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)
