Abdomen Flashcards
A 52 year old thin lady reports a painless mass in the groin area. A mass is noted on coughing. It is below and lateral to the pubic tubercle. What is the most likely cause?
Direct inguinal hernia Indirect inguinal hernia Femoral hernia Obturator hernia Lipoma
Femoral hernia
-mass below and lateral to the pubic tubercle
Groin masses are common and include: Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm Saphena varix (more a swelling than a mass!)
An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following forms the posterior wall of the femoral canal?
Pectineal ligament Lacunar ligament Inguinal ligament Adductor longus Sartorius
Pectineal ligament
Borders of the femoral canal -Laterally Femoral vein -Medially Lacunar ligament -Anteriorly Inguinal ligament -Posteriorly Pectineal ligament
A 14 month old child is admitted with colicky abdominal pain and on investigation is found to have an ileo-ileal intussusception. What is the best course of action?
Attempt hydrostatic reduction with barium enema
Attempt pneumatic reduction with air insufflation
Undertake a laparotomy
Undertake a colonoscopy
Undertake a flexible sigmoidoscopy
Undertake a laparotomy
Ileo-ileal intussusception are far less common than the ileo-colic variant. However, where they occur, they require surgery and are not amenable to pneumatic reduction.
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?
Haematoma Intra abdominal adhesions Anastomotic leak Anastomotic stricture Obstructed incisional hernia
Obstructed incisional hernia
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.
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 adhesions are noted between the liver and abdominal wall. Her appendix is normal. What is the most likely diagnosis?
Mesenteric infarct Fitz Hugh Curtis Syndrome Perforated peptic ulcer Appendicitis Pancreatitis
Fitz Hugh Curtis Syndrome
This is Fitz Hugh Curtis syndrome in which pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions.
Appendicitis
Features
- migratory pain
- fever
- anorexia
- evidence of right iliac fossa tenderness
- mild pyrexia
rare
-diarrhoea and profuse vomiting
INV
- differential WBC
- B-hCg
- C-reactive protein
- amylase
- urine dipstick
Tx
-appendicectomy
Mesenteric adenitis
Features
- recent upper URTI
- high fever
- generalised abdominal discomfort-true localised pain and signs
- mainly children
- adenovirus, EBV, haemolytic streptococcus, E.coli
INV
- FBC (increase WBC)
- Urine dipsticks (normal)
- Abdominal US (no free fluid)
Tx
-conservative management appendicectomy if diagnosis doubt
Fitz-Hugh Curtis syndrome
Features
- disseminated infection with chlamydia
- seen in female
- evidence of PID + peri-hepatic inflammation and subsequent adhesion formation
INV
- abdominal US (may show free fluid)
- high vaginal swab (SXI)
TX
-usually medically managed by doxycycline or azithromycin
Abdominal aortic aneurysm (ruptured)
Features
- sudden onset abdominal pain
- radiating to back
- older adults
- collapse
- stable if contained haematoma
- pulsatile mass
INV
- haemodynamically stable patient do CT
TX
-unstable patient immediate surgery
Perforated peptic ulcer
Features
- sudden onset of pain (epigastric) (sharp)
- upper abdominal pain
- generalised abdominal pain
- may have peritonitis
INV
- CXR- free air
- CT if have diagnostic doubt
TX
-Laparotomy
Intestinal obstruction
Features
- colicky abdominal
- pain & vomiting
- may have constipation (depends on site of obstruction)
- peritonism
INV
- plain abdominal film
- CT scan
TX
-laparotomy
Mesenteric infarction
Features
- embolic events
- sudden pain and forceful evacuation
- acute on chronic events (longer history and previously weight loss)
- pain is typically greater than physical signs.
INV
- arterial pH and lactate
- arterial phase CT scanning
TX
-immediate laparotomy resection of segments in acute embolic events SMA embolectomy
Which abdominal sign is described as being present when a patient with cholecystitis experiences pain on palpation of the right upper quadrant most marked on inspiration?
Murphy's sign Boas' sign Rovsing's sign Cullens sign Grey Turners sign
Murphy’s sign
- Rovsings sign- appendicitis
- Boas sign -cholecystitis
- Murphys sign- cholecystitis
- Cullens sign- pancreatitis (other intraabdominal haemorrhage)
- Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
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. What is the most likely cause?
Appendicitis Irritable bowel syndrome Inflammatory bowel disease Infective gastroenteritis Meckels diverticulum
Inflammatory bowel disease
The history of weight loss and intermittent diarrhea makes inflammatory bowel disease the most likely diagnosis.
Diverticulitis
Features
- both left and right side disease may present with right iliac fossa pain
- change in bowel habits
INV
-CT
Meckels diverticulitis
Features
- congenital abnormality present 2%
- 2 feet proximal to ileocecal valve
- may be lined by ectopic gastric mucosal tissue and produce bleeding
Incarcerated right inguinal / femoral hernia
-right iliac fossa pain if right sided or bowel obstruction
Bowel perforation secondary to caecal or colon carcinoma
- seldom localised to right iliac fossa
- complete large bowel obstruction with caecal distension may cause pain priror to perforation
A 78 year old lady is admitted with small bowel obstruction. On examination, she has a distended abdomen and the leg is held semi flexed. She has some groin pain radiating to the ipsilateral knee. What is the most likely diagnosis
Inguinal hernia Obturator hernia Lumbar hernia Spigelian hernia Incisional hernia
Obturator hernia
The groin swelling in obturator hernia is subtle and hard to elicit clinically. There may be pain in the region of sensory distribution of the obturator nerve. The defect is usually repaired from within the abdomen.
Spigelian hernia
- Interparietal hernia occurring at the level of the arcuate line
- Rare
- May lie beneath internal oblique muscle. Usually between internal and external oblique
- Position is lateral to rectus abdominis
- Both open and laparoscopic repair are possible, the former in cases of strangulation
Lumbar hernia
The lumbar triangle (through which these may occur) is bounded by:
- Crest of ilium (inferiorly)
- External oblique (laterally)
- Latissimus dorsi (medially)
- Primary lumbar herniae are rare, most are incisional hernias following renal surgery
- Direct anatomical repair with or without mesh re-enforcement is the procedure of choice
Obturator hernia
Herniation through the obturator canal
- Commoner in females
- Usually lies behind pectineus muscle
- Elective diagnosis is unusual most will present acutely with obstruction
- When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if indicated)
Richters hernia
- condition which part of the wall of small bowel is strangulated within a hernia
- no typical features of intestinal obstruction as lumenal patency is preserved
- vomiting prominent due to paralytic ileus from peritonitis (hernia perforated)
Incisional hernia
- sites of surgical access into abdominal cavity
- common wound infection
- repair either open or laparoscopically
Bochdalek hernia
- congenital diaphragmatic hernia
- 85% cases are located in the left hemi diaphragm
- associated with lung hypoplasia on the affected site
- common in male
- associated with other birth defects
- may contain stomach
- may be treated by direct anatomical apposition or placement of mesh
Morgagni Hernia
- rare type diaphragmatic hernia
- herniation through foramen of morgagni
- located on the right and tend to be less symptomatic
- more advanced cases may contain transverse colon
- defect are small pulmonary hypoplasia
- direct anatomical repair is performed
Umbilical hernia
- hernia through weak umbilicus
- childhood
- symptomatic
- by age 2 resolve
- surgery perform after 3rd birthday
Paraumbilical hernia
- condition of adulthood
- defect is in the linea alba
- common in female
- multiparity and obesity are risk factors
- traditionally repaired using mayos technique (overlapping repair, mesh may be used though not if small bowel resection is required owing to acute strangulation
Littres hernia
- Hernia containing Meckels diverticulum
- Resection of the diverticulum is usually required and this will preclude a mesh repair
A 72 year old obese man undergoes an emergency repair of a ruptured abdominal aortic aneurysm. The wound is closed with an onlay prolene mesh to augment the closure. Post operatively he is taken to the intensive care unit. Over the following twenty four hours his nasogastric aspirates increase, his urine output falls and he has a metabolic acidosis. What is the most likely underlying cause?
Colonic ischaemia Abdominal compartment syndrome Peritonitis Reactionary haemorrhage Aorto-duodenal fistula
Abdominal compartment syndrome
Obese patients with ileus following major abdominal surgery are at increased risk of intra abdominal compartment syndrome. The risk is increased by the use of prosthetic meshes, which some surgeons favor following a major vascular case as they may reduce the incidence of incisional hernia. They prevent abdominal distension and may increase the risk of intra abdominal hypertension in the short term. Although colonic ischaemia may occur following major aortic surgery it would not typically present in this way.
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?
Abdominal ultrasound scan Barium enema Rectal MRI Scan Endoanal ultrasound scan Abdominal CT scan
Abdominal CT scan
Patients with suspected large bowel obstruction due to tumour should have this confirmed with gastrograffin enema, sigmoidoscopy or CT scanning prior to surgery.
A 16 year old female presents to the emergency department with a 12 hour history of pelvic discomfort. She is otherwise well and her last normal menstrual period was 2 weeks ago. On examination, she has a soft abdomen with some mild supra pubic discomfort. What is the most likely underlying cause?
Ruptured ectopic pregnancy Degenerating fibroid Pelvic inflammatory disease Appendicitis Mittelschmerz
Mittelschmerz
Mid cycle pain is very common and is due to the small amount of fluid released during ovulation. Inflammatory markers are usually normal and the pain typically subsides over the next 24-48 hours.
Features
- mild, cycle pain
- sharp pain at onset
- little systemic disturbance
- may have recurrent episode
- usually settles over 24-28hr
INV
- FBC
- US (small quantity of free fluid)
TX
-conservative
Endometriosis
Features
- 25% asymptomatic
- 25% associated with other pelvic organ pathology
- 50% menstrual irregularity, infertility, pain and deep dyspareunia.
INV
- US (free fluid)
- Laparoscopy (lesions)
TX
-managed medically, complex disease will often require surgery
Ovarian torsion
Features
- sudden onset of deep seated colicky abdominal pain
- associated with vomiting and distress
- vaginal examination may reveal adnexial tenderness
INV
- US (free fluid)
- laparoscopy (both diagnostic and therapeutic)
TX
-laparoscopy
Ectopic gestation
Features
- symptoms of pregnancy without eveidence of intra-uterine gestation
- sudden abdominal pain
- circulatory collapse
- vaginal discharge
- adnexial tenderness.
INV
-US showing no intra-uterine pregnancy and B-hCG
TX
- laparoscopy or laparotomy
- salphingectomy
Pelvic inflammatory disease
Features
- bilateral lower abdominal pain associated with vaginal discharge
- Dysuria
- peri-hepatic inflammation secondary to chlamydia (fitz Hugh Curtis syndrome)
- right upper quadrant discomfort
- fever >38
INV
- FBC (leucocytosis)
- B-Hcg -
- amylase normal or slightly raised
- high vaginal and urethral swabs
TX
-medical management
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. What is the most likely explanation?
Lymphadenitis Saphena varix Femoral artery aneurysm Abscess Incarcerated hernia
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.
A 22 year old lady undergoes a total thyroidectomy for Graves disease. 6 hours post operatively she develops respiratory stridor and develops a small haematoma in the neck. What is the most appropriate course of action?
Perform a cricothyroidotomy Re-open the neck wound Perform a percutaneous tracheostomy Reassure the patient and prescribe an anxiolytic Insert a nasopharyngeal airway
Re-open the neck wound
This is true emergency and evacuation and release of pressure must be performed immediately, in this case by removal of skin clips on the ward. Attempts to access the airway surgically will delay this and can result in death.
Which of the following signs is seen in patients who have a significant retroperitoneal haemorrhage?
Boas' sign Pembertons sign Grey Turners sign Cullens sign Rovsing's sign
Bruising of the flank is described as Grey Turners sign
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
An 18 year-old female presents to the Emergency Department with sudden onset sharp, tearing pelvic pain associated with a small amount of vaginal bleeding. She also complains of shoulder tip pain. On examination, she is hypotensive, tachycardic and has marked cervical excitation. What is the most likely explanation?
Degenerating fibroid Adnexial torsion Ruptured ectopic pregnancy Ruptured appendicitis Endometriosis
Ruptured ectopic pregnancy
The history of tearing pain and haemodynamic compromise in a women of child bearing years should prompt a diagnosis of ectopic pregnancy
A 1 day old infant is born with severe respiratory compromise. On examination, he has a scaphoid abdomen and an absent apex beat. Which of the following anomalies is most likely?
Situs inversus Morgagni hernia Necrotising enterocolitis Bochdalek hernia Cystic fibrosis
Bochdalek hernia
Bochdalek hernia is a diseases of 3 P’s and 3 B’s
1- Birth defect (congenital)
2- Posterior located
3- Big
4- Bad Prognosis
5- Pulmonary hyPoPlais is common
6- Placement of mesh may be needed to treat
A hernia is the most likely diagnosis given the abdominal findings. The large hernia may displace the heart although true dextrocardia is not present. The associated pulmonary hypoplasia will compromise lung development.
An 11 month-old girl develops sudden onset abdominal pain. Her mother stated that she had not been her usual self for the past 48 hours. Assessing her, she has a high pitched scream and draws up her legs. Her BP is 90/40 mm/Hg, her pulse 118/min and abdominal examination is normal. What is the most likely diagnosis?
Mid gut volvulus Intussusception Appendicitis Mesenteric adenitis Spontaneous bacterial peritonitis
Intussusception
Intussusception should be considered in toddlers and infants presenting with screaming attacks. The child often has a history of being unwell for one to three days prior to presentation. The child may pass bloody mucus stool, which is a late sign. Examination of the abdomen is often normal as the sausage mass in the right upper quadrant is difficult to feel.
An 8 year old boy is examined by his doctor as part of a routine clinical examination. The doctor notices a smooth swelling in the right iliac fossa. It is mobile and he is otherwise well. What is the most likely underlying cause?
Meckels diverticulum Spigelian hernia Mesenteric cyst Appendix mass Liposarcoma
Mesenteric cyst
Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although rare, they most often occur in young children (up to 30% present before the age of 15). Many are asymptomatic and discovered incidentally. Acute presentations are recognised and may occur following cyst torsion, infarction or rupture. Most cysts will be surgically resected.
Spigelian hernias are very rare in children, liposarcomas are not smooth swellings. An appendix mass will usually produce systemic illness.
Which of the following interventions is most likely to reduce the incidence of intra abdominal adhesions?
Peritoneal lavage with cetrimide following elective right hemicolectomy
Use of a laparoscopic approach over open surgery
Use of talc to coat surgical gloves
Performing a Nobles plication of the small bowel
Using stapled rather than a hand sewn anastamosis
Use of a laparoscopic approach over open surgery
Laparoscopy results in fewer adhesions. When talc was used to coat surgical gloves it was a major cause of adhesion formation and withdrawn for that reason. A Nobles plication is an old fashioned operation which has no place in the prevention of adhesion formation. Use of an anastamotic stapling device will not influence the development of adhesions per se although clearly an anastamotic leak will result in more adhesion formation
A 30 year old man is suspected of having appendicitis. At operation an inflamed Meckels diverticulum is found. Which of the following vessels is responsible for the blood supply to a Meckels diverticulum?
Right colic artery Vitelline artery Appendicular artery Internal iliac artery External iliac artery
Vitelline artery
The vitelline arteries supply a Meckels these are usually derived from the ileal arcades.
Meckel’s diverticulum
- This disappears at 6 weeks gestation.
- Associated with enterocystomas, umbilical sinuses, and omphaloileal fistulas.
- Arterial supply: omphalomesenteric artery.
- 2% of population, 2 inches long, 2 feet from the ileocaecal valve.
Normally asymptomatic and an incidental finding.
Complications are the result of obstruction, ectopic tissue, or inflammation.
Removal if narrow neck or symptomatic. Options are between wedge excision or formal small bowel resection and anastomosis.
A 78 year old lady presents with a tender swelling in her right groin. On examination there is a tender swelling that lies below and lateral to the pubic tubercle. It has a cough impulse. What is the most likely underlying diagnosis?
Thrombophlebitis of the great saphenous vein Femoral hernia Thrombophlebitis of saphena varix Inguinal hernia Obturator hernia
Femoral hernia
Whilst a thrombophlebitis of a saphena varix may cause a tender swelling at this site, it would not usually be associated with a cough impulse.
A 21 year old man is admitted with a tender mass in the right groin, fevers and sweats. He is on multiple medical therapy for HIV infection. On examination, he has a swelling in his right groin, hip extension exacerbates the pain. What is the most likely cause?
Septic arthritis Psoas abscess Infected lymph node HIV related lymphadenopathy Femoral hernia
Psoas abscess
Psoas abscesses may be either primary or secondary. Primary cases often occur in the immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may complicated intra abdominal diseases such as Crohns. Patients usually present with low back pain and if the abscess is extensive a mass that may be localised to the inguinal region or femoral triangle . Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous route fails, then surgery (via a retroperitoneal approach) should be performed.
A 5 year old boy develops a persistent fever following an open appendicectomy for gangrenous appendicitis. On examination, he has erythema of the wound and some abdominal distension. What is the most appropriate course of action?
Diagnostic laparoscopy Open the wound Arrange an abdominal ultrasound scan Arrange an abdominal CT scan Arrange an abdominal X-ray
Arrange an abdominal ultrasound scan
This patient has risk factors for a wound infection which is not in itself an indication for scanning. However, he also had abdominal distension and this, together with the history of distension would generally attract a recommendation for imaging. A USS will show an abdominal wall collection and more importantly any phrenic or pelvic collections. Unlike adult practice, CT scanning is rarely performed in children.
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?
Inflammation of Peyers patches Cystic fibrosis Meckels diverticulum Mesenteric cyst Mucosal polyps
Mesenteric cyst
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.
A 67 year old female undergoes an oesophagogastrectomy for carcinoma of the distal oesophagus. She complains of chest pain. The following day there is brisk bubbling into the chest drain when suction is applied. What is the most likely cause?
Anastomotic leak Air leak from lung Chyle leak Bile leak Cutaneous wound breakdown
Air leak from lung
Damage to the lung substance may produce an air leak. Air leaks will manifest themselves as a persistent pneumothorax that fails to settle despite chest drainage. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury
A 5 year old boy is found to have a Meckels diverticulum at an appendicectomy and it looks to be non inflamed. What type of epithelium is most likely to be found in the diverticulum?
Gastric mucosa Non stratified squamous epithelium Ileal mucosa Stratified squamous epithelium Jejunal mucosa
Ileal mucosa
Most asymptomatic Meckels diverticulum will be lined by ileal mucosa. Those which present with bleeding are more likely to contain gastric type mucosa.
Which of the following forms the medial wall of the femoral canal?
Pectineal ligament Adductor longus Sartorius Lacunar ligament Inguinal ligament
Lacunar ligament
The femoral canal and the femoral triangle are distinct anatomical structures. Do not confuse them, especially in the time pressured exam situation.
Borders of the femoral canal Laterally -Femoral vein Medially -Lacunar ligament Anteriorly -Inguinal ligament Posteriorly -Pectineal ligament
In which of the conditions listed below is Cullens sign most likely to be seen?
Ruptured ectopic pregnancy Appendicitis Intestinal malrotation Perforated peptic ulcer Incarcerared femoral hernia
Ruptured ectopic pregnancy
Cullens sign is seen with significant intra peritoneal haemorrhage.
Rovsings sign- appendicitis
Boas sign -
cholecystitis
Murphys sign- cholecystitis
Cullens sign-
pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
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 undertaken as investigation for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal. What is the most likely cause?
Appendicitis Crohns disease Peptic ulcer disease Meckels diverticulum Irritable bowel syndrome
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. The iron deficiency anaemia makes a Meckels more likely than IBD.
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. What type of hernia is this?
Richters hernia Littres hernia Morgagni hernia Spigelian hernia Bochdalek 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
