Surgery for PRES Level 2

A 24-year-old man presents with 18 hours of central abdominal pain that has moved to the right iliac fossa, anorexia and one episode of vomiting. Temperature 37.9°C, tenderness with guarding at McBurney's point, white cells 15.2 × 10⁹/L, CRP 62 mg/L. What is the most appropriate management?

1. Perform a diagnostic laparoscopy only if the CRP exceeds 100 mg/L Wrong. There is no CRP threshold that rules appendicitis in or out, and a normal CRP early in the illness does not exclude it.
2. Surgical referral for appendicectomy, with analgesia and intravenous fluids while awaiting theatre correct Correct. The history of migratory pain with localised peritonism, fever and a raised white cell count is a classic appendicitis presentation with a high Alvarado score. This is a clinical diagnosis and the treatment is surgical.
3. Withhold analgesia so that serial examination is not masked An outdated practice that has been disproven. Adequate analgesia does not obscure the diagnosis and withholding it is unjustifiable.
4. Discharge with oral antibiotics and review in 48 hours Wrong. Antibiotic-first strategies exist for selected uncomplicated appendicitis within a trial or structured pathway, but discharging a patient with guarding for 48 hours risks perforation.
5. Arrange an outpatient CT abdomen next week Wrong. Imaging has a role where the diagnosis is unclear, particularly in women and older patients, but next week is not a timescale that applies to suspected appendicitis.

The point: Appendicitis is a clinical diagnosis: migratory pain, anorexia, localised peritonism. Imaging is for diagnostic uncertainty, especially in women of childbearing age where gynaecological causes and pregnancy must be excluded. Always do a pregnancy test.

Source: Medical Council of Ireland PRES blueprint — surgery; WSES Jerusalem guidelines for acute appendicitis Medical Council of Ireland · tier 0, exam blueprint / regulator

A 70-year-old man presents with colicky abdominal pain, distension, absolute constipation and vomiting for two days. He has had previous open appendicectomy. Abdominal radiograph shows dilated loops of small bowel with no gas in the rectum. What is the most appropriate initial management?

1. Oral laxatives and an enema Wrong and potentially harmful. He has a mechanical small bowel obstruction with vomiting; stimulating peristalsis proximal to an obstruction increases perforation risk.
2. Discharge with oral analgesia and outpatient CT Wrong. He is vomiting with an obstructed bowel and needs admission for decompression and fluid correction.
3. Start a prokinetic such as metoclopramide Wrong. Prokinetics are contraindicated in mechanical obstruction.
4. Immediate laparotomy in all cases of small bowel obstruction Wrong as a blanket rule. Surgery is indicated for strangulation, peritonism, an obstructed hernia, or failure to resolve, not for every obstruction.
5. Nil by mouth, nasogastric tube on free drainage, intravenous fluids, and surgical review correct Correct. This is small bowel obstruction, most likely adhesional given the previous laparotomy. Initial management is drip and suck with fluid and electrolyte correction and surgical assessment. A substantial proportion of adhesional obstruction settles without an operation.

The point: Small bowel obstruction: adhesions, hernias and malignancy account for most of it, so always examine the hernial orifices. Drip and suck, correct electrolytes, and involve surgeons early. CT with contrast identifies the level, the cause, and signs of ischaemia that mandate operating.

Source: Bologna guidelines for the diagnosis and management of adhesive small bowel obstruction World Society of Emergency Surgery · tier 2, specialty society or college