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Post-appendectomy staple-line leak — USMLE Step 3 MCQ

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HardSurgeryPost-appendectomy staple-line leakUSMLE Step 3

A 61-year-old with decompensated cirrhosis has abdominal pain, fever, ascitic neutrophils 620/mm³, creatinine 1.8 mg/dL, and bilirubin 5.4 mg/dL. Blood pressure is stable and there is no surgically treatable intra-abdominal source. Which regimen best reduces renal failure and death from this infection?

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Correct answer: A — Give intravenous ceftriaxone plus scheduled intravenous albumin

The best answer is “Give intravenous ceftriaxone plus scheduled intravenous albumin”. An ascitic neutrophil count above 250/mm³ establishes spontaneous bacterial peritonitis and treatment begins before culture results. Ceftriaxone is an accepted antibiotic, while renal dysfunction and high bilirubin identify substantial hepatorenal-syndrome risk; scheduled albumin reduces renal failure and mortality. Albumin alone does not treat the infection, oral prophylaxis is not treatment, and reserving albumin for shock forfeits its renal-protective benefit in this high-risk presentation. The alternatives are less suitable because they mistime the intervention, omit a necessary component, or apply treatment for a different physiologic problem; the stem's decisive findings determine the sequence.

Reference: AASLD, Ascites and Spontaneous Bacterial Peritonitis Guidance: https://www.aasld.org/practice-guidelines/diagnosis-evaluation-and-management-ascites-spontaneous-bacterial-peritonitis