USMLE Step 2 CK Surgical Emergencies: Torsion, Mesenteric Ischemia, Pancreatitis and Variceal Bleeding

This is testicular torsion, a surgical emergency. When the clinical picture is clear, do not delay surgery for imaging. The testis is most likely to be saved if it is untwisted within 6 hours. Both testes are fixed (orchiopexy) during the operation.

Torsion vs epididymitis: torsion starts suddenly, the testis rides high, the cremasteric reflex is absent and lifting the scrotum does not help (negative Prehn sign). Epididymitis comes on gradually, often with fever or dysuria, the reflex is present, and lifting the scrotum may ease the pain.

Why the other options are wrong:

• Antibiotics treat epididymitis, not torsion.
• Ultrasound wastes time when the diagnosis is clear; it is used only when the diagnosis is uncertain.
• Discharge would lead to loss of the testis.

This is ovarian torsion. An ovarian cyst or mass (often over 5 cm) makes the ovary twist on its blood supply. Like testicular torsion, it is a surgical emergency: laparoscopy to untwist the ovary and save it. Doppler blood flow can look normal in some cases, so a strong clinical picture still needs surgery.

Why the other options are wrong:

• Antibiotics are for pelvic inflammatory disease or abscess.
• Waiting 24 hours risks losing the ovary.
• Oral contraceptives may prevent new cysts but do not treat torsion.

PID that does not improve on antibiotics and now has an adnexal mass suggests a tubo-ovarian abscess. It is confirmed by ultrasound or CT. Treatment is hospital admission with IV antibiotics, and drainage if the abscess is large (about 7 cm or more) or does not respond. A ruptured abscess is a surgical emergency.

Why the other options are wrong:

• Appendicitis does not cause cervical discharge and cervical motion tenderness.
• Ectopic pregnancy is ruled out by the negative pregnancy test.
• Ovarian torsion starts suddenly and is not usually caused by PID.

Pain out of proportion to the physical exam in a patient with atrial fibrillation is acute mesenteric ischemia until proven otherwise, most often from an embolus to the superior mesenteric artery. CT angiography is the test of choice. Treatment is fluids, heparin, and urgent restoration of blood flow (embolectomy or endovascular therapy), with removal of any dead bowel.

Why the other options are wrong:

• Ultrasound and plain X-ray are not reliable for this diagnosis; X-ray findings appear late.
• Colonoscopy does not show the small bowel or the mesenteric arteries and is risky in ischemic bowel.

Ischemic colitis happens when blood flow to the colon drops. AAA repair can tie off the inferior mesenteric artery. The watershed areas are most at risk: the splenic flexure and the rectosigmoid junction. The typical story is crampy pain followed by bloody diarrhea. Most cases improve with fluids, bowel rest and observation.

Why the other options are wrong:

• Diverticular bleeding is usually painless.
• Infectious colitis does not fit the timing after vascular surgery.
• Ulcerative colitis is a chronic disease that usually starts in young adults.

In mild gallstone pancreatitis without cholangitis or a blocked bile duct, the patient gets supportive care and then cholecystectomy during the same admission. If surgery is delayed, many patients have another attack within weeks.

Why the other options are wrong:

• ERCP is for cholangitis or a persistently blocked common bile duct.
• Laparotomy is not needed in uncomplicated pancreatitis.
• Antibiotics are not routine in pancreatitis; they are used for infected necrosis or cholangitis.

This is severe acute pancreatitis with organ failure (shock and respiratory failure, which can be ARDS). He needs ICU care: fluids, oxygen or ventilation, and close monitoring. Early feeding through the gut (when possible) is preferred later over IV nutrition.

Why the other options are wrong:

• Antibiotics are not routine; give them only if infected necrosis or cholangitis is suspected.
• ERCP is for cholangitis or a bile duct that stays blocked.
• Oral feeding is not safe in an unstable patient with falling oxygen.

This is an anastomotic leak with peritonitis and shock. A leak typically appears days 3 to 7 after bowel surgery. With diffuse peritonitis and an unstable patient, the answer is to return to the operating room (along with fluids and antibiotics).

Why the other options are wrong:

• Antibiotics alone or observation are not enough in an unstable patient with peritonitis.
• Percutaneous drainage is used only for a small, contained leak in a stable patient.

Malignant hyperthermia is an inherited reaction (often a RYR1 mutation, autosomal dominant) to volatile anesthetics or succinylcholine. Uncontrolled calcium release in muscle causes rigidity, high fever, rising end-tidal CO2, high CK, high potassium and acidosis. Treatment: stop the trigger, give IV dantrolene, cool the patient and treat the high potassium.

Why the other options are wrong:

• Neuroleptic malignant syndrome follows antipsychotic drugs and develops over days.
• Serotonin syndrome follows serotonergic drugs and causes clonus and hyperreflexia, not lead-pipe rigidity.
• Thyroid storm does not cause rigidity or a very high CK.

The first step in any major GI bleed is to stabilize the patient: two large IV lines, fluids and blood. For suspected variceal bleeding, also give IV octreotide (lowers portal pressure) and IV antibiotics such as ceftriaxone (prevents infection and lowers death rates in cirrhosis). Endoscopic band ligation follows within 12 hours, once the patient is stable.

Why the other options are wrong:

• β-blockers (propranolol, nadolol) are for preventing bleeding, not for active bleeding with low blood pressure.
• Banding comes after resuscitation, not before.
• A PPI alone is the treatment for a peptic ulcer, not for varices.

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Four free sampler PDFs by Dr. Ray Makar: Step 1 (Pathology & Pharmacology) and Step 2 CK (Medicine, Surgery & Pediatrics), in both Review style and USMLE style, with answers and explanations. Also useful for NEET-PG, INI-CET and FMGE.