Appendix, Small Intestine and Intestinal Obstruction MCQs

Surgery · 94 free questions with answers & explanations.

1. A 25-year-old woman presents with central abdominal pain that migrated to the right iliac fossa over 12 hours, fever (38.2°C), and nausea. Examination shows point tenderness at McBurney's point, positive Rovsing's sign, and guarding. WBC is 15,000/mm3. The Alvarado score is 8. What is the next best step?
2. A 70-year-old man with previous abdominal surgery presents with central colicky pain, abdominal distension, absolute constipation, and bile-stained vomiting for 24 hours. Abdominal X-ray shows dilated small bowel loops with a ladder pattern and no gas in the colon. What is the most likely cause of the obstruction?
3. A 55-year-old woman undergoes laparoscopic appendicectomy for presumed acute appendicitis. Histology reveals a well-differentiated appendiceal neuroendocrine tumor (NET) of 2.5 cm at the tip of the appendix with no local invasion or metastasis. What is the recommended management?
4. A 70-year-old man presents with complete small bowel obstruction following previous sigmoid colectomy 10 years ago. CT abdomen shows a transition point in the mid-ileum with closed-loop obstruction. Despite 24 hours of nasogastric decompression, he has not improved and develops peritonism. The most appropriate management is:
5. A 70-year-old woman presents with abdominal pain, absolute constipation, and a massively distended abdomen. Plain X-ray shows a 'coffee bean' sign with the apex pointing to the right upper quadrant. CT confirms the diagnosis. The most appropriate initial management is:
6. Regarding acute appendicitis in a pregnant woman at 24 weeks gestation, which statement about the clinical features and management is most accurate?
7. A 55-year-old woman presents with right iliac fossa pain for 3 days. CT abdomen shows a perforated appendix with a well-defined right iliac fossa abscess measuring 4.5 cm. She is hemodynamically stable and afebrile on antibiotics. The most appropriate management per current WSES 2020 appendicitis guidelines for this presentation is:
8. A 72-year-old man with no previous abdominal surgery presents with acute small bowel obstruction. CT abdomen confirms a closed-loop obstruction of the distal ileum with a transition point at the right iliac fossa. The bowel wall shows pneumatosis intestinalis and portal venous gas. The most appropriate next step is:
9. A 70-year-old woman with known osteoarthritis on NSAIDs presents with acute severe abdominal pain and vomiting. CT abdomen reveals a 'whirl sign' and 'beak sign' of small bowel mesentery. What diagnosis and management does this indicate?
10. The Alvarado score is used in assessment of suspected appendicitis. A patient scores 7 points. What is the recommended management?
11. A 75-year-old woman on long-term NSAIDs presents with colicky abdominal pain and bilious vomiting. AXR shows dilated small bowel loops with a ground glass opacity in the right iliac fossa. CT scan confirms Bouveret syndrome. Which of the following best describes this condition?
12. A 45-year-old man undergoes surgery for small bowel obstruction from adhesions. Intraoperatively, a 40 cm segment of ischaemic bowel is found with questionable viability. After resection of clearly necrotic bowel, the surgeon is uncertain about the viability of a remaining 30 cm segment. What is the correct damage control decision?
13. The CODA trial (2020) compared antibiotics versus appendectomy for uncomplicated acute appendicitis. Which of the following most accurately summarizes the 1-year outcomes?
14. A 75-year-old man presents with abdominal distension, absolute constipation, and a 'bent inner tube' or 'omega loop' sign on plain X-ray. The diagnosis and most appropriate initial management is:
15. The APPAC trial (Finland) randomized adults with uncomplicated acute appendicitis (CT-confirmed) to appendicectomy versus antibiotic therapy (IV ertapenem then oral levofloxacin/metronidazole for 7 days). What was the primary outcome at 5-year follow-up?
16. A patient with small bowel obstruction (SBO) from adhesions has been managed non-operatively for 72 hours. Water-soluble contrast (gastrografin) challenge shows contrast reaching the colon at 8 hours. What does this finding imply, and what is the next step?
17. A 35-year-old woman presents with 3-day history of RIF pain, nausea, and low-grade fever. CT shows a periappendiceal phlegmon with a 4 cm abscess. WBC 14,000/μL, CRP 180 mg/L. She is haemodynamically stable. According to CODA trial data and current guidelines, which is the most appropriate initial management?
18. A 70-year-old woman presents with absolute constipation for 3 days, massively distended abdomen, and minimal pain. Plain X-ray shows a 'coffee bean' or 'omega loop' sign arising from the left iliac fossa pointing to the right upper quadrant. CT confirms sigmoid volvulus without peritonitis. What is the first-line non-surgical management and when is emergency surgery indicated?
19. A 45-year-old woman undergoes appendicectomy for appendicitis. Histology reveals a 1.8 cm well-differentiated neuroendocrine tumor (NET) at the tip of the appendix with no lymphovascular invasion and clear margins. According to ENETS 2016 guidelines, the next management step is:
20. A 70-year-old patient develops adhesive small bowel obstruction (ASBO) with CT showing a transition point and no free air, no bowel wall thickening, and no mesenteric edema. He has mild abdominal pain and is passage-free for 24 hours. According to WSACS and EAST 2012 guidelines, the INITIAL management should be:
21. A 65-year-old woman presents with colicky central abdominal pain, vomiting, and absolute constipation for 24 hours. She has no prior abdominal surgery but has known right-sided colon cancer diagnosed 3 months ago (not yet treated). AXR shows dilated small bowel loops. CT scan confirms a closed-loop obstruction of the small bowel with venous engorgement. The mechanism distinguishing closed-loop obstruction from simple mechanical obstruction is:
22. A 78-year-old woman presents with acute massive colonic distension without mechanical obstruction on CT. The caecal diameter is 14 cm. The diagnosis is Ogilvie's syndrome (acute colonic pseudo-obstruction). After 48 hours of conservative management (NG tube, rectal tube, correcting electrolytes), she does not improve. The current evidence-based pharmacological treatment is:
23. The Alvarado (MANTRELS) score is used to predict acute appendicitis. A patient scores 7 out of 10. According to the scoring system, this score suggests:
24. In adhesion-related small bowel obstruction (SBO), which clinical/radiological sign mandates immediate surgical intervention rather than trial of non-operative management?
25. A 35-year-old woman presents with suspected acute appendicitis (Alvarado score 7). Ultrasound is non-diagnostic. CT scan confirms a 10 mm appendix with periappendiceal fat stranding, no free fluid, and no perforation. She declines surgery. Per APPAC and CODA trial evidence, which approach is most supported?
26. A 55-year-old man with prior extensive pelvic surgery develops small bowel obstruction. CT shows dilated small bowel loops with a 'bird's beak' transition point at the terminal ileum level. No free air or free fluid is present. After 48 hours of conservative management (NG decompression, IV fluids), he develops increasing abdominal pain and leukocytosis. What is the CT feature that most reliably predicts strangulation and mandates urgent surgery?
27. A 35-year-old female presents with right lower quadrant pain for 36 hours. CT abdomen shows a 12 mm appendix with periappendiceal fat stranding, a small periappendiceal abscess (3 cm), and no free perforation. Her Alvarado score is 7. Which management strategy has been validated by the APPAC trial?
28. A patient with Crohn's disease has multiple skip lesions in the terminal ileum, with stricturing disease and a penetrating fistula between two adjacent loops of small bowel (enteroenteric fistula). She has had two prior small bowel resections (total resected = 180 cm). What is the most important surgical consideration?
29. A 75-year-old patient with sigmoid volvulus on plain AXR (coffee bean/bent inner tube sign with apex pointing to right upper quadrant) is hemodynamically stable and has no peritonitis. What is the first-line treatment?
30. A 22-year-old woman presents with 36 hours of right iliac fossa pain with a palpable mass in the RIF on CT (appendix not visualised; heterogeneous inflammatory fat stranding with a central 3 cm fluid collection adjacent to the caecum). Her temperature is 37.8°C and WCC 14,000/μL. She is haemodynamically stable. According to the 'APPAC' trial evidence and WSES guidelines, the most appropriate initial management is:
31. A 65-year-old woman with known radiation history for cervical carcinoma treated 18 years ago presents with symptoms of recurrent small bowel obstruction. CT shows a long segment of thickened small bowel with a transition zone, mesenteric fibrosis, and a 'mesenteric fan sign'. No hernias are present. The mechanism of small bowel obstruction in this patient is best described as:
32. The Alvarado score for acute appendicitis includes which set of clinical and laboratory parameters?
33. In adhesive small bowel obstruction (SBO) with no signs of strangulation, which clinical/radiological finding is the strongest indication for urgent surgical intervention?
34. Meckel's diverticulum: using the 'rule of twos,' which statement is correct regarding its clinical presentation?
35. The APPAC trial compared antibiotic therapy (ertapenem 3 days then oral levofloxacin + metronidazole for 7 days) versus appendicectomy for uncomplicated acute appendicitis. What was the key 5-year outcome finding?
36. In closed loop bowel obstruction, which pathophysiological feature distinguishes it from simple obstruction and makes it a surgical emergency?
37. The CODA trial (2020) compared antibiotics vs appendectomy for uncomplicated acute appendicitis in adults. Which statement most accurately reflects its findings at 90 days?
38. In a patient with small bowel obstruction (SBO) secondary to adhesions and no evidence of strangulation or perforation, which clinical or radiological feature mandates early operative intervention rather than continued non-operative management?
39. A 70-year-old man with a history of previous sigmoid colectomy presents with abdominal distension, absolute constipation, and colicky pain. Plain AXR shows a coffee bean sign arising from the pelvis pointing to the right upper quadrant. CT confirms sigmoid volvulus. He has no signs of peritonitis. Immediate management is:
40. A 45-year-old woman 5 days after an open hysterectomy develops abdominal pain, distension, and vomiting. CT shows dilated small bowel loops up to 4 cm with a transition point in the right iliac fossa and collapsed distal bowel — consistent with early adhesive small bowel obstruction. She has no signs of strangulation. The most appropriate initial management is:
41. A 55-year-old patient with known Crohn's disease presents with a high-output fistula (1200 mL/day) from the terminal ileum to skin after a previous ileocaecal resection. Nutritional assessment shows serum albumin of 2.4 g/dL. The surgical acronym SNAP describes the stepwise approach to complex fistula management. 'N' in SNAP stands for:
42. The Alvarado score is used to risk-stratify patients with suspected acute appendicitis. A 22-year-old man scores 7 (migration of pain to RIF, nausea/vomiting, RIF tenderness, leukocytosis, and elevated CRP). According to the Alvarado score management pathway, what is the recommended action?
43. A 65-year-old woman presents with colicky central abdominal pain, distension, and absolute constipation for 48 hours. She had a previous appendicectomy 20 years ago. CT shows dilated small bowel loops with a transition point in the right iliac fossa and no free gas. She is haemodynamically stable. Initial management should include:
44. The Alvarado score for acute appendicitis assigns points for several clinical features. A patient has: migratory right iliac fossa pain (+1), anorexia (+1), nausea/vomiting (+1), RIF tenderness (+2), rebound tenderness (+1), elevated temperature 38.2°C (+1), leucocytosis 14 × 10⁹/L (+2), shift to left (+1) — total = 10. At this score, the recommended management is:
45. The APPAC trial (Finland) assessed non-operative management with antibiotics versus appendicectomy for CT-confirmed uncomplicated acute appendicitis in adults. At 5-year follow-up, the recurrence (subsequent appendicectomy) rate in the antibiotics group was approximately:
46. A 65-year-old man presents with central abdominal colic, vomiting, abdominal distension, and absolute constipation (no flatus) for 48 hours. Abdominal X-ray shows multiple air-fluid levels and distended loops of small bowel with a 'valvulae conniventes' pattern. CT abdomen shows a closed-loop obstruction. What complication is most feared in closed-loop obstruction?
47. A 72-year-old man with long-standing constipation presents with massive colonic distension seen on abdominal X-ray showing a 'coffee-bean sign.' CT confirms sigmoid volvulus. He is hemodynamically stable. What is the initial management?
48. A 40-year-old woman who had an appendectomy 10 years ago presents with features of small bowel obstruction. CT abdomen confirms adhesive small bowel obstruction (ASBO) without signs of strangulation. What is the preferred initial management according to current EAST/Bologna guidelines?
49. A 55-year-old man undergoes appendectomy for what appears to be acute appendicitis. Histopathology reveals a well-differentiated neuroendocrine tumor (carcinoid) of the appendix measuring 1.8 cm at the tip. What is the appropriate management?
50. The Alvarado score is used in the clinical assessment of suspected appendicitis. A patient with temperature 37.8°C, WBC 14,000/mm³, rebound tenderness, guarding, migration of pain to RIF, anorexia, and nausea scores how many points?
51. The NOTA study demonstrated that non-operative management (antibiotics alone) for uncomplicated acute appendicitis (no perforation, no abscess on CT) achieves successful short-term resolution in approximately what percentage of patients?
52. The most common cause of small bowel obstruction in adults in developed countries is:
53. A 25-year-old woman with an Alvarado score of 7 has an equivocal CT abdomen showing mild pericecal fat stranding without a visible appendix. What is the most appropriate next step?
54. A 70-year-old man presents with acute large bowel obstruction. CT abdomen shows a sigmoid colon carcinoma causing 95% luminal narrowing, no peritonitis, no perforation. The preferred treatment approach in a non-specialized center is:
55. A 50-year-old woman with a previous midline laparotomy presents with colicky abdominal pain, absolute constipation for 18 hours, and bilious vomiting. CT shows small bowel loops dilated to 4.5 cm with a transition point in the mid-ileum. She has no peritonism. After nasogastric tube insertion, her pain and vomiting improve. What is the most appropriate management?
56. The Alvarado score (MANTRELS) is used in the diagnostic workup of suspected appendicitis. A score of 7 out of 10 in a 25-year-old man would be interpreted as:
57. In adhesional small bowel obstruction, the Gastrografin challenge (water-soluble contrast study) has therapeutic as well as diagnostic value. Its therapeutic mechanism is attributed to:
58. Carcinoid tumour of the appendix is most commonly located at the tip of the appendix and is the most common primary appendiceal tumour. Simple appendicectomy is curative for carcinoid tumours less than which diameter?
59. The Alvarado scoring system (MANTRELS) is used to predict acute appendicitis. A score of 7–10 indicates:
60. A 70-year-old woman presents with central colicky abdominal pain, vomiting, and abdominal distension. She has had no previous surgery. AXR shows multiple distended small bowel loops with a 'coffee bean' sign pointing to the right iliac fossa. The MOST likely diagnosis is:
61. A 65-year-old man with known cirrhosis presents with abdominal pain and distension. CT shows a closed-loop small bowel obstruction with 'whirl sign' of mesenteric vessels. Which feature on CT most strongly indicates bowel ischaemia/strangulation requiring urgent surgery?
62. The Alvarado score is used to predict the likelihood of acute appendicitis. A patient has: migratory right iliac fossa pain, anorexia, nausea/vomiting, RIF tenderness, rebound tenderness, elevated temperature (38.2°C), leukocytosis (14,000), and left shift (band forms). What is the Alvarado score?
63. A 65-year-old female presents with colicky abdominal pain, vomiting, and abdominal distention for 2 days. X-ray shows dilated small bowel loops with air-fluid levels. Oral contrast CT shows a beaked point in the small bowel transition zone. Past history includes two prior lower abdominal surgeries. What is the most likely cause of small bowel obstruction?
64. In an obstructed colonic carcinoma at the sigmoid colon with proximal bowel dilation, the Hartmann procedure is performed as an emergency. Six months later, the patient is fit for re-anastomosis. What is the term for the reverse Hartmann procedure?
65. A 55-year-old man with previous right hemicolectomy presents with 24-hour history of colicky central abdominal pain, vomiting, abdominal distension, and absolute constipation. Plain radiograph shows multiple dilated small bowel loops with a 'stack of coins' appearance. CT abdomen confirms mechanical small bowel obstruction. What is the MOST common cause in this setting?
66. The Alvarado score (MANTRELS) is used to predict the probability of acute appendicitis. A score of 7-8 indicates:
67. A 30-year-old woman presents with right iliac fossa pain and tenderness. Alvarado score is 7. Ultrasound is non-diagnostic. CT scan shows a periappendiceal phlegmon with no free perforation. She is haemodynamically stable. Current evidence-based first-line management is:
68. A 70-year-old man presents with absolute constipation, distension, and obstipation for 3 days. Abdominal X-ray shows a massively dilated loop of sigmoid colon with a 'coffee bean sign.' He is haemodynamically stable. The first-line treatment is:
69. A carcinoid tumour of the appendix is found incidentally in a 35-year-old woman undergoing appendicectomy for acute appendicitis. Histology shows a 1.2 cm well-differentiated NET at the tip with clear margins and no invasion of mesoappendix. What is the recommended management?
70. A 45-year-old woman presents with right iliac fossa pain. The Alvarado score is calculated: migratory pain (1), anorexia (1), nausea/vomiting (1), RIF tenderness (2), rebound tenderness (1), elevated temperature (1), leukocytosis (2) = 9/10. Management should be:
71. A 70-year-old man presents with absolute constipation, abdominal distension, and X-ray showing a grossly dilated sigmoid loop with a 'coffee bean' or 'omega loop' sign pointing to the right upper quadrant. There is no peritonitis. Initial management should be:
72. A patient 3 days post appendicectomy for gangrenous appendicitis develops a fever of 38.9°C, right lower quadrant pain, and a tender mass in the RIF. CT scan shows a 5 cm pericaecal collection with no free perforation. The preferred management is:
73. A 30-year-old woman with Crohn's disease involving the terminal ileum has developed two symptomatic strictures, each < 4 cm long, 20 cm apart. She is otherwise well. The preferred surgical approach to preserve maximal intestinal length is:
74. A 55-year-old woman is found to have a 2.5 cm carcinoid tumour (neuroendocrine tumour) at the tip of the appendix incidentally during laparoscopic cholecystectomy. The appendix is removed. What is the most appropriate next step?
75. A 70-year-old woman with no prior abdominal surgery presents with progressive large bowel obstruction. CT shows a sigmoid colon mass causing complete obstruction with dilation of the right colon. She is haemodynamically stable. What is the most appropriate acute management strategy that also allows future cancer surgery?
76. A 45-year-old man with known Crohn's disease presents with recurrent small bowel obstruction. CT shows a 15 cm stricture in the terminal ileum with prestenotic dilation. He has had two prior ileocaecal resections and his remaining small bowel is estimated at 180 cm. What is the preferred management to preserve bowel length?
77. The Alvarado score (MANTRELS) is used to stratify probability of acute appendicitis. A score of 7 corresponds to which clinical decision?
78. In adhesive small bowel obstruction (SBO), the Gastrografin challenge involves oral or nasogastric administration of water-soluble contrast. Appearance of contrast in the colon within 24 hours predicts:
79. Intussusception in a 7-month-old child presents with intermittent colic, redcurrant jelly stools, and a palpable right iliac fossa mass. The first-line non-operative reduction method of choice is:
80. The Alvarado score for acute appendicitis uses eight criteria. A patient scores 7 points. Which management is most appropriate based on the score?
81. The Ogilvie syndrome (colonic pseudo-obstruction) is best distinguished from mechanical large bowel obstruction by which finding?
82. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the GIT. The majority harbor activating mutations in which gene?
83. Carcinoid syndrome occurs in neuroendocrine tumors when serotonin and vasoactive peptides reach the systemic circulation. In which clinical scenario does carcinoid syndrome most commonly occur?
84. The APPAC trial compared antibiotic treatment (ertapenem IV then levofloxacin + metronidazole orally for 7 days) versus appendicectomy for uncomplicated acute appendicitis. At 5 years, the recurrence rate in the antibiotic group was approximately:
85. Which scoring system uses CT morphology, CRP, and clinical parameters to differentiate complicated (perforation/abscess) from uncomplicated acute appendicitis pre-operatively?
86. A 65-year-old woman presents with a 3-day history of colicky central abdominal pain, vomiting, and absolute constipation. CT shows dilated small bowel loops with a 'beak sign' in the right iliac fossa and a calcified density. The most likely diagnosis is:
87. The Alvarado score is widely used for risk stratification in suspected appendicitis. A score of 7–10 indicates which probability of acute appendicitis and management?
88. In the management of adhesive small bowel obstruction (ASBO), the EAST Practice Management Guidelines recommend a water-soluble contrast (gastrografin) challenge. Which outcome defines 'success' and what is the therapeutic benefit of gastrografin beyond diagnosis?
89. A 70-year-old woman presents with colicky central abdominal pain, distension, and absolute constipation for 3 days. AXR shows massively dilated sigmoid colon, and on CT the 'coffee bean' sign is present. No peritonism is found. What is the FIRST-LINE treatment?
90. A 50-year-old man has a small bowel obstruction secondary to adhesions. Conservative management is initiated. Which of the following clinical findings would indicate the need for URGENT surgical intervention?
91. A 55-year-old man presents with right iliac fossa pain for 5 days. CT shows a peri-appendicular abscess of 4 cm. He is afebrile after 48 hours of IV antibiotics. What is the MOST appropriate management of the appendiceal abscess at this time?
92. A 45-year-old woman with Crohn's disease of the terminal ileum is found to have a 3 cm stricture causing recurrent subacute obstruction. Medical therapy has been optimised. Which minimally invasive surgical option is MOST appropriate?
93. Small bowel obstruction (SBO) due to adhesions is managed initially non-operatively in 75–80% of cases. A water-soluble contrast follow-through (Gastrografin challenge) is used diagnostically and therapeutically. The therapeutic benefit (shortening hospital stay) was demonstrated in which RCT?
94. A 72-year-old man with sigmoid diverticular disease presents with left iliac fossa pain and CT showing a 5 cm pericolic abscess without free perforation (Hinchey Stage II). The MOST appropriate initial management is: