A 53 year old man undergoes a reversal of a loop colostomy. He recovers well and is discharged home. He is readmitted 10 days later with symptoms of vomiting and colicky abdominal pain. On examination he has a swelling of the loop colostomy site and it is tender. What is the most likely underlying diagnosis? A. Haematoma B. Intra abdominal adhesions C. Anastomotic leak D. Anastomotic stricture E. Obstructed incisional hernia Theme from September 2011 Exam In this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt surgical exploration is warranted. Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections. Acute incisional hernia Any surgical procedure involving entry into a cavity containing viscera may be complicated by post operative hernia The abdomen is the commonest site The deep layer of the wound has usually broken down, allowing internal viscera to protrude through Management is dictated by the patients clinical status and the timing of the hernia in relation to recent surgery Bowel obstruction or tenderness at the hernia site both mandate early surgical intervention to reduce the risk of bowel necrosis Mature incisional hernias with a wide neck and no symptoms may be either left or listed for elective repair Risk factors for the development of post operative incisional hernias include post operative wound infections, long term steroid use, obesity and chronic cough Theme: Abdominal stomas A. End ileostomy B. End colostomy C. Loop ileostomy D. Loop colostomy
1. A 53 year old man undergoes a reversal of a loop colostomy.
He recovers well and is discharged home. He is readmitted 10 days
later with symptoms of vomiting and colicky abdominal pain. On
examination he has a swelling of the loop colostomy site and it is
tender. What is the most likely underlying diagnosis? A. Haematoma
B. Intra abdominal adhesions C. Anastomotic leak D. Anastomotic
stricture E. Obstructed incisional hernia Theme from September 2011
Exam In this scenario the most likely diagnosis would be obstructed
incisional hernia. The tender swelling coupled with symptoms of
obstruction point to this diagnosis. Prompt surgical exploration is
warranted. Loop colostomy reversals are at high risk of this
complication as the operative site is at increased risk of the
development of post operative wound infections. Acute incisional
hernia Any surgical procedure involving entry into a cavity
containing viscera may be complicated by post operative hernia The
abdomen is the commonest site The deep layer of the wound has
usually broken down, allowing internal viscera to protrude through
Management is dictated by the patients clinical status and the
timing of the hernia in relation to recent surgery Bowel
obstruction or tenderness at the hernia site both mandate early
surgical intervention to reduce the risk of bowel necrosis Mature
incisional hernias with a wide neck and no symptoms may be either
left or listed for elective repair Risk factors for the development
of post operative incisional hernias include post operative wound
infections, long term steroid use, obesity and chronic cough Theme:
Abdominal stomas A. End ileostomy B. End colostomy C. Loop
ileostomy D. Loop colostomy
2. E. End jejunostomy F. Loop jejunostomy G. Caecostomy For
each of the following scenarios, please select the most appropriate
type of stoma to be constructed. Each option may be selected once,
more than once or not at all. 2. A 56 year old man is undergoing a
low anterior resection for carcinoma of the rectum. It is planned
to restore intestinal continuity. You answered End colostomy The
correct answer is Loop ileostomy Colonic resections with an
anastomosis below the peritoneal reflection may have an anastomotic
leak rate (both clinical and radiological) of up to 15%. Therefore
most surgeons will defunction such an anastomosis to reduce the
clinical severity of an anastomotic leak. A loop ileostomy will
achieve this end point and is relatively easy to reverse. 3. A 23
year old man with uncontrolled ulcerative colitis is undergoing an
emergency sub total colectomy. You answered Loop ileostomy The
correct answer is End ileostomy Following a sub total colectomy the
immediate surgical options include an end ileostomy or ileorectal
anastomosis. In the emergency setting an ileorectal anastomosis
would be unsafe. 4. A 63 year old women presents with large bowel
obstruction. On examination she has a carcinoma 10cm from the anal
verge. You answered End colostomy The correct answer is Loop
colostomy Large bowel obstruction resulting from carcinoma should
be resected, stented or defunctioned. The first two options
typically apply to tumours above the peritoneal reflection. Lower
tumours should be defunctioned with a loop colostomy and then
formal staging undertaken prior to definitive surgery. An emergency
attempted rectal resection carries a high risk of involvement of
the circumferential resection margin and is not recommended.
3. Abdominal stomas Stomas may be sited during a range of
abdominal procedures and involve bringing the lumen or visceral
contents onto the skin. In most cases this applies to the bowel.
However, other organs or their contents may be diverted in case of
need. With bowel stomas the type method of construction and to a
lesser extent the site will be determined by the contents of the
bowel. In practice, small bowel stomas should be spouted so that
their irritant contents are not in contact with the skin. Colonic
stomas do not need to be spouted as their contents are less
irritant. In the ideal situation the site of the stoma should be
marked with the patient prior to surgery. Stoma siting is important
as it will ultimately influence the ability of the patient to
manage their stoma and also reduce the risk of leakage. Leakage of
stoma contents and subsequent maceration of the surrounding skin
can rapidly progress into a spiraling loss of control of stoma
contents. Types of stomas Name of stoma Use Common sites
Gastrostomy Gastric decompression or fixation Feeding Epigastrium
Loop jejunostomy Seldom used as very high output May be used
following emergency laparotomy with planned early closure Any
location according to need Percutaneous jejunostomy Usually
performed for feeding purposes and site in the proximal bowel
Usually left upper quadrant Loop ileostomy Defunctioning of colon
e.g. following rectal cancer surgery Does not decompress colon (if
ileocaecal valve competent) Usually right iliac fossa End ilestomy
Usually following complete excision of colon or where ileo- colic
anastomosis is not planned May be used to defunction colon, but
reversal is more difficult Usually right iliac fossa End colostomy
Where a colon is diverted or resected and anastomosis is not
primarily achievable or desirable Either left or right iliac
fossa
4. Loop colostomy To defunction a distal segment of colon Since
both lumens are present the distal lumen acts as a vent May be
located in any region of the abdomen, depending upon colonic
segment used Caecostomy Stoma of last resort where loop colostomy
is not possible Right iliac fossa Mucous fistula To decompress a
distal segment of bowel following colonic division or resection
Where closure of a distal resection margin is not safe or
achievable May be located in any region of the abdomen according to
clinical need Theme: Acute abdominal pain A. Ruptured abdominal
aortic aneurysm B. Perforated peptic ulcer C. Perforated
appendicitis D. Mesenteric infarction E. Small bowel obstruction F.
Large bowel obstruction G. Pelvic inflammatory disease H.
Mesenteric adenitis I. Pancreatitis J. None of the above Please
select the most likely cause of abdominal pain for the scenario
given. Each option may be used once, more than once or not at all.
5. A 75 year old man is admitted with sudden onset severe
generalised abdominal pain, vomiting and a single episode of bloody
diarrhoea. On examination he looks unwell and is in uncontrolled
atrial fibrillation. Although diffusely tender his abdomen is soft.
Mesenteric infarction In mesenteric infarction there is sudden
onset of pain together with vomiting and occasionally passage of
bloody diarrhoea. The pain present is usually out of proportion to
the physical signs. 6. A 19 year old lady is admitted with lower
abdominal pain. On examination she is diffusely tender. A
laparoscopy is performed and at operation multiple fine
5. adhesions are noted between the liver and abdominal wall.
Her appendix is normal. You answered Small bowel obstruction The
correct answer is Pelvic inflammatory disease This is Fitz Hugh
Curtis syndrome in which pelvic inflammatory disease (usually
Chlamydia) causes the formation of fine peri hepatic adhesions. 7.
A 78 year old man is walking to the bus stop when he suddenly
develops severe back pain and collapses. On examination he has a
blood pressure of 90/40 and pulse rate of 110. His abdomen is
distended and he is obese. Though tender his abdomen itself is
soft. Ruptured abdominal aortic aneurysm This will be a
retroperitoneal rupture (anterior ones generally don't survive to
hospital). The debate regarding CT varies, it is the authors
opinion that a systolic BP of 60 years Continued bleeding despite
endoscopic intervention Recurrent bleeding Known cardiovascular
disease with poor response to hypotension Surgery Selective
mesenteric embolisation if life threatening bleeding. This is most
helpful if conducted during a period of relative haemodynamic
instability. If all haemodynamic parameters are normal then the
bleeding is most likely to have stopped and any angiography normal
in appearance. In many units a CT angiogram will replace selective
angiography but the same caveats will apply. If source of colonic
bleeding unclear perform a laparotomy, on table colonic lavage and
following this attempt a resection. A blind sub total colectomy is
most unwise, for example bleeding from an small bowel
arterio-venous malformation will not be treated by this manoeuvre.
Summary of Acute Lower GI bleeding recommendations Consider
admission if: * Over 60 years * Haemodynamically unstable/profuse
PR bleeding * On aspirin or NSAID * Significant co morbidity
Management All patients should have a history and examination, PR
and proctoscopy Colonoscopic haemostasis aimed for in post
polypectomy or diverticular bleeding References
http://www.sign.ac.uk/guidelines/fulltext/105/index.html heme:
Surgical signs A. Rovsing's sign B. Boas' sign C. Psoas stretch
sign D. Cullen's sign E. Grey-Turner's sign F. Murphy's sign G.
None of the above Please select the most appropriate eponymous
abdominal sign for the scenario given. Each option may be used
once, more than once or not at all.
11. 11. Severe acute peri-umbilical bruising in the setting of
acute pancreatitis. Cullen's sign Cullens sign occurs when there
has been intraabdominal haemorrage. It is seen in cases of severe
haemorrhagic pancreatitis and is associated with a poor prognosis.
It is also seen in other cases of intraabdominal haemorrhage (such
as ruptured ectopic pregnancy). 12. In acute cholecystitis there is
hyperaesthesia beneath the right scapula. Boas' sign Boas sign
refers to this hyperaesthesia. It occurs because the abdominal wall
innervation of this region is from the spinal roots that lie at
this level. 13. In appendicitis palpation of the left iliac fossa
causes pain in the right iliac fossa. Rovsing's sign Rovsings sign
elicits tenderness because the deep palpation induces shift of the
appendix (which is inflamed) against the peritoneal surface. This
has somatic innervation and will therefore localise the pain. It is
less reliable in pelvic appendicitis and when the appendix is truly
retrocaecal Abdominal signs A number of eponymous abdominal signs
are noted. These include: Rovsings sign- appendicitis Boas sign
-cholecystitis Murphys sign- cholecystitis Cullens sign-
pancreatitis (other intraabdominal haemorrhage) Grey-Turners sign-
pancreatitis (or other retroperitoneal haemorrhage) In clinical
practice haemorrhagic pancreatitis is thankfully rare. The signs
are important and thus shown below: Cullen's sign
12. Image sourced from Wikipedia Grey Turner's sign Image
sourced from Wikipedia Theme: Surgical access A. Gridiron B. Lanz
C. McEvedy D. Midline abdominal E. Rutherford Morrison F. Battle
(abdominal) G. Lower midline Please select the most appropriate
incision for the procedure required. Each option may be used once,
more than once or not at all. 14. A 78 year old lady is admitted
with a tender lump in her right groin. It is within the femoral
triangle and there is concern that there may be small bowel
obstruction developing.
13. McEvedy This is one approach to an obstructed femoral
hernia. It is possible to undertake a small bowel resection through
this approach. Although recourse to laparotomy may be needed if
access is difficult. 15. A 45 year old woman with end stage renal
failure is due to undergo a cadaveric renal transplant. This will
be her first transplant. Rutherford Morrison This is the incision
of choice for the extraperitoneal approach to the iliac vessels
which will be required for a renal transplant. 16. A slim 20 year
old lady is suffering from appendicitis and requires an
appendicectomy. Lanz Either a Lanz or Gridiron incision will give
access for appendicectomy. However, in the case described a Lanz
incision will give better cosmesis and can be extended should
pelvic surgery be required eg for gynaecological disease. Abdominal
incisions Theme in January 2012 exam Midline incision Commonest
approach to the abdomen Structures divided: linea alba,
transversalis fascia, extraperitoneal fat, peritoneum (avoid
falciform ligament above the umbilicus) Bladder can be accessed via
an extraperitoneal approach through the space of Retzius Paramedian
incision Parallel to the midline (about 3-4cm) Structures
divided/retracted: anterior rectus sheath, rectus (retracted),
posterior rectus sheath, transversalis fascia, extraperitoneal fat,
peritoneum Incision is closed in layers
14. Battle Similar location to paramedian but rectus displaced
medially (and thus denervated) Now seldom used Kocher's Incision
under right subcostal margin e.g. Cholecystectomy (open) Lanz
Incision in right iliac fossa e.g. Appendicectomy Gridiron Oblique
incision centered over McBurneys point- usually appendicectomy
(less cosmetically acceptable than Lanz Gable Rooftop incision
Pfannenstiel's Transverse supra pubic, primarily used to access
pelvic organs McEvedy's Groin incision e.g. Emergency repair
strangulated femoral hernia Rutherford Morrison Extraperitoneal
approach to left or right lower quadrants. Gives excellent access
to iliac vessels and is the approach of choice for first time renal
transplantation. Image sourced from Wikipedia Theme: Hernias A.
Littres hernia B. Richters hernia C. Bochdalek hernia D. Morgagni
hernia E. Spigelian hernia F. Lumbar hernia G. Obturator hernia
Please select the type of hernia that most closely matches the
description given. Each option may be used once, more than once or
not at all.
15. 17. A 73 year old lady presents with peritonitis and
tenderness of the left groin. At operation she has a left femoral
hernia with perforation of the anti mesenteric border of ileum
associated with the hernia. Richters hernia When part of the bowel
wall is trapped in a hernia such as this it is termed a Richters
hernia and may complicate any hernia although femoral and obturator
hernias are most typically implicated. 18. A 22 year old man is
operated on for a left inguinal hernia, at operation the sac is
opened to reveal a large Meckels diverticulum. Littres hernia
Hernia containing Meckels diverticulum is termed a Littres hernia.
19. A 45 year old man has recurrent colicky abdominal pain. As part
of a series of investigations he undergoes a CT scan and this
demonstrates a hernia lateral to the rectus muscle at the level of
the arcuate line. Spigelian hernia This is the site for a spigelian
hernia. Theme: Groin masses A. Femoral hernia B. Lymphadenitis C.
Inguinal hernia D. Psoas abscess E. Saphenous varix F. Femoral
artery aneurysm G. Metastatic lymphadenopathy H. Lymphangitis I.
False femoral artery aneurysm What is the likely diagnosis for
groin mass described? Each option may be used once, more than once,
or not at all. 20. A 52 year old obese lady reports a painless
grape sized mass in her groin area.
16. She has no medical conditions apart from some varicose
veins. There is a cough impulse and the mass disappears on lying
down. Saphenous varix The history of varicose veins should indicate
a more likely diagnosis of a varix. The varix can enlarge during
coughing/sneezing. A blue discolouration may be noted. 21. A 32
year old male is noted to have a tender mass in the right groin
area. There are also red streaks on the thigh, extending from a
small abrasion. You answered Lymphangitis The correct answer is
Lymphadenitis The red streaks are along the line of the lymphatics,
indicating infection of the lymphatic vessels. Lymphadenitis is
infection of the local lymph nodes. 22. A 23 year old male
suffering from hepatitis C presents with right groin pain and
swelling. On examination there is a large abscess in the groin.
Adjacent to this is an expansile swelling. There is no cough
impulse. False femoral artery aneurysm False aneurysms may occur
following arterial trauma in IVDU. They may have associated blood
borne virus infections and should undergo duplex scanning prior to
surgery. False aneurysms do not contain all layers of the arterial
wall. Groin masses clinical Groin masses are common and include:
Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm
Saphena varix (more a swelling than a mass!) In the history
features relating to systemic illness and tempo of onset will often
give a
17. clue as to the most likely underlying diagnosis. Groin
lumps- some key questions Is there a cough impulse Is it pulsatile
AND is it expansile (to distinguish between false and true
aneurysm) Are both testes intra scrotal Any lesions in the legs
such as malignancy or infections (?lymph nodes) Examine the ano
rectum as anal cancer may metastasise to the groin Is the lump
soft, small and very superficial (?lipoma) Scrotal lumps - some key
questions Is the lump entirely intra scrotal Does it
transilluminate (?hydrocele) Is there a cough impulse (?hernia) In
most cases a diagnosis can be made clinically. Where it is not
clear an ultrasound scan is often the most convenient next
investigation. heme: Right iliac fossa pain A. Urinary tract
infection B. Appendicitis C. Mittelschmerz D. Mesenteric adenitis
E. Crohns disease F. Ulcerative colitis G. Meckels diverticulum
Please select the most likely cause for right iliac fossa pain for
the scenario given. Each option may be used once, more than once or
not at all. 23. A 17 year old male is admitted with lower abdominal
discomfort. He has been suffering from intermittent right iliac
fossa pain for the past few months. His past medical history
includes a negative colonoscopy and gastroscopy for iron deficiency
anaemia. The pain is worse after meals. Inflammatory markers are
normal. Meckels diverticulum This scenario should raise suspicion
for Meckels as these may contain ectopic gastric mucosa which may
secrete acid with subsequent bleeding and ulceration.
18. 24. A 14 year old female is admitted with sudden onset
right iliac fossa pain. She is otherwise well and on examination
has some right iliac fossa tenderness but no guarding. She is
afebrile. Urinary dipstick is normal. Her previous menstrual period
two weeks ago was normal and pregnancy test is negative.
Mittelschmerz Typical story and timing for mid cycle pain. Mid
cycle pain typically occurs because a small amount of fluid is
released at the time of ovulation. It will usually resolve over
24-48 hours. 25. A 21 year old male is admitted with a 3 month
history of intermittent right iliac fossa pain. He suffers from
episodic diarrhoea and has lost 2 kilos in weight. On examination
he has some right iliac fossa tenderness and is febrile. Crohns
disease Weight loss and chronic symptoms coupled with change in
bowel habit should raise suspicion for Crohns. The presence of
intermittent right iliac fossa pain is far more typical of terminal
ileal Crohns disease. Both UC and Crohns may be associated with a
low grade pyrexia. The main concern here would be locally
perforated Crohns disease with a small associated abscess. Right
iliac fossa pain Differential diagnosis Appendicitis Pain radiating
to right iliac fossa Anorexia Typically short history Diarrhoea and
profuse vomiting rare Crohn's disease Often long history Signs of
malnutrition Change in bowel habit, especially diarrhoea Mesenteric
adenitis Mainly affects children Causes include Adenoviruses,
Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus
spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with
appendicitis
19. If laparotomy is performed, enlarged mesenteric lymph nodes
will be present Diverticulitis Both left and right sided disease
may present with right iliac fossa pain Clinical history may be
similar, although some change in bowel habit is usual When
suspected a CT scan may help in refining the diagnosis Meckel's
diverticulitis A Meckel's diverticulum is a congenital abnormality
that is present in about 2% of the population Typically 2 feet
proximal to the ileocaecal valve May be lined by ectopic gastric
mucosal tissue and produce bleeding Perforated peptic ulcer This
usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the
history Incarcerated right inguinal or femoral hernia Usually only
right iliac fossa pain if right sided or bowel obstruction. Bowel
perforation secondary to caecal or colon carcinoma Seldom localised
to right iliac fossa, although complete large bowel obstruction
with caecal distension may cause pain prior to perforation.
Gynaecological causes Pelvic inflammatory
disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian
torsion/Threatened or complete abortion/Mittelschmerz Urological
causes Ureteric colic/UTI/Testicular torsion Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus A 78 year old lady
presents with colicky abdominal pain and a tender mass in her
groin. On examination there is a small firm mass below and lateral
to the pubic tubercle. Which of the following is the most likely
underlying diagnosis? A. Incarcerated inguinal hernia B.
Thrombophlebitis of a saphena varix C. Incarcerated femoral
hernia
20. D. Incarcerated obturator hernia E. Deep vein thrombosis
Femoral hernia = High risk of strangulation (repair urgently)
Femoral herniae account for 3 times normal go against this
diagnosis. 41. A 79 year old lady develops sudden onset of
abdominal pain and collapses, she has passed a large amount of
diarrhoea. In casualty her pH is 7.35 and WCC is 18. You answered
Acute on chronic mesenteric ischaemia The correct answer is Acute
mesenteric embolus Although mesenteric infarct may raise the
lactate the pH may be raised often secondary to vomiting.
Mesenteric vessel disease Mesenteric ischaemia accounts for 1 in
1000 acute surgical admissions. It is primarily caused by arterial
embolism resulting in infarction of the colon. It is more likely to
occur in areas such as the splenic flexure that are located at the
borders of the territory supplied by the superior and inferior
mesenteric arteries. Types Acute mesenteric embolus (commonest 50%)
Sudden onset abdominal pain followed by profuse diarrhoea. May be
associated with vomiting. Rapid clinical deterioration. Serological
tests: WCC, lactate, amylase may all be abnormal particularly in
established disease. These can be normal in the early phases. Acute
on chronic mesenteric ischaemia Usually longer prodromal history.
Post prandial abdominal discomfort and weight loss are dominant
features. Patients will usually present with an acute on chronic
event, but otherwise will tend not to present until mesenteric flow
is reduced by greater than 80%. When acute thrombosis occurs
presentation may be as above. In the chronic setting the symptoms
will often be those of ischaemic colitis (mucosa is the most
sensitive area to this insult).
38. Mesenteric vein thrombosis Usually a history over weeks.
Overt abdominal signs and symptoms will not occur until venous
thrombosis has reached a stage to compromise arterial inflow.
Thrombophilia accounts for 60% of cases. Low flow mesenteric
infarction This occurs in patients with multiple co morbidities in
whom mesenteric perfusion is significantly compromised by overuse
of inotropes or background cardiovascular compromise. The end
result is that the bowel is not adequately perfused and infarcts
occur from the mucosa outwards. Diagnosis Serological tests: WCC,
lactate, CRP, amylase (can be normal in early disease). Cornerstone
for diagnosis of arterial AND venous mesenteric disease is CT
angiography scanning in the arterial phase with thin slices (8cm
Fluid levels in the colon Ground glass appearance to film (usually
due to large amounts of free fluid). Sentinel loop in patients with
inflammation of other organs (e.g. pancreatitis). Features which
should be expected/ or occur without pathology In Chialditis
syndrome, a loop of bowel may be interposed between the liver and
diaphragm, giving the mistaken impression that free air is present.
Following ERCP (and sphincterotomy) air may be identified in the
biliary tree. Free intra abdominal air following laparoscopy /
laparotomy, although usually dissipates after 48-72 hours. A 56
year old lady presents with a large bowel obstruction and abdominal
distension. Which of the following confirmatory tests should be
performed prior to surgery A. Abdominal ultrasound scan B. Barium
enema C. Rectal MRI Scan D. Endoanal ultrasound scan E.
Gastrograffin enema Patients with clinical evidence of large bowel
obstruction, should have the presence or absence of an obstructing
lesion confirmed prior to surgery. This is because colonic
pseudo-obstruction may produce a similar radiological picture. A
gastrograffin enema is the traditional test, as barium is too toxic
if it spills into the abdominal cavity. An MRI scan will not
provide the relevant information, unless the lesion is rectal and
below the peritoneal reflection.
42. Abdominal radiology Plain abdominal x-rays are often used
as a first line investigation in patients with acute abdominal
pain. A plain abdominal film may demonstrate free air, evidence of
bowel obstruction and possibly other causes of pain (e.g. renal or
gallbladder stones). Investigation of potential visceral
perforation is usually best performed by obtaining an erect chest
x-ray, as this is a more sensitive investigation for suspected
visceral perforation. Features which are usually abnormal Large
amounts of free air (colonic perforation), smaller volumes seen
with more proximal perforations. A positive Riglers sign (gas on
both sides of the bowel wall). Caecal diameter of >8cm Fluid
levels in the colon Ground glass appearance to film (usually due to
large amounts of free fluid). Sentinel loop in patients with
inflammation of other organs (e.g. pancreatitis). Features which
should be expected/ or occur without pathology In Chialditis
syndrome, a loop of bowel may be interposed between the liver and
diaphragm, giving the mistaken impression that free air is present.
Following ERCP (and sphincterotomy) air may be identified in the
biliary tree. Free intra abdominal air following laparoscopy /
laparotomy, although usually dissipates after 48-72 hours. Theme:
Management of splenic trauma A. Splenectomy B. Angiography C. CT
Scan D. Admit for bed rest and observation E. Ultrasound scan F.
Splenic conservation G. MRI of the abdomen Please select the most
appropriate intervention for the scenario given. Each option may be
used once, more than once or not at all. 1. A 7 year old boy falls
off a wall the distance is 7 feet. He lands on his left side and
there is left flank bruising. There is no haematuria. He is
otherwise stable and haemoglobin is within normal limits.
Ultrasound scan
43. This will demonstrate any overt splenic injury. A CT scan
carries a significant dose of radiation. In the absence of
haemodynamic instability or other major associated injuries the use
of USS to exclude intraabdominal free fluid (blood) would seem safe
when coupled with active observation. An USS will also show splenic
haematomas. 2. A 42 year old motorcyclist is involved in a road
traffic accident. A FAST scan in the emergency department shows
free intrabdominal fluid and a laparotomy is performed. At
operation there is evidence of small liver laceration that has
stopped bleeding and a tear to the inferior pole of the spleen.
Splenic conservation As minimum damage, attempt conservation. 3. An
18 year old man is involved in a road traffic accident. A CT scan
shows disruption of the splenic hilum and a moderate sized
perisplenic haematoma. Splenectomy Hilar injuries usually mandate
splenectomy. The main risk with conservative management here is
that he will rebleed and with hilar injuries this can be dramatic.
Splenic trauma The spleen is one of the more commonly injured intra
abdominal organs In most cases the spleen can be conserved. The
management is dictated by the associated injuries, haemodynamic
status and extent of direct splenic injury. Management of splenic
trauma Conservative Small subcapsular haematoma Minimal intra
abdominal blood No hilar disruption Laparotomy with conservation
Increased amounts of intraabdominal blood Moderate haemodynamic
compromise Tears or lacerations affecting 3 loose or watery stool
per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days
Acute Diarrhoea Gastroenteritis May be accompanied by abdominal
pain or nausea/vomiting Diverticulitis Classically causes left
lower quadrant pain, diarrhoea and fever Antibiotic therapy More
common with broad spectrum antibiotics Clostridium difficile is
also seen with antibiotic use Constipation causing overflow A
history of alternating diarrhoea and constipation may be given May
lead to faecal incontinence in the elderly Chronic Diarrhoea
Irritable bowel syndrome Extremely common. The most consistent
features are abdominal pain, bloating and change in bowel habit.
Patients may be divided into those with diarrhoea predominant IBS
and those with constipation predominant IBS. Features such as
lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal
pain and weight loss are also common. Faecal urgency and tenesmus
may occur Crohn's disease Crampy abdominal pains and diarrhoea.
Bloody diarrhoea less common than in ulcerative colitis. Other
features include malabsorption, mouth ulcers perianal disease and
intestinal obstruction Colorectal cancer Symptoms depend on the
site of the lesion but include diarrhoea, rectal bleeding, anaemia
and constitutional symptoms e.g. Weight loss and anorexia
48. Coeliac disease In children may present with failure to
thrive, diarrhoea and abdominal distension In adults lethargy,
anaemia, diarrhoea and weight loss are seen. Other autoimmune
conditions may coexist Other conditions associated with diarrhoea
include: Thyrotoxicosis Laxative abuse Appendicitis with pelvic
abscess or pelvic appendix Radiation enteritis Diagnosis Stool
culture Abdominal and digital rectal examination Consider
colonoscopy (radiological studies unhelpful) Thyroid function
tests, serum calcium, anti endomysial antibodies, glucose A 6 year
old child presents with colicky abdominal pain, vomiting and the
passage of red current jelly stool per rectum. On examination the
child has a tender abdomen and a palpable mass in the right upper
quadrant. Imaging shows an intussusception. Which of the conditions
below is least recognised as a precipitant A. Inflammation of
Payers patches B. Cystic fibrosis C. Meckels diverticulum D.
Mesenteric cyst E. Mucosal polyps Mesenteric cysts may be
associated with intra abdominal catastrophes where these occur they
are typically either intestinal volvulus or intestinal infarction.
They seldom cause intussusception. Cystic fibrosis may lead to the
formation of meconium ileus equivalent and plugs may occasionally
serve as the lead points for an intussusception. Intussusception-
Paediatric Intussusception typcially presents with colicky
abdominal pain and vomiting. The telescoping of the bowel produces
mucosal ischaemia and bleeding may occur resulting in the passage
of "red current jelly" stools. Recognised causes include lumenal
pathologies such as polyps, lymphadenopathy and diseases such as
cystic fibrosis. Idiopathic intussceception of the ileocaecal valve
and terminal ileum is the most common variant and typically affects
young children and toddlers. The diagnosis is usually made by
abdominal ultrasound investigation. The decision as
49. to the optimal treatment is dictated by the patients
physiological status and abdominal signs. In general children who
are unstable with localising peritoneal signs should undergo
laparotomy as should those in whom attempted radiological reduction
has failed. In relatively well children without localising signs
attempted hydrostatic reduction under fluroscopic guidance is the
usual treatment. Which one of the following is least likely to
cause malabsorption? A. Primary biliary cirrhosis B. Ileo-colic
bypass C. Chronic pancreatitis D. Whipples disease E. Hartmans
procedure In a Hartmans procedure the sigmoid colon is removed and
an end colostomy is fashioned. The bowel remains in continuity and
no absorptive ability is lost. An ileo-colic bypass leaves a
redundant loop of small bowel in continuity, where the contents
will stagnate and bacterial overgrowth will occur. Therefore this
is recognised cause of malabsorption. Malabsorption Malabsorption
is characterised by diarrhoea, steatorrhoea and weight loss. Causes
may be broadly divided into intestinal (e.g. villous atrophy),
pancreatic (deficiency of pancreatic enzyme production or
secretion) and biliary (deficiency of bile-salts needed for
emulsification of fats) Intestinal causes of malabsorption coeliac
disease Crohn's disease tropical sprue Whipple's disease Giardiasis
brush border enzyme deficiencies (e.g. lactase insufficiency)
Pancreatic causes of malabsorption chronic pancreatitis cystic
fibrosis pancreatic cancer
50. Biliary causes of malabsorption biliary obstruction primary
biliary cirrhosis Other causes bacterial overgrowth (e.g. systemic
sclerosis, diverticulae, blind loop) short bowel syndrome lymphoma
Theme: Intra abdominal malignancies A. Metastatic adenocarcinoma of
the pancreas B. Metastatic appendiceal carcinoid C. Metastatic
colonic cancer D. Pseudomyxoma peritonei E. MALT lymphoma F.
Retroperitoneal liposarcoma G. Retroperitoneal fibrosis For the
disease given please give the most likely primary disease process.
Each option may be used once, more than once or not at all. 10. A
32 year old man is admitted with a distended tense abdomen. He
previously underwent a difficult appendicectomy 1 year previously
and was discharged. At laparotomy the abdomen is filled with a
gelatinous substance. You answered Metastatic appendiceal carcinoid
The correct answer is Pseudomyxoma peritonei Pseudomyxoma is
classically associated with mucin production and the appendix is
the commonest source. 11. A 62 year old man is admitted with dull
lower back pain and abdominal discomfort. On examination he is
hypertensive and a lower abdominal fullness is elicited on
examination. An abdominal ultrasound demonstrates hydronephrosis
and intravenous urography demonstrated medially displaced ureters.
A CT scan shows a periaortic mass. You answered Metastatic colonic
cancer
51. The correct answer is Retroperitoneal fibrosis
Retroperitoneal fibrosis is an uncommon condition and its aetiology
is poorly understood. In a significant proportion the ureters are
displaced medially. In most retroperitoneal malignancies they are
displaced laterally. Hypertension is another common finding. A CT
scan will often show a para-aortic mass 12. A 48 year old lady is
admitted with abdominal distension. On examination she is cachectic
and has ascites. Her CA19-9 returns highly elevated. Metastatic
adenocarcinoma of the pancreas Although not specific CA 19-9 in the
context of this history is highly suggestive of pancreatic cancer
over the other scenarios. Pseudomyxoma peritoneii- Curative
treatment is peritonectomy (Sugarbaker procedure) and heated intra
peritoneal chemotherapy. Pseudomyxoma Peritonei Rare mucinous
tumour Most commonly arising from the appendix (other abdominal
viscera are also recognised as primary sites) Incidence of
1-2/1,000,000 per year The disease is characterised by the
accumulation of large amounts of mucinous material in the abdominal
cavity Treatment Is usually surgical and consists of cytoreductive
surgery (and often peritonectomy c.f Sugarbaker procedure) combined
with intra peritoneal chemotherapy with mitomycin C. Survival is
related to the quality of primary treatment and in Sugarbakers own
centre 5 year survival rates of 75% have been quoted. Patients with
disseminated intraperitoneal malignancy from another source fare
far worse. In selected patients a second look laparotomy is
advocated and some practice this routinely. Theme: Abdominal pain
A. Acute mesenteric embolus B. Acute on chronic mesenteric
ischaemia
52. C. Mesenteric vein thrombosis D. Ruptured abdominal aortic
aneurysm E. Pancreatitis F. Appendicitis G. Acute cholecystitis
Please select the most likely underlying diagnosis from the list
above. Each option may be used once, more than once or not at all.
13. A 72 year old man collapses with sudden onset abdominal pain.
He has been suffering from back pain recently and has been taking
ibuprofen. Ruptured abdominal aortic aneurysm Back pain is a common
feature with expanding aneurysms and may be miss classified as
being of musculoskeletal origin. 14. A 73 year old women collapses
with sudden onset of abdominal pain and the passes a large amount
of diarrhoea. On admission she is vomiting repeatedly. She has
recently been discharged from hospital following a myocardial
infarct but recovered well. You answered Mesenteric vein thrombosis
The correct answer is Acute mesenteric embolus Sudden onset of
abdominal pain and forceful bowel evacuation are features of acute
mesenteric infarct. 15. A 66 year old man has been suffering from
weight loss and develops severe abdominal pain. He is admitted to
hospital and undergoes a laparotomy. At operation the entire small
bowel is infarcted and only the left colon is viable. You answered
Mesenteric vein thrombosis The correct answer is Acute on chronic
mesenteric ischaemia This man is likely to have underlying chronic
mesenteric vascular disease. Only 15% of emboli will occlude SMA
orifice leading to entire small bowel infarct. The background
history of weight loss also favours an acute on chronic event.
53. Mesenteric vessel disease Mesenteric ischaemia accounts for
1 in 1000 acute surgical admissions. It is primarily caused by
arterial embolism resulting in infarction of the colon. It is more
likely to occur in areas such as the splenic flexure that are
located at the borders of the territory supplied by the superior
and inferior mesenteric arteries. Types Acute mesenteric embolus
(commonest 50%) Sudden onset abdominal pain followed by profuse
diarrhoea. May be associated with vomiting. Rapid clinical
deterioration. Serological tests: WCC, lactate, amylase may all be
abnormal particularly in established disease. These can be normal
in the early phases. Acute on chronic mesenteric ischaemia Usually
longer prodromal history. Post prandial abdominal discomfort and
weight loss are dominant features. Patients will usually present
with an acute on chronic event, but otherwise will tend not to
present until mesenteric flow is reduced by greater than 80%. When
acute thrombosis occurs presentation may be as above. In the
chronic setting the symptoms will often be those of ischaemic
colitis (mucosa is the most sensitive area to this insult).
Mesenteric vein thrombosis Usually a history over weeks. Overt
abdominal signs and symptoms will not occur until venous thrombosis
has reached a stage to compromise arterial inflow. Thrombophilia
accounts for 60% of cases. Low flow mesenteric infarction This
occurs in patients with multiple co morbidities in whom mesenteric
perfusion is significantly compromised by overuse of inotropes or
background cardiovascular compromise. The end result is that the
bowel is not adequately perfused and infarcts occur from the mucosa
outwards. Diagnosis Serological tests: WCC, lactate, CRP, amylase
(can be normal in early disease). Cornerstone for diagnosis of
arterial AND venous mesenteric disease is CT angiography scanning
in the arterial phase with thin slices (