Abdominal Pain

Question 1

What are the symptoms of incaecerated/ strangulated hernia?

Answer 1

history of hernia, intermittent, cramp-like abdominal pain; painful bulge; nausea, vomiting, decreased or absent bowel function; absence of flatus; distended abdomen

Question 2

What are the signs of strangulated hernia?

Answer 2

high-pitched (hyperactive) bowel sounds with rushes; distended abdomen, tenderness to abdominal palpation; tender bulge in abdominal wall or inguinal/femoral region; involuntary guarding; or indirect hernia (more common on right than left)

Question 3

What first line investigations would you consider in strangulated hernia?

Answer 3

plain abdominal x-rays: may see dilated loops of bowel
chest x-ray: may see free air under the diaphragm
FBC: may not see any abnormalities with early obstruction; elevated WBC count as bowel infarction develops
serum electrolytes: may not see any abnormalities with early obstruction; may confirm hypochloraemia and hypokalaemia

Question 4

What other investigations would you consider in strangulated hernia?

Answer 4

CT of abdomen and pelvis: may see dilated loops of proximal bowel with collapsed loops posterior to site of obstruction

Question 5

What are the symptoms of cholecystitis?

Answer 5

history of cholelithiasis and biliary colic; intense right upper quadrant pain, lasting more than 30 minutes, exacerbated by eating (especially fatty foods); right shoulder pain (referred pain from the gallbladder may be felt in the right shoulder or interscapular region); fever, nausea, and/or vomiting; more common in women than men

Question 6

What are the signs of cholecystitis?

Answer 6

fever, tachycardia, right upper quadrant tenderness, Murphy’s sign (right upper quadrant tenderness with arrest of inhalation during palpation), palpable gallbladder (30% to 40% of patients), local guarding, and jaundice (mild jaundice present in about 10% of patients)

Question 7

What first line investigations would you consider in cholecystitis

Answer 7

FBC: elevated WBC count
liver function panel: may see elevated alkaline phosphatase, bilirubin, and aminotransferase
right upper quadrant ultrasound: gallstones; thickened gallbladder wall (>4 mm); pericholecystic fluid; may also see ultrasonographic Murphy’s sign

Question 8

What other investigations would you consider in cholecystitis?

Answer 8

cholescintigraphy: no contrast filling in gallbladder; may see patent cystic duct

Question 9

What are the risk factors of cholecystitis?

Answer 9

obesity, age over 50, pregnancy, use of oestrogen, history of liver disease, cirrhosis, and pancreatitis

Question 10

What are the symptoms of gastric ulcer?

Answer 10

background of recurrent upper abdominal pain (dyspepsia); with nausea, vomiting, loss of appetite, and pain made worse by food; weight loss; use of non-steroidal anti-inflammatory drugs; sudden-onset severe upper abdominal pain with fever, nausea, vomiting, and peritoneal signs; referred pain to shoulders secondary to diaphragmatic irritation

Question 11

What are the signs of gastric ulcer?

Answer 11

often points to site of pain (‘pointing sign’); develops into spreading upper abdominal pain; fever, peritoneal signs with guarding and rebound

Question 12

What first line investigation would you consider in gastric cancer?

Answer 12

FBC: microcytic anaemia; elevated WBC count
Serum antibodies to Helicobacter pylori: may be positive
plain abdominal x-rays: may see abdominal free air on erect abdominal film if perforation present

Question 13

What other investigations would you consider in gastric cancer?

Answer 13

upper gastrointestinal series with water-soluble contrast: extravasation of contrast from stomach
oesophagogastroduodenoscopy with biopsy: may show Helicobacter pylori on culture and/or malignancy on histology
fasting serum gastrin level: hypergastrinaemia in Zollinger-Ellison syndrome

Question 14

What are the symptoms of appendicitis?

Answer 14

sudden-onset, constant, severe abdominal pain often periumbilical with migration to right lower quadrant, usually worse on movement; nausea, vomiting, anorexia, fever, diarrhoea, more common in children and young adults; pain may improve after appendix rupture

Question 15

What are the signs of appendicitis?

Answer 15

fever, tachycardia, patient may be lying in right lateral decubitus position with hips flexed; no or decreased bowel sounds; pain commonly originates near the umbilicus or the epigastrium; right lower quadrant (McBurney’s point) tenderness with rigid abdomen; guarding and rebound tenderness; psoas sign (right lower quadrant pain with right thigh extension)

Question 16

What first line investigations would you consider in appendicitis?

Answer 16

FBC: elevated WBC count
human chorionic gonadotrophin (hCG) (if female): variable
CT scan of abdomen and pelvis with intravenous, oral, and rectal contrast: thickened appendix to 5-7 mm; periappendiceal inflammation; appendicolith; periappendiceal abscess; fluid collections; oedema; phlegmon

Question 17

What other investigations would you consider in appendicitis?

Answer 17

right lower quadrant ultrasound: non-compressible appendix of ≥7 mm in anteroposterior diameter appendicolith; interruption of the continuity of the echogenic submucosa; periappendiceal fluid or mass

Question 18

What are the symptoms of ectopic pregnancy

Answer 18

vaginal bleeding with severe, usually unilateral pelvic pain; amenorrhoea or painless vaginal bleeding; history of recent early pregnancy or missed last menstrual period; risk factors include history of ectopic pregnancy, tubal surgery, pelvic inflammatory disease, infertility treatment and pregnancy with an intrauterine device in situ

Question 19

What are the signs of ectopic pregnancy?

Answer 19

may have palpable adnexal mass with or without tenderness; rigid abdomen, guarding, and rebound tenderness with ruptured ectopic leading to haemoperitoneum, tachycardia and hypotension; vaginal bleeding on speculum examination

Question 20

What first line investigations would you consider in ectopic pregnancy?

Answer 20

hCG: positive
FBC: possible anaemia
pelvic ultrasound: blood or pseudogestational sac in uterus,may see ectopic pregnancy, or complex mass in adnexa

Question 21

What other investigation would you consider in ectopic pregnancy?

Answer 21

diagnostic laparoscopy: ectopic pregnancy or complex mass seen

Question 22

What are the symptoms of acute pancreatitis?

Answer 22

acute-onset, constant, severe mid-abdominal/epigastric pain that often radiates to the back; nausea, vomiting; anorexia; history of biliary colic, alcohol misuse, use of specific medicines (e.g., sulphonamides, tetracycline, oestrogens, corticosteroids), trauma, or surgery

Question 23

What are the signs of acute pancreatitis?

Answer 23

varying degrees of abdominal tenderness, usually worse in the epigastric region; guarding, abdominal distension, and reduced or absent bowel sounds; ecchymoses in the skin of one or both flanks (Turner’s sign) and/or the periumbilical area (Cullen’s sign)

Question 24

What first line investigations would you consider in acute pancreatitis?

Answer 24

serum amylase: elevated (3 times the upper limit of normal)
serum lipase: elevated (3 times the upper limit of normal)
FBC: elevated WBC count
LFTs: elevated aspartate transaminase (AST) (>37 IU/L); elevated alanine transaminase (ALT) (>40 IU/L); elevated alkaline phosphatase (>126 IU/L); elevated bilirubin (>1.0 mg/dL)
chemistry panel: elevated glucose >6.4 mmol/L (115 mg/dL)
serum triglycerides: often elevated >5.6 mmol/L (500 mg/dL)

Question 25

What other investigations would you consider in acute pancreatitis?

Answer 25

abdominal ultrasound: may see ascites, gallstones, dilated common bile duct, and enlarged pancreas CT scan of abdomen with oral and intravenous contrast: may see enlarged pancreas, peripancreatic inflammation, and ascites abdominal MRI: may see enlarged pancreas, peripancreatic inflammation, and ascites

Question 26

What are the symptoms of acute diverticulitis?

Answer 26

persistent left lower quadrant pain; fever, anorexia, nausea, vomiting, and abdominal distension (with ileus), patient may have a known history of diverticulosis

Question 27

What are the signs of acute diverticulitis?

Answer 27

fever; left lower quadrant tenderness; frank blood in stool; diffuse tenderness with peritoneal signs (guarding, rebound tenderness, rigid abdomen) with perforation or ruptured abscess

Question 28

What first line investigations would you consider in acute diverticulitis?

Answer 28

FBC: elevated WBC count CT abdomen/pelvis with intravenous, oral, and rectal contrast: may see diverticula, inflammation of pericolonic fat, thickening of the bowel wall, free abdominal air, and an abscess abdominal ultrasound: may see fluid collections around the colon or a thickened hypoechoic bowel wall

Question 29

What other investigations would you consider in acute diverticulitis?

Answer 29

water-soluble contrast enema: may see diverticula along with extravasation of contrast material into an abscess cavity or into the peritoneum endoscopy: may see inflamed diverticulum, abscess and perforation laparoscopy: allows direct visualisation of bowel if diagnosis is unclear

Question 30

What are the symptoms of ulcerative colitis?

Answer 30

bloody mucous diarrhoea and/or frank blood; fever, abdominal pain, weight loss, and growth retardation; back and joint pain and stiffness

Question 31

What are the signs of ulcerative colitis?

Answer 31

abdominal tenderness; fevers; skin rash; episcleritis; pallor; guaiac-positive stools or frank blood on rectal exam

Question 32

What first line investigations would you consider in ulcerative colitis?

Answer 32

FBC: variable degree of anaemia, leukocytosis, or thrombocytosis comprehensive metabolic panel (including LFTs): hypokalaemic metabolic acidosis; elevated sodium and urea; elevated alkaline phosphatase, bilirubin, AST, and ALT; hypoalbuminaemia stool studies: negative culture and Clostridium difficile toxins A and B; WBCs present; elevated faecal calprotectin plain abdominal radiograph: dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to ≥6 cm in diameter CT abdomen/pelvis with oral and intravenous contrast: may show thickening, inflammation, abscess, fistulisation, obstruction of the bowel; biliary dilation suggests primary sclerosing cholangitis colonoscopy/sigmoidoscopy: rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild 'backwash' ileitis in pancolitis) biopsies: continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata, and anal sparing; only mucosal/submucosal involvement

Question 33

What other investigations would you consider in ulcerative colitis?

Answer 33

double-contrast barium enema: results range from a fine granular appearance of the bowel wall to diffuse ulceration, thumbprinting (due to mucosal oedema), and narrowing and shortening of the bowel, depending on the severity of the disease serological markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA): about 70% of patients with ulcerative colitis have positive pANCA; about 70% of patients with Crohn's disease have positive ASCA radionuclide studies: positive areas of inflammation

Question 34

What are the differentials for right upper hypochrondrium pain?

Answer 34

``` Costochondritis Biliary Colic (Gallstones) Hepatitis Renal Colic Pneumonia ```

Question 35

What are the differentials for left upper hypochondrium pain?

Answer 35

``` Pneumonia Costochondritis Spleen infection Splenomegaly Renal Colic Constipation Spleen rupture ```

Question 36

What are the differentials for epigastric pain?

Answer 36

``` GORD MI Gastritis Oesophagitis Peptic Ulcer Pancreatitis Biliary Tract Disease ```

Question 37

What are the differentials for umbilical region pain?

Answer 37

Appendicitis Mesenteris Adenitis Meckel's Diverticulum

Question 38

What are the differentials for right flank pain?

Answer 38

Renal Colic | Pyelonephritis

Question 39

What are the differentials for left flank pain?

Answer 39

Renal Colic | Pyelonephritis

Question 40

What are the differentials for right iliac fossa pain?

Answer 40

``` Apendicitis Crohn's Disease Ovarian Cyst Ovarian Torsion Ectopic Pregnancy Hernia ```

Question 41

What are the differentials for suprapubic pain?

Answer 41

Urinary Retention Cystitis Endometriosis Menstrual Cramps

Question 42

What are the differentials for left iliac fossa pain?

Answer 42

``` Diverticulitis Ulcerative Colitis Constipation Ovarian Cyst Hernia Ectopic Pregnancy ```

Question 43

What are the symptoms of crohn's disease?

Answer 43

family history of Crohn's disease; typical age range 15-40 or 60-80 years; fevers, abdominal pain, prolonged intermittent bloody or non-bloody diarrhoea; fatigue; anal discharge and abscess; weight loss; growth retardation in children

Question 44

What are the signs of crohn's disease?

Answer 44

abdominal tenderness often periumbilical or right lower quadrant if terminal ileum inflamed, mimicking appendicitis; perianal disease with fissures, skin tags fistulae, sinuses, and abscesses; aphthous ulcers; guaiac-positive stools or frank blood on rectal exam

Question 45

What first line investigations would you consider in crohn's disease?

Answer 45

FBC: anaemia; leukocytosis; may be thrombocytosis comprehensive metabolic panel: hypoalbuminaemia, hypocholesterolaemia, hypocalcaemia C-reactive protein and erythrocyte sedimentation rate: elevated iron studies (serum iron, serum ferritin, total iron binding capacity, transferrin saturation): normal, or may demonstrate changes consistent with iron deficiency serum vitamin B12: may be normal or low serum folate: may be normal or low stool testing: absence of infectious elements seen on microscopy or culture plain abdominal films: small bowel or colonic dilation; calcification; sacroiliitis; intra-abdominal abscesses CT abdomen: skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulae Yersinia enterocolitica serology: negative

Question 46

What other investigations would you consider in crohn's disease?

Answer 46

MRI abdomen/pelvis: skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulae abdominal and pelvic ultrasonography: bowel wall thickening, surrounding inflammation, abscess; tubo-ovarian abscess colonoscopy: aphthous ulcers, hyperaemia, oedema, cobblestoning, skip lesions tissue biopsy: mucosal bowel biopsies demonstrate transmural involvement with non-caseating granulomas technetium-99 labelled WBC scanning: increased uptake in the inflamed segments oesophagogastroduodenoscopy: aphthous ulcers; mucosal inflammation wireless capsule endoscopy: aphthous ulcers; hyperaemia; oedema; cobblestoning; skip lesions autoantibodies: positive anti- Saccharomyces cerevisiae mannan antibodies and negative perinuclear neutrophil cytoplasmic antibodies

Question 47

What are the symptoms of cholelithiasis?

Answer 47

right upper quadrant or epigastric pain (lasting more than 30 minutes) sometimes associated with food

Question 48

What are the signs of cholelithiasis?

Answer 48

right upper quadrant or epigastric tenderness; jaundice

Question 49

What first line investigations would you consider in cholelithiasis?

Answer 49

LFTs: may be normal or elevated alkaline phosphatase and elevated bilirubin abdominal ultrasound: demonstrates stones in the gallbladder serum lipase and amylase: elevated (>3 times upper limit of normal) in acute pancreatitis

Question 50

What other investigations would you consider in cholelithiasis?

Answer 50

endoscopic retrograde cholangiopancreatography (ERCP): ERCP demonstrates stones in the gallbladder or bile duct magnetic resonance cholangiopancreatography (MRCP): MRCP demonstrates stones in the gallbladder or bile duct

Question 51

What are the symptoms of gastrointestinal malignancy?

Answer 51

nausea, vomiting, abdominal pain and distension (especially with distal obstruction); little or no flatus or bowel function; weight loss; black stools

Question 52

What are the signs of GI malignancy?

Answer 52

distended abdomen, high-pitched (hyperactive) bowel sounds with rushes; tenderness to abdominal palpation, involuntary guarding; tachycardia; may have palpable mass

Question 53

What first line investigations would you order in GI malignancy?

Answer 53

CBC: variable level of anaemia renal function: normal, except if advanced pelvic disease is compressing ureters liver biochemistry: normal, except if liver metastases present faecal occult blood testing: positive chest x-ray: normal or evidence of metastatic disease oesophagogastroduodenoscopy with biopsy: may show upper gastrointestinal ulcer, mass, or mucosal changes and provide histological confirmation colonoscopy with biopsy: ulcerating exophytic mucosal lesion that may narrow the bowel lumen; histological confirmation CT thorax/abdomen/pelvis with oral and intravenous contrast: hypodense lesions around tumour site or at distance metastatic sites (e.g. liver); colonic wall thickening, enlarged lymph nodes, liver metastases, ascites, lung secondaries; invasion of mesorectal fascia CT colonography: appearances similar to conventional colonoscopy, with an ulcerating exophytic mucosal lesion that may narrow the bowel lumen

Question 54

What other investigations would you consider in GI malignancy?

Answer 54

upper gastrointestinal endoscopic ultrasound: determines clinical tumour (T) and node (N) stage of upper gastrointestinal tumours transrectal endoscopic ultrasound: with rectal cancer enlarged perirectal lymph nodes indicate malignant involvement; invasion through the submucosa and into muscularis propria identifies a T2 tumour and extension of tumour into perirectal space identifies a T3 tumour carcinoembryonic antigen: elevated in colorectal cancer

Question 55

What symptoms are present in Mallory-Weiss tear?

Answer 55

vomiting or coughing with subsequent haematemesis; retrosternal, epigastric, or back pain; melena; presyncope/syncope; dysphagia, odynophagia

Question 56

What signs are present in Mallory Weiss tear?

Answer 56

postural/orthostatic hypotension; pallor, tachycardia

Question 57

What first line investigations would you consider in Mallory Weiss tear?

Answer 57

upright chest x-ray: may show free air oesophagogastroduodenoscopy: bleeding, adherent clot, or fibrous rind over an area of mucosal split at or near the gastro-oesophageal junction

Question 58

What are the symptoms of hepatitis?

Answer 58

high-risk activities (e.g., perinatal exposure, family history of hepatitis B virus infection, multiple sexual partners, men who have sex with men, injection drug users, intravenous drug use, blood transfusions), right upper quadrant pain; fever, chills, fatigue, myalgia/arthralgia; nausea, vomiting; jaundice

Question 59

What are the signs of hepatitis?

Answer 59

right upper quadrant tenderness; hepatosplenomegaly; jaundice; ascites; maculopapular or urticarial rash

Question 60

What first line investigations would you consider in hepatitis?

Answer 60

FBC: elevated; non-specific LFTs: elevated transaminases (ALT/AST), alkaline phosphatase, and bilirubin serum electrolytes: normal or deranged

Question 61

What other investigations would you consider in hepatitis?

Answer 61

ultrasound right upper quadrant: poorly defined margins and coarse, irregular internal echoes in hepatitis B hepatitis serology: positive prothrombin time: prolonged

Question 62

What are the symptoms of gastroenteritis?

Answer 62

nausea, vomiting, diarrhoea, crampy abdominal pain; history of sick contacts with similar symptoms; ingestion of questionable food or water; recent travel to places with unsanitary conditions

Question 63

What are the signs of gastroenteritis?

Answer 63

dehydration; tachycardia; soft, non-distended abdomen; diffuse abdominal tenderness

Question 64

What first line investigations would you consider in gastroenteritis

Answer 64

CBC: elevated WBC count serum electrolytes and urea: variable, may show dehydration stool culture: may identify infectious agent faecal occult blood: may be positive

Question 65

What other investigations would you consider in gastroenteritis?

Answer 65

stool leukocytes: positive | CT abdomen/pelvis with oral and intravenous contrast: may show non-specific thickening of affected bowel

Question 66

What are the symptoms of renal colic?

Answer 66

previous history of kidney stones; may be asymptomatic to severe abdominal flank pain radiating to the groin; other symptoms include nausea, vomiting, diaphoresis, haematuria; urinary frequency/urgency; occupations in hot conditions (e.g., chefs, steel workers); family history of stones

Question 67

What are the signs of renal colic?

Answer 67

often obese; abdomen soft; when in pain, may be severe, unable to find comfortable position; tender to palpation/percussion of costovertebral angle/flank; if urosepsis also present may be tachycardic, hypotensive, pyrexial

Question 68

What first line investigations would you consider in renal colic?

Answer 68

urinalysis: dipstick positive for leukocytes, nitrates, blood; microscopic analysis positive for WBCs, RBCs, or bacteria; may be normal CBC and differential: normal or raised WBC count serum electrolytes, urea, and creatinine: normal or deranged uric acid level: normal or elevated kidneys, ureters, bladder (KUB) x-ray: calcification seen within urinary tract non-contrast helical CT abdomen/pelvis (stone protocol): calcification seen in renal collecting system or ureter

Question 69

What are the other investigations that you would do in renal colic?

Answer 69

intravenous pyelogram: calcification seen within urinary tract or a filling defect seen when dye is passing through the kidney and down the ureter renal ultrasound: calcification seen within urinary tract retrograde urethrogram: calcification seen within urinary tract or a filling defect seen

Question 70

What are the symptoms of pyelonephritis?

Answer 70

family history of kidney stones; history of urinary tract infection, stress incontinence, or frequent sexual intercourse; fever with chills; dysuria, frequency, urgency; flank pain; nausea, vomiting, diaphoresis, haematuria

Question 71

What are the signs of pyelonephritis?

Answer 71

pyrexia; flushed looking; flank pain and/or costovertebral angle tenderness on palpation/percussion

Question 72

What are the first line investigations of pyelonephritis?

Answer 72

urinalysis: pyuria (>10 WBCs per high-power field [HPF]), RBCs ≥5/HPF, leukocyte esterase, nitrites, WBC casts, proteinuria up to 20 g/L (2 g/dL) Gram stain: typically gram-negative rods; less typically gram-positive cocci urine culture: positive FBC: leukocytosis C-reactive protein: elevated

Question 73

What other investigations would you consider in pyelonephritis?

Answer 73

blood cultures: may be positive CT abdomen/pelvis with intravenous contrast: altered renal parenchymal perfusion; altered excretion of contrast; perinephric fluid; non-renal disease; may show abscess formation 99mTc-dimercaptosuccinic acid scintigraphy: inflammation or scarring of the renal cortex; unequal distribution of renal function between the kidneys MRI: structural anomalies of the genitourinary system (prenatal); renal inflammation or masses; abnormal renal vasculature; urinary obstruction renal ultrasound: gross structural abnormalities; hydronephrosis; stones; perirenal fluid collections

Question 74

What are the symptoms of volvulus?

Answer 74

steady abdominal pain that may have colicky characteristics varying from vague discomfort to excruciating (severe unremitting pain suggests gangrenous bowel); history of abdominal surgery, abdominal or inguinal hernia; nausea, vomiting, emesis may be absent in patients with sigmoid volvulus (more common in older or debilitated patients); periumbilical or hypogastric pain, diarrhoea or constipation (depending on the degree and location of the obstruction)

Question 75

What are the signs of volvulus?

Answer 75

often diffuse abdominal distension and tenderness; faint or no bowel sounds, rigid abdomen, guarding, rebound tenderness, fever, or haematochezia

Question 76

What first line investigations would you consider in

Answer 76

plain abdominal x-rays: partial or complete obstruction; dilated bowel loops; air-fluid levels; abdominal free air with perforation FBC: elevated WBC count

Question 77

What other investigations would you consider in volvulus?

Answer 77

barium or water-soluble contrast enema: bird's-beak sign of stricture at the site of the volvulus CT of abdomen: bowel obstruction with whirl pattern of mesentery

Question 78

What are the symptoms of duodenal ulcer?

Answer 78

acute onset of severe epigastric pain, nausea, vomiting, and loss of appetite; more common in men than women; history of melaena or bright red blood from rectum, episodic epigastric pain relieved by eating; use of non-steroidal anti-inflammatory drugs; may have latent period with symptom improvement that may last several hours, followed by peritonitis with fever, nausea, vomiting, and peritoneal signs; referred pain to shoulders secondary to diaphragmatic irritation

Question 79

What are the signs of duodenal ulcer?

Answer 79

tachycardia, fever, epigastric tenderness, rigid abdomen, guarding, rebound tenderness, and occult or frank blood in stool

Question 80

What first line investigations would you consider on someone with duodenal ulcer?

Answer 80

Helicobacter pylori breath test or stool antigen test: positive result if H pylori present FBC: elevated WBC count

Question 81

What other investigations would you do on someone with duodenal ulcer?

Answer 81

upper gastrointestinal series with water-soluble contrast: extravasation of contrast from stomach or duodenum esophagogastroduodenoscopy with biopsy: visualisation of ulcer; histological confirmation stool haem test: changes colour if occult blood is present

Question 82

What are the symptoms of acute mesenteric ischaemia and infarction?

Answer 82

age > 50 years; constant periumbilical non-radiating abdominal pain; recent history of post-prandial abdominal pain; history of atrial fibrillation, coronary artery disease, myocardial infarction, and congestive heart failure; melaena or bright red blood from rectum, and patient taking vaso-active medicines; risk factors include smoking, hypertension, hyperlipidaemia, and diabetes

Question 83

What are the signs of acute mesenteric ischaemia and infarction?

Answer 83

initially, pain out of proportion to exam findings with soft, non-tender abdomen despite severe abdominal pain, followed by rigid abdomen, guarding, and rebound tenderness with bowel necrosis and perforation, and, in advanced cases, fever, tachycardia, and hypotension will be present

Question 84

What first line investigation would you do on someone with acute mesenteric ischaemia and infarction?

Answer 84

CT of abdomen: vessel thrombosis; thickened bowel wall; abnormal bowel wall enhancement; pneumatosis; portal or mesenteric venous gas plain abdominal x-rays: may see dilated loops of bowel; may see formless loops of large or small bowel; pneumatosis; vascular gas FBC: elevated WBC count lactic acid analysis: elevated

Question 85

What other investigation would you do on someone with acute mesenteric ischaemia and infarction?

Answer 85

mesenteric angiography: arterial or venous obstruction

Question 86

What are the symptoms of DKA?

Answer 86

inadequate or inappropriate insulin therapy, infection (pneumonia and urinary tract infections are the most common), myocardial infarction; anorexia, nausea, vomiting, polyuria, thirst; abdominal pain; fever; dizziness, weakness, mental status change

Question 87

What are the signs of DKA?

Answer 87

acetone breath; deep, laboured, gasping breathing (Kussmaul's breathing); signs of hypovolaemia (tachycardia, hypotension, poor capillary refill, sunken eyes); abdominal tenderness; altered mental status

Question 88

What first line investigations would you consider in DKA?

Answer 88

plasma glucose: elevated serum electrolytes and urea: usually sodium low, potassium elevated, chloride low, magnesium low, calcium low, phosphate normal or elevated, urea elevated, creatinine elevated arterial blood gases: pH varies from 7.00 to 7.30 in diabetic ketoacidosis (DKA); arterial bicarbonate ranges from <10 mmol/L (<10 mEq/L) in severe DKA to >15 mmol/L (>15 mEq/L) in mild DKA urinalysis: positive for glucose and ketones; positive for leukocytes and nitrites in the presence of infection serum ketones: positive CBC: elevated WBC count

Question 89

What are the symptoms of hypercalcaemia?

Answer 89

bone pain; depression; fatigue; confusion; nausea, anorexia; constipation; abdominal or flank pain; polyuria, polydipsia

Question 90

What are the signs of hypercalcaemia?

Answer 90

non-specific findings; abdominal pain, hyperreflexia, tongue fasciculations, bony tenderness on palpation; hypertension and bradycardia

Question 91

What first line investigations would you do in hypercalacemia?

Answer 91

corrected or ionised calcium: elevated 12-lead ECG: typically short QT interval and widened T waves serum parathyroid hormone: elevated

Question 92

What are the other investigations that you would in hypercalcaemia?

Answer 92

ultrasound neck: may indicate hyperparathyroidism nuclear scan neck: may indicate hyperparathyroidism MRI neck: may indicate hyperparathyroidism CT abdomen/pelvis with oral and intravenous contrast: may indicate alternative source of acute abdomen