 38Visceral surgery: inflammatory, obstructive and biliary disease

A 68-year-old woman has acute sigmoid diverticulitis with a 5.5 cm pelvic abscess on CT. She is stable, has no generalized peritonitis and the abscess is accessible radiologically. What is the best treatment plan?

  1. Intravenous antibiotics alone with no drainage regardless of response
  2. Antibiotics and CT- or ultrasound-guided percutaneous drainage Correct answer.
  3. Immediate subtotal colectomy with ileorectal anastomosis
  4. Barium enema to decompress the sigmoid colon

Explanation

Large diverticular abscesses are best treated with antibiotics plus percutaneous drainage when feasible. Antibiotics alone are more suitable for small abscesses or when drainage is impossible and the patient remains stable.

Question 39Visceral surgery: inflammatory, obstructive and biliary disease

A frail 82-year-old patient presents in septic shock with generalized peritonitis. CT shows perforated sigmoid diverticulitis with free faecal contamination. Which operative strategy is most appropriate?

  1. Laparoscopic lavage only
  2. Elective sigmoid colectomy after 6 weeks of antibiotics
  3. Endoscopic stenting of the sigmoid colon
  4. Sigmoid resection with end colostomy and rectal stump closure Correct answer.

Explanation

Faecal peritonitis with shock requires urgent source control. In a frail unstable patient, Hartmann-type resection is usually safer than primary anastomosis or lavage.

Question 40Visceral surgery: inflammatory, obstructive and biliary disease

A fit 69-year-old man presents with large bowel obstruction from an apparently resectable caecal cancer. There is no perforation or peritonitis. What is the preferred operative management?

  1. Right hemicolectomy with oncological lymphadenectomy and primary ileocolic anastomosis if bowel viability is satisfactory Correct answer.
  2. Defunctioning loop colostomy only
  3. Endoscopic caecal stent as definitive treatment
  4. Subtotal colectomy with permanent end ileostomy in all cases

Explanation

Obstructing right-sided colon cancer in a fit stable patient is usually treated with oncological right hemicolectomy and primary anastomosis when local conditions are acceptable.

Question 41Visceral surgery: inflammatory, obstructive and biliary disease

A 74-year-old patient has obstructing sigmoid cancer without perforation. CT shows no distant metastases. The patient is stable, and an experienced colorectal endoscopist is available. Which option is most appropriate as a bridge to elective surgery?

  1. Urgent abdominoperineal excision
  2. Chemoradiotherapy before decompression
  3. Self-expanding metal stent placement followed by planned oncological resection Correct answer.
  4. Repeated phosphate enemas until the obstruction resolves

Explanation

In selected stable patients with left-sided malignant obstruction and no perforation, colonic stenting by an experienced team can decompress the bowel and allow staged elective resection.

Question 42Visceral surgery: inflammatory, obstructive and biliary disease

A 63-year-old man undergoes anterior resection for sigmoid adenocarcinoma. The pathology report describes pT3N1 disease with 2 of 18 nodes positive and clear margins. What is the key implication of the nodal status?

  1. It means the operation was non-curative because fewer than 25 nodes were retrieved
  2. It removes the need for postoperative surveillance
  3. It defines stage III disease and should prompt discussion of adjuvant systemic chemotherapy Correct answer.
  4. It is an indication for immediate completion proctocolectomy

Explanation

Any regional nodal metastasis in colon cancer is stage III disease. After curative resection, adjuvant chemotherapy should be considered according to fitness and oncology review.

Question 43Visceral surgery: inflammatory, obstructive and biliary disease

A patient with acute severe ulcerative colitis develops increasing abdominal distension, systemic toxicity and transverse colon dilatation of 7 cm despite maximal medical therapy. Free intraperitoneal air is now seen on erect chest radiograph. What is the correct surgical response?

  1. Urgent subtotal colectomy with end ileostomy and rectal stump management Correct answer.
  2. Segmental transverse colectomy with primary anastomosis
  3. Colonoscopy with decompression and full bowel preparation
  4. Delay surgery until biologic rescue therapy has been given for 7 days

Explanation

Toxic megacolon with perforation is a surgical emergency. Subtotal colectomy with end ileostomy avoids a high-risk pelvic dissection and removes the diseased colon.

Question 44Visceral surgery: inflammatory, obstructive and biliary disease

A 34-year-old patient with Crohn's disease has recurrent post-prandial cramping and partial small bowel obstruction. MRI enterography shows a short fibrotic terminal ileal stricture with minimal active inflammation and no abscess. What is the best management discussion?

  1. High-dose intravenous steroids as definitive treatment for fibrosis
  2. Immediate total proctocolectomy
  3. No treatment because fibrotic strictures do not obstruct
  4. Elective ileocaecal resection or bowel-sparing strictureplasty depending on anatomy and bowel length Correct answer.

Explanation

Fibrotic Crohn strictures respond poorly to anti-inflammatory escalation. Surgery, using limited resection or strictureplasty when appropriate, addresses obstruction while preserving bowel.

Question 45Visceral surgery: inflammatory, obstructive and biliary disease

A patient with known ileocolic Crohn's disease presents with fever and right iliac fossa pain. CT shows active terminal ileitis with a 4 cm intra-abdominal abscess. There is no diffuse peritonitis. What is the best initial approach?

  1. Start anti-TNF therapy immediately before treating sepsis
  2. Antibiotics and image-guided abscess drainage where feasible, followed by reassessment for elective surgery or medical therapy Correct answer.
  3. High-dose steroids alone until the abscess resolves
  4. Immediate ileorectal anastomosis

Explanation

Crohn-related abscess management starts with sepsis control using antibiotics and drainage when possible. Immunosuppression or elective resection is considered after source control.

Question 46Visceral surgery: inflammatory, obstructive and biliary disease

A 39-year-old man presents with severe anal pain, fever and a fluctuant perianal swelling. He has no immunosuppression and no extensive cellulitis. What is the cornerstone of treatment?

  1. Oral antibiotics alone for 10 days
  2. Prompt incision and drainage close to the anal verge Correct answer.
  3. Needle aspiration only to avoid fistula formation
  4. Elective MRI before any drainage

Explanation

Acute anorectal abscess requires prompt drainage. Antibiotics are adjunctive for selected patients with cellulitis, systemic infection, immunosuppression or specific risk factors, but they do not replace drainage.

Question 47Visceral surgery: inflammatory, obstructive and biliary disease

A patient has a recurrent posterior horseshoe anorectal abscess involving the deep postanal space. Continence is normal. Which operative principle is most appropriate?

  1. Wide division of the entire external sphincter to deroof the tract
  2. Close the skin primarily after aspiration
  3. Treat with long-term antibiotics and avoid examination under anaesthesia
  4. Drain the deep postanal space with counter-drainage and use setons where needed to control sepsis while protecting sphincter function Correct answer.

Explanation

Horseshoe abscesses need adequate drainage of the deep postanal space and extensions. Seton-based strategies help control sepsis while avoiding unnecessary sphincter division.

Question 48Visceral surgery: inflammatory, obstructive and biliary disease

A 45-year-old woman has a low intersphincteric fistula after previous perianal abscess drainage. Examination shows a short tract crossing minimal sphincter, and continence is normal. What is the most appropriate definitive treatment?

  1. Lay-open fistulotomy Correct answer.
  2. Abdominoperineal excision
  3. Permanent loose seton as the only possible treatment
  4. Topical glyceryl trinitrate

Explanation

A simple low fistula in a patient with normal continence is usually suitable for fistulotomy. Complex or high fistulas require sphincter-sparing approaches.

Question 49Visceral surgery: inflammatory, obstructive and biliary disease

A patient has a chronic posterior anal fissure with sphincter hypertonia after optimized fibre, stool-softening and topical calcium-channel blocker therapy have failed. Continence is normal. Which operation gives the highest healing rate but requires counselling about continence risk?

  1. Excision of all external haemorrhoids
  2. Seton insertion through the fissure
  3. Lateral internal sphincterotomy Correct answer.
  4. Low anterior resection

Explanation

Lateral internal sphincterotomy is highly effective for chronic fissure with hypertonia after failed medical therapy, but patients must be counselled about flatus or faecal incontinence risk.

Question 50Visceral surgery: inflammatory, obstructive and biliary disease

On the first postoperative day after an emergency Hartmann procedure, a new end colostomy is dusky. Endoscopic inspection through the stoma shows necrosis extending below the fascial level. What is the best management?

  1. Observation because all early stomas look cyanotic
  2. Apply silver nitrate to the mucosa
  3. Urgent operative revision, with laparotomy if needed Correct answer.
  4. Start loperamide and restrict oral fluids

Explanation

Superficial mucosal ischaemia may be observed, but necrosis extending below the fascia risks intra-abdominal contamination and requires urgent revision.