During laparoscopy for suspected appendicitis in a 15-year-old boy, the appendix looks normal. There is some free fluid in the right iliac fossa but no gynaecological organs to inspect. Where should the surgeon look next for a Meckel diverticulum?

Antimesenteric border of the ileum, about 60 cm from the ileocaecal valve

Mesenteric border of the jejunum, near the duodenojejunal flexure

Mesenteric border of the terminal ileum, just above the valve

Antimesenteric border of the caecum, beside the appendix base

A 75-year-old man with sigmoid volvulus undergoes flexible sigmoidoscopy for decompression. At the point of twist, the mucosa is black and does not bleed on touch; he becomes tachycardic with lower abdominal tenderness. What is the most appropriate management?

Emergency laparotomy, sigmoid resection and end colostomy

Laparotomy with detorsion and sigmoidopexy

Pass a flatus tube and observe for 24 hours

Repeat endoscopic detorsion after resuscitation

A 26-year-old man presents to a district hospital with right iliac fossa pain for 5 days. He is febrile but stable, and a tender, firm 6 cm mass is felt in the right iliac fossa. CT shows an inflammatory phlegmon around the appendix with no drainable collection. What is the most appropriate management?

IV antibiotics and close observation

Percutaneous drainage of the mass

Oral antibiotics and discharge home

Appendicitis, intestinal obstruction and perforation

46 NEET-PG practice questions on Appendicitis, intestinal obstruction and perforation, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 22-year-old man comes to the surgical OPD with pain that began around the umbilicus a day ago and has shifted to the right iliac fossa, with loss of appetite but no nausea or vomiting. Temperature is 38.1 °C. There is right iliac fossa tenderness without rebound. WBC is 12,600/µL with 84% neutrophils. What is his Alvarado score?
1. A6 of 10
2. B7 of 10
3. C9 of 10
4. D8 of 10
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Answer: D · 8 of 10
Alvarado (MANTRELS) scores Migration of pain 1, Anorexia 1, Nausea or vomiting 1, Tenderness in the right iliac fossa 2, Rebound 1, Elevated temperature (37.3 °C or more) 1, Leucocytosis (over 10,000/µL) 2 and Shift to the left (neutrophils over 75%) 1. He scores 1 + 1 + 0 + 2 + 0 + 1 + 2 + 1 = 8. A score of 7-8 means appendicitis is probable and 9-10 very probable, so he should be admitted for appendicectomy. Scores of 5-6 are equivocal and suit observation or imaging (ultrasound, or CT in adults).
- A: 6 comes from scoring both tenderness and leucocytosis as 1.
- B: 7 comes from scoring tenderness or leucocytosis as 1 instead of 2.
- C: 9 counts nausea or rebound, both absent here.
Question 2 · Medium
During laparoscopy for suspected appendicitis in a 15-year-old boy, the appendix looks normal. There is some free fluid in the right iliac fossa but no gynaecological organs to inspect. Where should the surgeon look next for a Meckel diverticulum?
1. AMesenteric border of the jejunum, near the duodenojejunal flexure
2. BMesenteric border of the terminal ileum, just above the valve
3. CAntimesenteric border of the caecum, beside the appendix base
4. DAntimesenteric border of the ileum, about 60 cm from the ileocaecal valve
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Answer: D · Antimesenteric border of the ileum, about 60 cm from the ileocaecal valve
When the appendix is normal at operation, the terminal ileum is examined for Meckel diverticulitis, along with the mesentery for nodes. A Meckel diverticulum is a remnant of the vitellointestinal duct, usually found on the antimesenteric border of the ileum about 60 cm (2 feet) from the ileocaecal valve, in about 2% of people. It may contain gastric or pancreatic tissue and can bleed, perforate or cause obstruction. An inflamed diverticulum is excised.
- A: The vitellointestinal duct remnant lies on the ileum, not near the duodenojejunal flexure.
- B: It arises from the antimesenteric, not the mesenteric, border.
- C: It is not on the caecum.
Question 3 · Hard
A 75-year-old man with sigmoid volvulus undergoes flexible sigmoidoscopy for decompression. At the point of twist, the mucosa is black and does not bleed on touch; he becomes tachycardic with lower abdominal tenderness. What is the most appropriate management?
1. ALaparotomy with detorsion and sigmoidopexy
2. BEmergency laparotomy, sigmoid resection and end colostomy
3. CPass a flatus tube and observe for 24 hours
4. DRepeat endoscopic detorsion after resuscitation
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Answer: B · Emergency laparotomy, sigmoid resection and end colostomy
Black, non-bleeding mucosa means gangrene of the sigmoid loop, and tenderness and tachycardia indicate peritonitis. Endoscopic decompression must stop, and he needs emergency laparotomy with resection of the gangrenous loop without untwisting it first (to avoid releasing toxins and bacteria into the circulation). In a sick patient with gangrene, the safest option is a Hartmann procedure (end colostomy and closed rectal stump), with reversal later.
- A: Fixing a gangrenous loop leaves dead bowel behind.
- C: A flatus tube does not treat gangrenous bowel.
- D: Repeated endoscopy in gangrene risks perforation and delay.
Question 4 · Medium
An 11-month-old girl has ileocolic intussusception on ultrasound. Consider these findings: 1. Generalised peritonitis on examination. 2. Redcurrant jelly stool. 3. Free intraperitoneal air on X-ray. 4. Symptoms for 18 hours. Which findings are contraindications to enema reduction?
1. A1 and 3 only
2. B1, 3 and 4 only
3. C2 and 3 only
4. D3 and 4 only
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Answer: A · 1 and 3 only
Findings 1 and 3 are contraindications. Air or hydrostatic enema reduction under ultrasound or fluoroscopic guidance is first-line for a stable child with intussusception. Peritonitis suggests gangrenous bowel and free air means perforation, so both need laparotomy; shock that does not respond to resuscitation is also a contraindication. Blood in the stool is a typical feature and does not prevent reduction, and symptoms for less than a day do not either, though longer histories lower the success rate.
- B: Includes an 18-hour history, which does not by itself prevent reduction.
- C: Includes redcurrant jelly stool, a typical feature, and leaves out peritonitis.
- D: Includes the 18-hour history and leaves out peritonitis.
Question 5 · Medium
A 26-year-old man presents to a district hospital with right iliac fossa pain for 5 days. He is febrile but stable, and a tender, firm 6 cm mass is felt in the right iliac fossa. CT shows an inflammatory phlegmon around the appendix with no drainable collection. What is the most appropriate management?
1. AIV antibiotics and close observation
2. BPercutaneous drainage of the mass
3. COral antibiotics and discharge home
4. DEmergency open appendicectomy
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Answer: A · IV antibiotics and close observation
A tender mass after several days of appendicitis is an appendicular mass (phlegmon), where omentum and bowel have walled off the inflamed appendix. Operating now is difficult and risks injury to the inflamed caecum and bowel, so conservative treatment (Ochsner-Sherren regimen: rest, IV fluids, IV antibiotics, chart of pulse, temperature and mass size) is preferred. Most settle; worsening pain, a growing mass or rising pulse means an abscess or spreading peritonitis needing intervention.
- B: There is no collection to drain in a phlegmon.
- C: A febrile patient with a mass needs inpatient IV treatment and monitoring.
- D: Early surgery in a phlegmon is hazardous and may end in a right hemicolectomy.
Question 6 · Medium
A 62-year-old man admitted with small bowel obstruction is reviewed on the evening round. Consider these findings: 1. His colicky pain has become constant. 2. Temperature 38.2 °C and pulse 118/min. 3. Localised tenderness with guarding over a loop of bowel. 4. Visible peristalsis with high-pitched, tinkling bowel sounds. Which findings point to strangulation?
1. A1 and 3 only
2. B1, 2 and 3 only
3. C2, 3 and 4 only
4. D1, 3 and 4 only
Answer and explanation in LearnFree account
Question 7 · Medium
A 74-year-old man with atrial fibrillation who stopped his anticoagulant a month ago has sudden severe periumbilical pain. He is restless and in agony, yet the abdomen is soft with only mild tenderness. Lactate is 4.8 mmol/L. Which investigation is most appropriate?
1. AUpper GI endoscopy
2. BErect chest X-ray
3. CCT angiography of the abdomen
4. DUltrasound of the abdomen
Answer and explanation in LearnFree account
Question 8 · Easy
Parents in a small town in Assam bring their 9-month-old son to the paediatric surgery OPD. Since morning he has had sudden episodes of inconsolable crying with pallor and drawing up of the knees, then lies quiet; he has vomited twice and passed a jelly-like red stool. A sausage-shaped lump is palpable under the right costal margin. What is the investigation of choice?
1. APlain X-ray of the abdomen
2. BBarium meal follow-through
3. CContrast CT of the abdomen
4. DUltrasound of the abdomen
Answer and explanation in LearnFree account
Question 9 · Easy
A 26-year-old woman at 24 weeks of gestation is seen in the labour room with 20 hours of right-sided abdominal pain, anorexia and a temperature of 37.9 °C. Graded-compression ultrasound does not show the appendix. What is the preferred next imaging investigation?
1. AContrast-enhanced CT abdomen
2. BMRI abdomen without gadolinium
3. CPlain X-ray of the abdomen
4. DDiagnostic laparoscopy straightaway
Answer and explanation in LearnFree account
Question 10 · Medium
A 52-year-old man has had three episodes of colicky right-sided abdominal pain with vomiting over 2 months, and has lost 5 kg. CT shows a target-shaped mass at the ileocaecal region with telescoped bowel. What most likely underlies this condition?
1. AAn inflamed Meckel diverticulum
2. BHypertrophied Peyer patches
3. CA tumour acting as a lead point
4. DIdiopathic, with no cause found
Answer and explanation in LearnFree account
Question 11 · Medium
On day 5 after an open right hemicolectomy, a 64-year-old man still has abdominal distension, no flatus and absent bowel sounds. He is afebrile, the abdomen is not tender, and X-ray shows uniformly distended small and large bowel with gas throughout. Serum potassium is 2.9 mmol/L. What is the next best step?
1. AStart oral feeds to stimulate the bowel
2. BNeostigmine to restart peristalsis
3. CCorrect the potassium and continue supportive care
4. DRelaparotomy for anastomotic leak
Answer and explanation in LearnFree account
Question 12 · Hard
A 62-year-old man was treated conservatively for an appendicular mass at a district hospital; the mass resolved over 3 weeks. He had mild anaemia (Hb 10.4 g/dL) and recalls a change in bowel habit for some months before the illness. He comes for follow-up 6 weeks later. What is the most appropriate next step?
1. AInterval appendicectomy without further tests
2. BUltrasound abdomen only
3. CDischarge with reassurance
4. DColonoscopy
Answer and explanation in LearnFree account
Question 13 · Easy
A 70-year-old man from rural Bihar with long-standing constipation has had gross abdominal distension and absolute constipation for 2 days, with little pain. Plain X-ray shows a hugely dilated loop of bowel shaped like a bent inner tube, rising from the pelvis towards the right upper quadrant. What is the most likely diagnosis?
1. AToxic megacolon
2. BSigmoid volvulus
3. CCaecal volvulus
4. DSmall bowel volvulus
Answer and explanation in LearnFree account
Question 14 · Easy
A 48-year-old woman who had an abdominal hysterectomy 6 years ago is admitted with colicky central abdominal pain, bilious vomiting and distension for 1 day. She has no groin swelling, and X-ray shows dilated small bowel loops with fluid levels. What is the most likely cause of the obstruction?
1. AObstructed inguinal hernia
2. BSmall bowel tumour
3. CPostoperative adhesions
4. DGallstone ileus
Answer and explanation in LearnFree account
Question 15 · Easy
A 19-year-old man has had right-sided abdominal pain for a day. Tenderness in the right iliac fossa is mild, but he lies with the right hip slightly flexed, and passive extension of the right hip while he lies on his left side worsens the pain. Where is the inflamed appendix most likely to lie?
1. ARetrocaecal
2. BPelvic
3. CPre-ileal
4. DSubhepatic
Answer and explanation in LearnFree account
Question 16 · Medium
A 40-year-old man has colicky central pain and vomiting. Supine abdominal X-ray shows several centrally placed dilated loops whose mucosal folds cross the full width of the bowel, giving a stacked-coin appearance; there is no gas in the colon. Which part of the bowel is dilated?
1. AJejunum
2. BTransverse colon
3. CTerminal ileum
4. DSigmoid colon
Answer and explanation in LearnFree account
Question 17 · Easy
A 45-year-old labourer who takes painkillers for back pain is brought to casualty with sudden severe epigastric pain that spread over the whole abdomen within an hour. The abdomen is rigid and board-like, and liver dullness is reduced. What is the first investigation to order?
1. ASerum amylase
2. BUltrasound abdomen
3. CErect chest X-ray
4. DUpper GI endoscopy
Answer and explanation in LearnFree account
Question 18 · Medium
A 30-year-old man had a laparoscopic appendicectomy for acute appendicitis. Histopathology shows a 0.8 cm well-differentiated neuroendocrine tumour at the tip, completely excised, with no lymphovascular invasion and clear margins. What further treatment is needed?
1. AAdjuvant chemotherapy
2. BRight hemicolectomy
3. CNo further surgery; reassure and follow up
4. DLong-acting octreotide therapy
Answer and explanation in LearnFree account
Question 19 · Medium
A 17-year-old boy from a village in Uttar Pradesh has had high fever for 16 days, treated irregularly. He now has sudden severe abdominal pain, distension and guarding, and X-ray shows free gas under the diaphragm. Blood culture earlier grew Salmonella Typhi. Where is the perforation most likely to be?
1. AMesenteric border of the jejunum
2. BSigmoid colon
3. CFirst part of the duodenum
4. DAntimesenteric border of the terminal ileum
Answer and explanation in LearnFree account
Question 20 · Medium
A 58-year-old woman with no previous surgery presents with small bowel obstruction. Hernial orifices are normal and she is stable. Which investigation best shows the site and cause of the obstruction and any signs of strangulation?
1. AErect and supine abdominal X-rays
2. BUltrasound of the abdomen
3. CContrast-enhanced CT of the abdomen
4. DBarium follow-through study
Answer and explanation in LearnFree account
Question 21 · Medium
A 24-year-old software engineer with CT-confirmed acute appendicitis asks to avoid surgery. CT shows an inflamed 9 mm appendix without perforation or abscess. Consider these counselling points: 1. An appendicolith on CT raises the chance that antibiotics will fail. 2. Some patients treated with antibiotics later need appendicectomy for recurrence. 3. Antibiotic treatment suits perforated appendicitis with generalised peritonitis equally well. 4. Imaging should confirm uncomplicated appendicitis before choosing this option. Which points are correct?
1. A1, 2 and 4 only
2. B1 and 4 only
3. C1, 3 and 4 only
4. D2, 3 and 4 only
Answer and explanation in LearnFree account
Question 22 · Medium
An 80-year-old woman with diabetes and heart failure has gallstone ileus confirmed on CT, with a 3 cm stone impacted in the terminal ileum and a cholecystoduodenal fistula. After resuscitation, what operation is most appropriate?
1. AEnterolithotomy with cholecystectomy and fistula repair
2. BRight hemicolectomy
3. CEnterolithotomy alone
4. DResection of the ileum with the stone inside
Answer and explanation in LearnFree account
Question 23 · Hard
A 10-day-old baby has bilious vomiting and is pale and lethargic. An upper GI contrast study shows the duodenojejunal flexure to the right of the spine and a corkscrew duodenum. At laparotomy, the midgut is twisted around a narrow mesentery but is still pink. Which procedure is performed?
1. AKasai portoenterostomy
2. BRamstedt pyloromyotomy
3. CDuodenoduodenostomy
4. DLadd procedure
Answer and explanation in LearnFree account
Question 24 · Easy
A 76-year-old woman with recurrent biliary colic in the past is admitted with vomiting and colicky abdominal pain for 3 days. Plain X-ray shows dilated small bowel loops, air in the biliary tree and a rounded calcified opacity in the right iliac fossa. What is the diagnosis?
1. AMesenteric ischaemia
2. BGallstone ileus
3. CEmphysematous cholecystitis
4. DCaecal volvulus
Answer and explanation in LearnFree account
Question 25 · Hard
A 35-year-old woman had a laparoscopic appendicectomy. Histopathology shows a 2.4 cm well-differentiated neuroendocrine tumour at the base of the appendix, invading the mesoappendix. CT shows no liver deposits. What is the most appropriate further management?
1. ARepeat CT after one year only
2. BLong-acting octreotide alone
3. CRight hemicolectomy
4. DNo further treatment
Answer and explanation in LearnFree account

21 more Appendicitis, intestinal obstruction and perforation questions

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Appendicitis, intestinal obstruction and perforation

During laparoscopy for suspected appendicitis in a 15-year-old boy, the appendix looks normal. There is some free fluid in the right iliac fossa but no gynaecological organs to inspect. Where should the surgeon look next for a Meckel diverticulum?

A 75-year-old man with sigmoid volvulus undergoes flexible sigmoidoscopy for decompression. At the point of twist, the mucosa is black and does not bleed on touch; he becomes tachycardic with lower abdominal tenderness. What is the most appropriate management?

An 11-month-old girl has ileocolic intussusception on ultrasound. Consider these findings: 1. Generalised peritonitis on examination. 2. Redcurrant jelly stool. 3. Free intraperitoneal air on X-ray. 4. Symptoms for 18 hours. Which findings are contraindications to enema reduction?

A 74-year-old man with atrial fibrillation who stopped his anticoagulant a month ago has sudden severe periumbilical pain. He is restless and in agony, yet the abdomen is soft with only mild tenderness. Lactate is 4.8 mmol/L. Which investigation is most appropriate?

A 26-year-old woman at 24 weeks of gestation is seen in the labour room with 20 hours of right-sided abdominal pain, anorexia and a temperature of 37.9 °C. Graded-compression ultrasound does not show the appendix. What is the preferred next imaging investigation?

A 52-year-old man has had three episodes of colicky right-sided abdominal pain with vomiting over 2 months, and has lost 5 kg. CT shows a target-shaped mass at the ileocaecal region with telescoped bowel. What most likely underlies this condition?

A 48-year-old woman who had an abdominal hysterectomy 6 years ago is admitted with colicky central abdominal pain, bilious vomiting and distension for 1 day. She has no groin swelling, and X-ray shows dilated small bowel loops with fluid levels. What is the most likely cause of the obstruction?

A 19-year-old man has had right-sided abdominal pain for a day. Tenderness in the right iliac fossa is mild, but he lies with the right hip slightly flexed, and passive extension of the right hip while he lies on his left side worsens the pain. Where is the inflamed appendix most likely to lie?

A 40-year-old man has colicky central pain and vomiting. Supine abdominal X-ray shows several centrally placed dilated loops whose mucosal folds cross the full width of the bowel, giving a stacked-coin appearance; there is no gas in the colon. Which part of the bowel is dilated?

A 45-year-old labourer who takes painkillers for back pain is brought to casualty with sudden severe epigastric pain that spread over the whole abdomen within an hour. The abdomen is rigid and board-like, and liver dullness is reduced. What is the first investigation to order?

A 30-year-old man had a laparoscopic appendicectomy for acute appendicitis. Histopathology shows a 0.8 cm well-differentiated neuroendocrine tumour at the tip, completely excised, with no lymphovascular invasion and clear margins. What further treatment is needed?

A 58-year-old woman with no previous surgery presents with small bowel obstruction. Hernial orifices are normal and she is stable. Which investigation best shows the site and cause of the obstruction and any signs of strangulation?

An 80-year-old woman with diabetes and heart failure has gallstone ileus confirmed on CT, with a 3 cm stone impacted in the terminal ileum and a cholecystoduodenal fistula. After resuscitation, what operation is most appropriate?

A 10-day-old baby has bilious vomiting and is pale and lethargic. An upper GI contrast study shows the duodenojejunal flexure to the right of the spine and a corkscrew duodenum. At laparotomy, the midgut is twisted around a narrow mesentery but is still pink. Which procedure is performed?

A 76-year-old woman with recurrent biliary colic in the past is admitted with vomiting and colicky abdominal pain for 3 days. Plain X-ray shows dilated small bowel loops, air in the biliary tree and a rounded calcified opacity in the right iliac fossa. What is the diagnosis?

A 35-year-old woman had a laparoscopic appendicectomy. Histopathology shows a 2.4 cm well-differentiated neuroendocrine tumour at the base of the appendix, invading the mesoappendix. CT shows no liver deposits. What is the most appropriate further management?