Clinical Ab

Question 1

Strangulated inguinal hernia

Answer 1

• Pain in midgut -> periumbilical pai
• most likely small intestine herniated
• SMA compressed

Question 2

SMA syndrome

Answer 2

• Compression of 3rd part of duodenum by SMA
• Congenital
  
  • short Treitz
  • low origin of SMA
• Acquired
  
  • narrowing of aorticomesenteric angle
  • structural changes that draw duodenum up into angle
  • aneurysm of artery
• Left renal v. may also be compressed NUTCRACKER

Question 3

Pt with groin pain, non-pulsatile, non-reducible tender lump palpated in left groin, exam revealed presence of large pulsatile mass in lower abdomen

Answer 3

• DDx: inguinal hernia, aortic aneurysm, aortic coarctation
• Imaging revealed aortic aneurysm with blood located in extraperitoneal tissue.
• Blood in spermatic cord; deep inguinal ring is in transversali fascia so blood enters cord from extraperitoneal tissue

Question 4

Pt presenting with severe pain in epigastrium and right iliac fossa. Pain increased severely with respiration. Imaging revealed air under diaphragm. Barium swallow revealed air in lesser sac

Answer 4

• DDx: ruptured gastric ulcer in posterior wall
• Gastric contents and blood passed into greater sasc via omental foramen and into right iliac fossa via right lateral paracolic gutter

Question 5

Pt presents with massive hematemesis with jaundice and enlarged abdomen dull to percussion. GI endoscopy revealed Esophageal varices

Answer 5

• Portal hypertension secondary to cirrhosis of liver

Question 6

Where are abdominal ventral rami located in Petit’s triangle as a site for nerve block?

Answer 6

B/w internal oblique and transversus abdominis

Question 7

Why is pain felt in hypochondrium and subscapular region of Pt with cholelithiasis?

Answer 7

• Visceral afferents travelling with sympathetic fibres
• coeliac plexus to coeliac ganglion
• greater thoracic splanchnic nerve to T5-9 cord levels via white rami and dorsal roots
• referred to T5-9 dermatomes
• Pain later radiated to right shoulder by irriation of diaphragmatic peritoneum

Question 8

What could cause an obstruction in the biliary tree?

Answer 8

• Gall stones or tumour of head of pancreas
• SMA or vein can be invaded by tumour

Question 9

How does referred pain from Meckel’s (ileal) diverticulum radiate to periumbilical region?

Answer 9

• Superior mesenteric plexus -> Superior mesenteric ganglion -> lesser splanchnic n. -> T10 level of cord -> T10 dermatome (same as appendix)
• Positive Psoas sign: parietal peritonium irritated; stretching psoas producing somatic pain from peritonium overlying muscle