Bowel Disease

Question 1

Pain in colon cancer

Answer 1

predominant over the
area of projection of sigmoid colon, intermittent,
associated with constipation

Question 2

Pain in appendicitis

Answer 2

Then: peritoneal irritation, right illiac fossa,
continuous, maxim severity; associated with
nausea, vomiting, diarrhea/constipation, fever

Question 3

Pain in intestinal perforation (acute appendicitis,
diverticulitis)- due to irritation and inflammation
of peritoneum

Answer 3

Sudden onset, severe, localized at the beginning and

then generalized

Question 4

Colic pain
Definition
Causes

Answer 4

= a severe paroxysmal pain in the abdomen, due to the
distention of the hollow viscera and/or muscle spasm
– Causes:
Gastroenteritis- diffuse pain, violent, sudden onset, diarrhea,
vomiting, fever
Mechanical ileus (=obstruction of the bowel arising from a
echanical cause, such as volvulus, a gallstone, or
adhesions)- increased peristalsis and distension proximal of
obstruction: cramp, progressive intensity, after 24 h:
generalized, continuous, severe
Konig sdr. (ileocaecal valve syndrome)= incomplete
obstruction of small bowel (Crohn disease, tuberculosis,
cancer)- intermittent, localized, hyperperistalsis, diarrhea

Question 5

Vascular pain:

Answer 5

produced by mesenteric infarction (mezenteric arteries/veins
thrombosis): sudden onset, severe, umbilical region, melena,
ileus
Due to mesenteric arteries stenosis- sec.to atherosclerosis,
compression: “intestinal angina”(epigastrium/umbilical region,
constrictive, after meal)

Question 6

Flatulences cause and

Normal volume

Answer 6

200-2000ml per day
– air swallowing (aerophagy): may indicate anxiety
– lactase deficiency
– intestinal malabsorption
– small bowel obstruction.

Question 7

Ileus definition mechanical, dynamic

Answer 7

– Dynamic (paralytic) ileus- postoperative ileus,
peritonitis
Ogilvie sdr.= acute pseudoobstruction and dilation of colon in
absence of any mechanical obstr.(after surgery- coronary
artery bypass)
– Mechanical: complete obstruction- due to:
compressions (extrinsic, intrinsic), volvulus,
strangulated hernia, meconium ileus, gallstone (a
large gallstone that complete occlude the small
bowel)

Question 8

Ileus manifestation

Answer 8

– Pain: colicky, severe 
– Nausea
– Vomiting: repetitive episodes (after meal, then 
bilious and fecaloid)
– Absence of the bowel sounds
– Abdominal distension
– Inability to defecate
Mechanical ileus: distal to the obstacle- possible to 
eliminate gas and faeces for a while

Question 9

Peutz Jeghers sdr.

Answer 9

pigmented macules on
hands, feet, lips; polyps in
small and large bowel

Question 10

Cronkhite- Canada sdr.:

Answer 10

hyperpigmentation, alopecia,
dystrophic nails; diarrhea,
polyps in large bowel

Question 11

Carcinoid sdr.:

Answer 11

teleangiectasis, flushing;

watery diarrhea

Question 12

Inflammatory bowel disease

Answer 12

Erythema nodosum

Question 13

(Skin) cancer

Answer 13

acantosis nigricans

Question 14

Hereditary haemorrhagic
telangiectasia (Rendu-
ler-Weber yndro e):

Answer 14

teleangiectasis on the
lips, mouth,
gastrointestinal tract

Question 15

Pallor

Answer 15

Secondary to hemorrhage

Question 16

Subcutaneous tissue

Gardner’s syndrome

Answer 16

lipoma, fibroma, polyps

Question 17

Subcutaneous tissue Dehydration-

Answer 17

gastroenteritis

Question 18

Cashexia

Answer 18

Cancer malabsorption

Question 19

Clubbing

Answer 19

Inflammatory bowel disease

Question 20

Muscle wasting

Answer 20

Severe malnutrition

Question 21

Arthritis

Answer 21

Inflammatory bowel disease

Question 22

Physical examination of the bowel

Answer 22

– Distension- ileus
– Visible peristalsis- mech.bowel obstruction
– Tenderness, rebound tenderness- peritonitis

Question 23

Bluish periumbilical discoloration= Retroperitoneal

hemorrhage

Answer 23

Cullen’s sign

hemorrhagic pancreatitis, abdominal aortic aneurysm rupture

Question 24

Severe left shoulder pain

Answer 24

Kehr’s sign
splenic rupture, ectopic
pregnancy rupture

Question 25

Tenderness located 2/3 distance from

anterior iliac spine to umbilicus on right side

Answer 25

Mc Burney’s sign

Appendicitis

Question 26

Abrupt interruption of inspiration on palpation of right

upper quadrant

Answer 26

Murphy’s sign acute cholecystitis

Question 27

Hyperextension of right hip causing abdominal pain

Answer 27

Ileopsoas sign apendicitis

Question 28

Internal rotation of flexed right hip causing

abdominal pain

Answer 28

Opturator sign appendicitis

Question 29

Discoloration of the flank

Answer 29

grey- turner sign
Retroperitoneal
hemorrhage
(hemorrhagic pancreatitis, abdominal aortic aneurysm rupture)

Question 30

Right lower quadrant pain with palpation of the left

lower quadrant

Answer 30

Appendicitis Rovsings sign

Question 31

Acute peritonitis
Definition
Causes

Answer 31

= inflammation of serosal membrane of peritoneum
- localized/generalized
- Causes:
- Infection:
- perforation- of the distal esophagus= Boerhave sdr, peptic ulcer,
gastric cancer, appendicitis, diverticulitis, Meckel diverticulum,
inflammatory bowel disease, intestinal infarction, intestinal
strangulation, colorectal carcinoma, cholecystitis; perforation due to
abdominal trauma, iatrogenic perforation; ruptured ovarian cyst
- trauma, surgical wound, continuous ambulatory peritoneal dialysis,
intra-peritoneal chemotherapy
- Spontaneous bacterial peritonitis: in cases with cirrhosis complicated
with ascites
- Tuberculosis: rare
- primary infection- from hematogenous dissemination, usually in
immunocompromised cases
- Non-infection: ‘sterile”- chemical (irritants: bile, blood, barium, other
substances, by transmural inflammation of visceral organs without
bacterial inoculation; mechanical causes

Question 32

Peritoneal abscess

Answer 32

an infected fluid collection
encapsulated by fibrinous exudate, omentum,
and/or adjacent visceral organs.

Question 33

Abscess formation

Answer 33

an infected fluid collection
encapsulated by fibrinous exudate, omentum,
and/or adjacent visceral organs.

Abscess formation is the leading cause of
persistent infection and development of tertiary
peritonitis.

Question 34

Acute peritonitis

Answer 34

Symptoms
- Abdominal pain: initially, the pain may be dull and poorly localized
(visceral peritoneum) and often progresses to steady, severe, and more
localized pain (parietal peritoneum).
-In certain situations: gastric perforation, severe acute pancreatitis,
intestinal ischemia, the abdominal pain may be generalized from the
beginning.
-Anorexia and nausea: may precede the abdominal pain.
Vomiting may be due to underlying visceral organ pathology or be
secondary to peritoneal irritation.

Question 35

Acute peritonitis physical examination

Answer 35

• fever: more than 38° C (infection- cause)
• Tachycardia
• Dehydration
• oliguria or anuria
• In severe peritonitis- septic shock

abdominal examination:

– Distension of the abdomen
– tenderness to palpation
– rebound tenderness= lumberg sign
– Absent bowel sounds- ileus

Question 36

Acute peritonitis

Differential diagnosis

Answer 36

– Thoracic processes with diaphragmatic
irritation (empyema)
– extraperitoneal processes (pyelonephritis,
cystitis, acute urinary retention)
– abdominal wall processes (infection, rectus
hematoma)

Question 37

Acute abdomen def. medico surgical causes

Answer 37

represents a rapid onset of severe symptoms that may
indicate life-threatening intra-abdominal pathology.

Medico-surgical causes:

a. inflammatory
b. mechanical
c. neoplastic
d. vascular
e. congenital defects
f. traumatic

Question 38

Acute abdomen causes

Answer 38

The inflammatory causes: bacterial, chemical.
– acute appendicitis, diverticulitis, pelvic inflammatory disease.
– perforation of a peptic ulcer, where spillage of acid gastric
contents causes an intense peritoneal reaction.
Mechanical causes: incarcerated hernia, post-operative
adhesions, malrotation of the gut with volvulus, congenital
atresia or stenosis of the gut.
– The most common cause of large bowel mechanical obstruction is
colon cancer.
Vascular: mesenteric arterial thrombosis or embolism-
mes.infacrtion
ongenital defects can produce an acute abdominal
emergency any time from the birth (duodenal atresia,
omphalocele or diaphragmatic hernia) to years afterward
(chronic malrotation of the intestine).
Traumatic: gunshot wounds, blunt abdominal injuries

Question 39

Characters of pain

Intensity

Answer 39

– dull - initial epigastric pain of appendicitis
– sharp - renal or biliary colic or obstruction of gut
– aching - pelvic inflammatory disease
– pleuritic - intensified by breathing
– lancinating - acute pancreatitis
– tearing - dissecting aneurysm

Intensity
– severe - rupture of viscus or blood in the peritoneal cavity
– moderate - RLQ appendiceal
– mild peptic ulcer, without perforation

Question 40

Temporal features of pain

Answer 40

– dull - initial epigastric pain of appendicitis
– sharp - renal or biliary colic or obstruction of gut
– aching - pelvic inflammatory disease
– pleuritic - intensified by breathing
– lancinating - acute pancreatitis
– tearing - dissecting aneurysm
ntensity
– severe - rupture of viscus or blood in the peritoneal cavity
– moderate - RLQ appendiceal
– mild peptic ulcer, without perforation

Question 41

factors which intensify or releave the pain

Answer 41

– relation to meals - peptic ulcer pain relieved by
food, cholecystitis pain aggravated by fatty meal
– motion - any movement causes intense pain in
generalized peritonitis

Question 42

Borborygmi

Answer 42

very hyperactive bowel sounds

associated with mechanical obstruction.

Question 43

Jarring test

Answer 43

a localized area of peritoneal irritation may also be
identified by having the patient rise on his toes and come
down suddenly on his heels, identifying where pain is felt

Question 44

Percussion of the abdomen

Answer 44

– When the abdomen is enlarged and hyperresonant, intestinal
distention or pneumo-peritoneum should be considered.
– shifting dullness- ascites,
– Dullness to percussion: the size of an enlarged spleen or liver or
a solid tumor mass.

Question 45

Rectal Palpation

Answer 45

– When an inflamed appendix lies low in the pelvis,
there may be rectal tenderness or a palpable pelvic
mass in the absence of abdominal signs.
– imanual pelvic examination may reveal a tubal or
ovarian mass, exquisite tenderness on movement of
the cervix, or bloody or purulent cervical discharge,
suggestive of acute pelvic complications.

Question 46

Acute appendicitis

Answer 46

Obstruction of the appendiceal lumen
leads to distension of the appendix
bacterial invasion of the appendiceal wall
perforation into the peritoneal cavity.

Question 47

Clinical manifestation of appendicitis

Answer 47

-The classic symptoms: anorexia and periumbilical pain
followed by nausea, right lower quadrant (RLQ) pain,
and vomiting; occur in only 50% of cases !!!!!!
-Migration of pain from the periumbilical area to the RLQ
is the most discriminating feature
When vomiting occurs, it nearly follows the onset of pain.
– Vomiting that precedes pain is suggestive of intestinal
obstruction
-Diarrhea or constipation
-Duration of symptoms is less than 48 hours in
approximately 80% of adults but tends to be longer in
elderly persons and in those with perforation.
-irritative voiding symptoms, hematuria or pyuria.

Question 48

Dunphy’s sign

Answer 48

sharp pain in the RLQ elicited by a voluntary cough-

localized peritonitis.

Question 49

Physical exmination in appendicitis

Answer 49

RLQ tenderness is present in majority of cases (96%) but is a
nonspecific finding.
– Rarely, left lower quadrant (LLQ) tenderness
The most specific physical findings are rebound tenderness, pain on
percussion, rigidity, and guarding.
The Rovsing sign= RLQ pain with palpation of the LLQ- suggests
peritoneal irritation in the RLQ
The obturator sign= RLQ pain with internal and external rotation of
the flexed right hip-suggests the inflammation of an appendix ocated
deep in the right hemipelvis.
The psoas sign= RLQ pain with extension of the right hip or with
flexion of the right hip against resistance- suggests the inflammation
of the appendix that is located along the course of the right psoas
muscle.
Dunphy’s sign= sharp pain in the RLQ elicited by a voluntary cough-
localized peritonitis.
Male infants and children occasionally present with an inflamed
hemiscrotum due to migration of an inflamed appendix or pus through
a patent processus vaginalis.

Question 50

Alvarado score

Answer 50

migratory right iliac fossa pain 1 point
Anorexia1 point
Nausea and vomiting1 point
Signs
Right iliac fossa tenderness2 points
Rebound tenderness1 point
Fever1 point
Laboratory
Leucocytosis2 points
Shift to left (segmented neutrophils) 1 point
Total score
10 points

Score of 7 or more is strongly predictive of acute appendicitis. In
patients with a score of 5-6, CT is done