Acute abdomen

Question 1

M:
A 23 year old woman presents with a 24 hour history of right illiac fossa pain. There is tenderness and guarding in the right illiac fossa. There are no menstrual symptoms. Abdominal and pelvic ultrasound are normal.

Answer 1

Diagnostic laparoscopy

An abdominal and pelvic CT scan would normally be ordered in situations like this, with possible appendicitis, but it is assumed here that the doctors were thinking of pregnancy as a possibility so a sonogram was done instead, which turns out to be inconclusive. Now, in this situation, you could do an abdominal MRI (especially in early pregnancy) or go ahead with a CT scan anyway, but a diagnostic laparoscopy is the best option here to diagnose and treat at the same time. The main differential here is either obstetric, such as a ruptured ectopic pregnancy, or acute appendicitis. You would have imagined they would have done the usual important tests like FBC and a urinary pregnancy test… but these results are not available, nor are they an option, but a prudent doctor would have ordered them in the diagnostic work up. However, given USS does not show a mass in the fallopian tubes, this may push you away from an ectopic pregnancy… however, USS is operator dependent, this is a female of childbearing age (this age is getting lower and lower in the UK) and the doctor has failed to obtain either serum or urine HCG levels or asked about any missed menstrual periods.

This patient, should be made NBM with maintenance IV fluids like lactated Ringer’s, and have a laparotomy/laparoscopy which can be both diagnostic and therapeutic. You can take the appendix out if this is the problem or deal with the ectopic, if that is the problem, or deal with whatever it could be.. say for instance, a rare Meckel’s diverticulitis.

Question 2

A 30 year old man presents with severe left loin pain, which is colicky in nature. It radiates to the left groin.

Answer 2

CT scan

This patient has renal colic which classically presents with severe flank pain radiating to the groin. Infection may complicate renal calculi. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy though, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition.

In reality the first test to order is urinalysis – it is quick and simple. You’d also always exclude ectopic pregnancy with a urine pregnancy test if this were a female of childbearing age, look for hypercalcaemia and hyperuricaemia and perform a FBC to look for infection.

Question 3

A 45 year old man presents with sudden onset epigastric pain, constant in nature. He has had several previous episodes. He drinks half a bottle of whisky a day.

Answer 3

Serum amylase

This patient has acute pancreatitis – the cause here being alcohol. He is describing mid-epigastric pain. This pain classically radiates around to the back, which in itself is almost diagnostic. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the causes of acute pancreatitis (GET SMASHED). Those caused by hypocalcaemia may also display Chvostek’s sign and Trousseau’s sign.

Key to diagnosis is serum amylase or lipase levels which are massively elevated. Prognostic criteria are outlined in Ranson’s criteria applied on admission and after 48 hours, or the modified Glasgow score which you can find in your Oxford Handbook. An abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.

Question 4

A 70 year old woman underwent a right hemicolectomy for caecal cancer 5 years ago. She presents with abdominal distension, colicky pain and profuse vomitting. There is minimal abdominal tenderness.

Answer 4

NG tube

Bowel obstruction has several causes such as adhesions or cancer in the older patient. In this case the PMH of recent surgery suggests adhesions as a likely aetiology. The profuse vomiting, distended and colicky painful abdomen are indicative. There may also be increased tinkling high pitched bowel sounds. The proximal segment of bowel dilates and distal bowel collapses. Completely obstructed patients generally require surgery. If, on AXR, air is seen to be seeping past the obstruction then the obstruction is partial. As a standard, all patients should be made NBM and given supplemental oxygen, IV fluids and NG decompression (to reduce flow/gastric contents/air towards the obstruction), unless they are rushed off for an emergency laparotomy because, for example, they have complete obstruction and are peritonitic.

Question 5

A 46 year old woman presents with a 1 day history of right upper quadrant pain, radiating around the right side of the chest. She says her urine may be darker than usual. Her GP started her on oral antibiotics. Amylase has already been ordered.

Answer 5

Ultrasound scan

Abdominal ultrasound is ordered when a patient presents with biliary pain and is the single best test for cholelithiasis (though has a low sensitivity for choledocholithiasis). Note that cholelithiasis refers to stones in the gallbladder and choledocholithiasis refers to stones in the bile duct. If stones are found then this would give weight to a diagnosis of acute cholecystitis. There are symptoms here of obstructive jaundice due to gallstone obstruction of bile outflow. Serum amylase would also be ordered in any patient presenting with pain located in the epigastric region, to rule out acute pancreatitis. This has been done here. In this patient you would also order LFTs, FBC looking for evidence of inflammation. MRCP, ERCP and EUS can be considered if necessary.

Question 6

A 78 year old woman has a 3 day history of constant left iliac fossa pain. She has a pyrexia of 38 degrees Celsius and left iliac fossa tenderness and guarding. The CT scan demonstrates an inflamed sigmoid colon with numerous diverticulae

Answer 6

Oral antibiotics

Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. Risk factors for diverticular disease include low dietary fibre and advanced age. Oral antibiotic therapy and analgesia is indicated. If there is no improvement in 72 hours after oral antibiotics then IV antibiotics are indicated. Make sure you understand the differences in the terms: diverticulosis, diverticulitis and diverticular disease.

Question 7

D:
A 33 year old woman has collapsed with severe generalised abdominal pain. She is apyrexial, pulse 140/min BP 90/40. Abdomen is rigid and tender with guarding. She denies being pregnant as she has an intra-uterine device (coil) in situ.

Answer 7

Ruptured ectopic pregnancy

Ectopic pregnancy usually presents between 6-8 weeks after the last normal menstrual period but it can present later on. The risk increases if the woman has had a previous ectopic, surgery on the tubes, genital infections, smokes or uses an IUD. The classic symptoms and signs are pain, vaginal bleeding and amenorrhoea. If the patient is haemodynamically unstable or there is cervical motion tenderness, this may indicate that a rupture has occured or is imminent. Rupture, which is a complication, can present with shock from blood loss and with unusual patterns of referred pain from the presence of intraperitoneal blood. Urine pregnancy test would be expected to confirm pregnancy. Once the patient is confirmed to be pregnant, a transvaginal USS is used to determine the location of the pregnancy. If an intrauterine gestation is visible on USS regardless of whether it is viable, then the chances of having an ectopic pregnancy are incredibly low. Occasionally, an ectopic pregnancy itself can be seen, either as a ‘doughnut sign’ (adnexal mass separate from two clearly seen ovaries) or ‘ring of fire’ (increased blood flood to the ectopic seen on colour Doppler). A transabdominal ultrasound is less sensitive than a TVUS. Treatment approaches can include expactant, medical (methotrexate) or surgical (salpingectomy, salpingostomy).

Question 8

D:
A 28 year old woman has a 24 hour history of severe constant, right loin pain and vomiting. She has had rigors and sweats. Urinalysis reveals blood and protein.

Answer 8

Pyelonephritis

Acute onset fever with rigors, flank pain, vomiting and positive urine dipstick all point to the diagnosis of acute pyelonephritis. Urinalysis is highly sensitive but not very specific. Note that pregnancy is a risk factor for complicated disease as the enlarging uterus compresses the ureters and hormonal changes increase the likelihood of obstructive uropathy. In uncomplicated pyelonephritis, the most common cause is E. coli and gram stain will typically reveal gram negative rods, either E. coli, Proteus or Klebsiella. Gram positive cocci that could be implicated include enterococci and staphylococci. Older patients can often also present non-specifically. Treatment should start before culture results are received to prevent the patient from deteriorating, with empirical antibiotics.

Question 9

D:
A 20 year old man has a 24 hour history of abdominal pain, which started in the para-umbilical region, but seems to have moved to his right iliac fossa. He is tender in this area with guarding and rebound tenderness.

Answer 9

Appendicitis

This is acute inflammation of the appendix. The presentation here is typical of this condition with acute abdominal pain starting in the mid-abdomen and then later localising to the RLQ. This condition is associated with fever, anorexia, N&V and raised neutrophil count. The diagnosis is clinical, though if required, CT scan and USS may show dilation of the appendix outder diameter to >6mm. Definitive treatment here is surgical with the removal of the offending appendix. Note that Rovsing’s sign may be present where pressing on the left side of the abdominal cavity elicits pain in the RLQ. Psoas sign and obturator sign may also be present. These are all rare but do crop up in EMQs. It has been postulated that the higher incidence of this condition in Western society may be attributed to the living conditions and improved personal hygiene.

Question 10

D:
A 60 year old man who has had a previous laparotomy for a perforated duodenal ulcer has a 24 hour history of colicky abdominal pain, absolute constipation and vomiting. He had a distended resonant abdomen and high pitched bowel sounds.

Answer 10

Bowel obstruction
Bowel obstruction has several causes such as adhesions or cancer in the older patient. The cause here is most likely adhesions due to the previous laparotomy this patient has had. The vomiting, distended and painful abdomen and tinkling high pitched bowel signs are all indicative. The proximal segment of bowel dilates and distal bowel collapses. Completely obstructed patients generally require surgery. If, on AXR, air is seen to be seeping past the obstruction then the obstruction is partial. As a standard, all patients should be made NBM and given supplemental oxygen, IV fluids and NG decompression (to reduce flow/gastric contents/air towards the obstruction), unless they are rushed off for an emergency laparotomy because, for example, they have complete obstruction and are peritonitic.

Question 11

D:
A 35 year old woman has a 2 day history of severe abdominal pain and profuse vomiting. She has previously had episodes of RUQ pain, particularly after fatty meals. She is jaundiced and mildly tender in her epigastrum. Pulse 120pbm and BP 90/50.

Answer 11

Cholecystitis
Cholecystitis is acute GB inflammation caused by an obstruction at the cystic duct. It occurs as a major complication of gallstones and classically presents with RUQ pain and fever. There previous episodes of biliary pain here which is a clue. Around 50% of patients who have had one episode of biliary pain will have another within one year. Vomiting is a non-specific symptom which is commonly associated with biliary disease. Mild jaundice is also present in 10% of patients with the condition. This is due to inflammation and oedemaGallstones in EMQs classically involves the Fs (Fat, Forty, Female, Fertile, Fair). USS is the definitive initial investigation. HIDA scanning and MRI may help if the diagnosis remains unclear. Treatment is with cholecystectomy.

Question 12

D:
A 70 year old man, who has a long history of hypertension and a recent history of intermittent back pain, collapses with severe central abdominal pain. The pain radiates to his back.

Answer 12

Ruptured abdominal aortic aneurysm

This is a history of a ruptured AAA. Hypertension is a weak risk factor here. Strong risk factors include male sex (prevalence), female sex (rupture), connective tissue disorders, increased age, FH and cigarette smoking. Males are 4-6 times more likely to have a AAA but female sex increases the risk of rupture. There is the classic abdominal pain radiating to the back here. Examination would likely reveal low BP and compensatory tachycardia due to the blood loss. This has resulted in this patient’s collapse. As this AAA has ruptured, this man will need urgent surgical repair, with standard resuscitation measures. The airway will needed to be managed with supplemental oxygen and ET intubation, a central venous catheter will need to be inserted, an arterial catheter and urinary catheter will also be needed for monitoring, and the target systolic BP is 50-70. Infusing too many fluids may increase the risk of death. The most effective form of surgical repair is an EVAR (endovascular AAA repair), anatomy permitting, otherwise traditional open repair is performed. Open repair has a mortality of 48%. Antibiotics will also be needed to cover bacteria to prevent graft infection. This will be prescribed in line with local protocols.

Question 13

D:
A 43 year old housewife complains of a colicky pain in the right upper quadrant which radiates to the back. Associated symptoms are nausea and vomiting. She says it is brought on by fatty foods and not relieved by pain killers bought over the counter. She is also jaundiced.

Answer 13

Biliary colic
This is cholelithiasis, or gallstones, which is causing biliary colic. The symptoms here are due to the obstruction of the cystic or bile duct, or the erosion of gallstones through the gallbladder. The main causes are defects in cholesterol metabolism and gallbladder hypomotility. Common risk risk factors include older age, female sex, obesity, rapid weight loss, drugs and pregnancy. Jaundice is uncommon in this condition but can develop in patients with choledocholithiasis, which may or may not occur on a background of cholangitis. Nausea often accompanies biliary pain. The pain is also classically worse after food, especially fatty foods. Fever, if present, would suggest a complication such as cholecystitis, cholangitis or pancreatitis. The definitive radiographic test for symptomatic patients is to do an abdominal ultrasound scan (and a CT follow up if unremarkable). MRCP is also an excellent non-invasive imaging method with a high sensitivty and specificity. The definitive treatment is with laparoscopic cholecystectomy. Complications of gallstones include cholecystitis, cholangitis and pancreatitis.

Question 14

D:
An 89 year old retired lady presents with generalised abdominal pain, nausea and vomiting of a week’s history. On questioning she hasn’t opened her bowels and there has been no flatus either.

Answer 14

Bowel obstruction
The cause here in this elderly patient may well be colorectal malignancy, which needs to be considered in all patients who present with large bowel obstruction. The symptom onset here is also gradual which is also suggestive of an enlarging lesion. There may also be recent weight loss and PR bleeding. If this patient had persistent tachycardia, fever and/or abdominal pain and tenderness then you should suspect possible perforation. An urgent surgical opinion is needed in this patient. An erect CXR needs to be ordered initially to assess for intestinal perforation. Diagnosis of obstruction is made on plain AXR. Where doubts exist on XR then contrast enema or CT scan may be useful. The latter may also show the underlying cause such as malignancy, colonic volvulus, stricture or diverticulitis. Note that colonic volvulus tends to be abrupt in onset compared to the other causes where symptom onset tends to be gradual. N&V may be a late sign in large bowel obstruction.

Question 15

D:
A young man was rushed to A&E with right iliac fossa pain. It started in the umbilical region. He says he’s also constipated and on examination is tender on light palpation with guarding.

Answer 15

Appendicitis
There is a currently controversial theory that low dietary fibre is linked with acute appendicitis. Children with appendectomies have low fibre in their diet compared to control. Please see: Naaeder SB, Archampong EQ. Acute appendicitis and dietary fibre intake. West Afr J Med. 1998;17:264-267

Regardless, this is a classical presentation of this condition. This is acute inflammation of the appendix. Typically there is acute abdominal pain starting in the mid-abdomen and then later localising to the RLQ. This condition is associated with fever, anorexia, N&V and raised neutrophil count. The diagnosis is clinical, though if required, CT scan and USS may show dilation of the appendix outder diameter to >6mm. Definitive treatment here is surgical with the removal of the offending appendix. Note that Rovsing’s sign may be present where pressing on the left side of the abdominal cavity elicits pain in the RLQ. Psoas sign and obturator sign may also be present. These are all rare but do crop up in EMQs. It has been postulated that the higher incidence of this condition in Western society may be attributed to the living conditions and improved personal hygiene.

Question 16

D:
An elderly man comes into hospital with abdominal pain and weight loss. Further questioning reveals he has had melaena and altered bowel habit.

Answer 16

Colorectal carcinoma
The symptoms of colorectal cancer are non-specific but the GI symptoms here combined with weight loss should make you suspicious. Symptoms include change in bowel habit, rectal bleeding and anaemia, commonly associated with right sided cancer. Increased frequency or looser stools, especially when combined with rectal bleeding is common in left sided cancers. Distension, weight loss and vomiting are usually associated with advanced disease. Colonoscopy will be needed in this patient for diagnosis and a biopsy of any suspicious lesion found. Main curative treatment is surgical resection. CEA is the classic tumour marker, which is raised in about 80% but is not really sensitive or specific enough to be useful in diagnosis or screening, but is used to monitor treatment and recurrence in those who have already been diagnosed. Key risk factors for this condition include advanced age, APC mutation, IBD, obesity and Lynch syndrome (HNPCC).

Question 17

D:
A 30 year old banker came in with pain in the epigastric region which radiated to his back. He says he can’t keep anything down & sitting forward helps. He is tachycardic, feverish, jaundiced, is in shock and has a rigid abdomen.

Answer 17

Pancreatitis
This patient has acute pancreatitis and is peritonitic. He has vomited (can’t keep anything down) and is describing mid-epigastric pain radiating around to the back, which in itself is almost diagnostic. Tachycardia here is as a result of hypovolaemia. Jaundice here is suggestive of gallstone aetiology with obstruction to the common bile duct, though pancreatic oedema can itself cause jaundice. Nausea and vomiting is not uncommon and can occur with agitation and confusion. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the causes of acute pancreatitis (GET SMASHED). Those caused by hypocalcaemia may also display Chvostek’s sign and Trousseau’s sign.

Question 18

D:
An 18 year old man presents with severe right iliac fossa pain which has been present for about 24 hours. He thinks the pain may have started more centrally. He feels nauseous and has vomited several times. He has a fever and his heart rate is 110bpm

Answer 18

Acute appendicitis
This is acute inflammation of the appendix. The presentation here is typical of this condition with acute abdominal pain starting in the mid-abdomen and then later localising to the RLQ. This condition is associated with fever, anorexia, N&V and raised neutrophil count. The diagnosis is clinical, though if required, CT scan and USS may show dilation of the appendix outder diameter to >6mm. Definitive treatment here is surgical with the removal of the offending appendix. Note that Rovsing’s sign may be present where pressing on the left side of the abdominal cavity elicits pain in the RLQ. Psoas sign and obturator sign may also be present. These are all rare but do crop up in EMQs. It has been postulated that the higher incidence of this condition in Western society may be attributed to the living conditions and improved personal hygiene.

Question 19

D:
A 42 year old homeless man presents to A&E with left-sided abdominal pain which radiates to his back. He appears jaundiced and smells of alcohol.

Answer 19

Acute pancreatitis
The cardinal symptom of acute pancreatitis is a steady, sudden onset abdominal pain which radiates to the back. It is associated with N&V and a history of either gallstones or alcohol intake is often present (these two are by far the main causative factors). Typical signs are epigastric tenderness, fever and tachycardia. Essential for diagnosis are elevated amylase and/or lipase levels. Initial treatment of this man will involve resuscitation with IV fluids and correcting any electrolyte abnormalities, analgesia and glucose control. The main aim is to prevent complications such as renal failure. This patient needs to stop drinking and sort out his life or else he is at risk of developing chronic pancreatitis. Chronic pancreatitis occurs due to recurrent attacks of acute pancreatitis which leads to chronic scarring. The classic characteristics of chronic pancreatitis are glucose intolerance, pancreatic insufficiency and calcifications.

Question 20

D:
A 49 year old man presents with severe right abdominal pain which radiates to the groin. His english is very poor and he is unable to give a good history. He appears very anxious and in a great deal of pain. You notice that he can not lie still, seemingly because of the pain. An abdominal X-ray is entirely normal

Answer 20

Ureteric colic
This patient has right sided renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radio-lucent so an unremarkable AXR does not exclude this diagnosis. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.

Question 21

D:
A 19 year old student presents with abdominal pains and a high fever which has been increasing over the past week. Paracetamol does not help. She has just returned from her gap year backpacking across India. She also suffering from a cough. Examination reveals splenomegaly.

Answer 21

Typhoid
Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic – India, for example, which has the highest incidence of this disease. Mexico should also ring alarm bells. The water supplies are not treated and sanitary conditions are dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection.
This person has a high fever which is a hallmark of infection (sometimes in a step-wise manner) which is not responding to paracetamol (it persists) and blood culture (you need a big sample of blood for testing as count is usually low) here may show a gram negative bacilli. Hepatomegaly and splenomegaly may exist in this condition. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen.

This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated due to resistance to fluoroquinolones in the Indian sub-continent. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.

Question 22

D:
A 68 year old obese Asian man presents with severe upper abdominal pain and nausea. He is sweaty and says he cannot catch his breath. The abdomen looks normal and there are no palpable masses. A full blood count is ordered but the results aren’t back yet.

Answer 22

MI
MI can present with an atypical location of pain, which may be in the epigastrium. The rest of the features here point towards MI. The nature of the pain may also be atypical in real life and may even be burning, throbbing or the patient may just describe feeling uneasy. However, chest pain is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. This is however an important diagnosis not to miss even if the patient presents atypically.

Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained. Cardiac biomarkers include CK-MB and troponin.

Question 23

D:
A 79 year old man who suffers from constipation presents with sudden onset colicky pain in the left iliac fossa. He has not passed stool or flatus for several days. He is generally well and has no history of weight loss. AXR confirms large bowel obstruction.

Answer 23

Sigmoid volvulus
There is no history of surgery here to suggest adhesions. Malignancy would cause a gradual symptom onset. This is also unlikely to be a hernia when compared to a colonic volvulus – especially when constipation is a risk factor. Symptoms in colonic volvulus are abrupt in onset. A volvulus is bowel obstruction occuring due to a loop of bowel twisting on its own mesenteric axis. Broadly speaking, there are three types: small bowel, sigmoid and gastric. A sigmoid volvulus is something you need to be able to recognise on AXR and it appears as a dilated loop of large bowel present in the lower abdomen, resembling a coffee bean shape (or like an upside down U shape). The rest of the bowel is usually dilated. For a caecal volvulus, the caecum leaves the RLQ to appear like a second satomach bubble in the centre of the film. There is often associated small bowel dilation. A gastric volvulus is very rare. Note that in Africa, sigmoid volvulus accounts for up to 50% of cases of bowel obstruction.

Question 24

D:
A 50 year old woman has lost weight over the last few months and has noticed that she has become more constipated than usual. She presents with abdominal pain and distension and has not passed stool for days.

Answer 24

Colon carcinoma
The symptom onset is more gradual here and this excludes a volvulus. The weight loss and GI symptoms in this lady point to colorectal carcinoma as the cause for colonic obstruction. This is more common in older people. When considering epidemiology, approximately 90% of cases of large bowel obstruction are caused by underlying colorectal cancer, 5% by colonic volvulus and 3% from a benign stricture (for example, diverticular, inflammatory, ischaemic etc). The remaining 2% are accounted for by rare conditions such as hernia and endometriosis.

Question 25

D:
A thin 24 year old gentleman has suffered from frequent chest infections since childhood. Last week he had a cough, productive of lots of thick sputum. He comes to the A&E department with abdominal pain and distension and is not passing any stool.

Answer 25

Distal intestinal obstruction syndrome

This is distal intestinal obstruction syndrome, which was previously known as meconium ileus equivalent. Here, abnormal salt and water balance in the intestines can lead to thickened and congealed stool and intestinal mucus which leads to bowel obstruction, usually occuring in the terminal ileum. This is known as meconium ileus in the neonate, and distal intestinal obstruction syndrome after the neonatal period. This condition occurs in patients with cystic fibrosis, which this patient’s history points towards. The first line treatment is with water soluble contrast enema and oral osmotic agents. The patient should be made NBM and an NG tube may also be placed for drainage. If medical management fails then surgery is indicated to resolve the obstruction.

Remember that meconium is the sticky tarry material found in the intestines of newborns and is composed of bile salts, amniotic fluid and substances ingested in utero. It is normally completely evacuated in the first few days following birth due to the trypsin and other pancreatic enzymes. However, in CF, as pancreatic exocrine ducts become blocked, the sticky meconium becomes inspissated and blocks the lower ileum of the newborn leading to obstruction. Furthermore, in some CF patients such as this one, a related disorder, distal intestinal obstruction syndrome, occurs in later life as a result of chronic constipation and malabsorption.

Question 26

D:
A 35 year old builder was lifting some heavy loads. That evening he noticed a lump in his right groin and after some hours it became painful, red and more swollen. He was not able to reduce the lump and by the time he arrives in the A&E department he is tachycardic and pyrexial.

Answer 26

Inguinal hernia
Builders are involved in heavy lifting which increases intra-abdominal pressure, predisposing to the development of a hernia. This hernia has strangulated and is irreducible. This occurs when the blood supply to the contents of a hernia is cut off due to the hernia twisting upon itself. In this case, a loop of bowel has strangulated, leading to intestinal obstruction. Femoral hernias are more likely to strangulate due to their relatively narrow neck. Urgent surgical intervention is needed in this patient with open repair. Treatment differs depending on whether the strangulated bowel is viable or not.

Question 27

Organism:
An 18 year old female presents with acute onset right iliac fossa pain. After a negative beta-HCG test she is taken to theatre for laparoscopy where the appendix is seen to be normal but there is inflammation of the fallopian tubes.

Answer 27

Neisseria gonorrhoea
Pelvic inflammatory disease is an acute ascending infection of the female tract that is often associated with Neisseria gonorrhoeae or Chlamydia trachomatis. Key risk factors include prior infection with chlamydia or gonorrhoea or PID, young age of onset of sexual activity, unprotected sex with multiple partners and IUD use. Signs and symptoms vary and can include tenderness of the lower abdomen, adnexal tenderness and cervical motion tenderness. Fever and cervical or vaginal discharge may also be present. Complications include tubo-ovarian abscess and subsequent infertility or ectopic pregnancy due to scarred or obstructed fallopian tubes.

Question 28

Organism:
A 50 year old gentleman visits his GP complaining of ‘indigestion’ especially if he eats spicy food. He has epigastric pain after eating and has recently lost some weight.

Answer 28

Helicobacter pylori
Helicobacter pylori is the appropriate choice for this question. Epigastric pain and tenderness related to eating a meal is typical of a peptic ulcer. The pain is generally relieved by drinking milk. 80% are duodenal and 20% are gastric. Ulcers may cause iron deficiency anaemia and associated symptoms may feature. Key risk factors are NSAID use, H. pylori infection, smoking and a family history of PUD. Zollinger-Ellison syndrome should be considered if there are multiple ulcers or ulcers refractory to treatment. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs. Testing for Helicobacter pylori can be with breath testing with radiolabelled urea or stool antigen testing. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.

Helicobacter pylori is known to have a role in the aetiology of this condition. If we exclude NSAIDs then 90% of duodenal ulcers and more than 70% of gastric ulcers have Helicobacter pylori infection compared to 30% and 50% in the general population. Infection increases the lifetime risk of getting a peptic ulcer. The likely postulated mechanism is through gastrin and acid hypersecretion (duodenal ulcers) and local mucosal damage (gastric ulcers).

Gastric ulcers classically cause pain which is exacerbated by eating and immediately relieved on vomiting. There is usually also weight loss due to a fear of food and its association with pain. Duodenal ulcers are classically made worse by hunger and are relieved by eating and the patient may wake at night with the pain. As a result, weight gain is typically a feature. In reality, it is difficult to differentiate the site of the ulcer based on these features.

Question 29

Organism:
A 70 year old man comes to the A&E department with a fever and productive cough for the previous week. He also complains of pain in the right upper quadrant. On examination the abdomen is soft and there is no organomegaly.

Answer 29

Streptococcus pneumoniae
The pain in the RUQ here is due to pneumonia of the right lower pulmonary zone. Respiratory symptoms are present here with a productive cough and the patient is feverish. Additionally abdominal examination is unremarkable in every way. A CXR will be needed here as it is the most specific and sensitive test for pneumonia. Remember that sometimes patients with lower lobe pneumonia may present with pain the abdomen.

Question 30

Organism:
A 42 year old intravenous drug user is admitted with jaundice, abdominal distension and right upper quadrant pain. On examination he is found to have a fullness in the right upper quadrant and a fluid thrill in the abdomen.

Answer 30

Hepatitis C
Worldwide, HBV and HCV are also major causes of cirrhosis. This patient has decompensated chronic liver disease with ascites and jaundice. The most common route which HCV is transmitted is through illicit IVDU. Following the acute exposure, most patients (55-85%) will go on to develop chronic hepatitis C. Most infections are asymptomatic. Treatment involves, usually, pegylated interferon and ribavirin with the aim of getting rid of viraemia. Triple therapy is used for the most common genotype 1, and this consists of the above two drugs as well as a HCV protease inhibitor. Long term complications of infection include cirrhosis or HCC. This patient has developed the first complication.

There are classic signs of liver disease with ascites as a sign of decompensation. It is really important to note that HCV is not sexually transmitted. This may sound like a paradox… but HCV is trasmitted by blood, not sex. The reason homosexual intercourse is a risk factor for HCV and HCV is increasing in incidence among homosexual men in London is likely due to traumatic anal intercourse. Hence, the virus is still transmitted by blood. This is what the majority of studies seem to suggest, although there is still a bit of contention here, as there is with whether HIV can be transmitted through oral sex.

This is not hepatitis A which is primarily transmitted via the faecal-oral route. Do you know how HAV infection presents?