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Emergency general surgery

Major Clinical Specialty Areas · 51 questions · 1 free to try

The acute abdomen from appendicitis to mesenteric ischaemia: adhesive small bowel obstruction, perforated ulcer, gastrointestinal bleeding, acute pancreatitis, obstructing colorectal cancer, volvulus, incarcerated hernia, abscesses, the emergency laparotomy standards and the open abdomen.

Every question in this topic is a single best answer item in the style of the exam, followed by an explanation that gives the reasoning for the correct option, why each distractor is wrong, a key point to carry into the exam and, where one applies, the guideline or trial it rests on. Practice mode lets you work through the topic on its own or mixed with others; exam mode draws it into timed papers.

Sample question from this topic

A 67-year-old woman presents with 24 hours of worsening generalised abdominal pain. She is febrile at 38.4°C, pulse 118 bpm, blood pressure 98/60 mmHg after two litres of crystalloid. Examination shows generalised peritonitis. CT demonstrates perforated sigmoid diverticulitis with free gas, free fluid throughout the abdomen, and locules of gas within the fluid; the radiologist reports findings consistent with faeculent peritonitis. She has type 2 diabetes and takes ramipril. After resuscitation and intravenous antibiotics, what is the most appropriate management?

  1. ALaparoscopic peritoneal lavage and drain placement
  2. BSigmoid resection with primary anastomosis and covering loop ileostomy
  3. CPercutaneous drainage of the pelvic collection
  4. DContinue intravenous antibiotics and reassess in 12 hours
  5. ESigmoid resection with end colostomy (Hartmann's procedure)
Show answer and explanation

Correct answer: E

Faeculent peritonitis from perforated diverticulitis (Hinchey IV) in a haemodynamically compromised, comorbid patient is treated with resection of the diseased segment and an end colostomy — Hartmann's procedure. Source control means removing the perforated sigmoid; an anastomosis in gross faecal contamination with hypotension and diabetes carries an unacceptable leak risk.

Why the others are wrong: A — laparoscopic lavage was investigated for purulent (Hinchey III) peritonitis with mixed results, and it has no role in faeculent contamination where the perforation is ongoing. B — primary anastomosis with a covering stoma is a reasonable option in selected stable patients with limited contamination, but not in shock with faeculent soiling. C — percutaneous drainage treats a localised abscess (Hinchey I–II), not generalised peritonitis. D — delaying source control in abdominal sepsis increases mortality hour by hour.

Key point: match the operation to the Hinchey grade and the patient — abscesses are drained, purulent peritonitis is resected (lavage now largely abandoned), and faeculent peritonitis or physiological compromise means Hartmann's.

Guidelines: WSES 2020 acute diverticulitis guidelines and ACPGBI diverticular disease guidance: resection for generalised purulent or faeculent peritonitis, procedure by physiology.

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