Coeliac disease, Hernias

Question 1

What is coeliac disease?

Answer 1

Immune mediated intolerance to gluten (gliadin) causes cytotoxic T-cell inflammation s.bowel→ villous atrophy + enteropathy → ↓Absorption, ↑Excretion of H2O, Ulcers, Strictures

Question 2

What are the classic signs of coeliac disease?

Answer 2

Diarrhoea + fatty stools
Weight loss/failure to thrive
Abdominal discomfort

Question 3

What are the late signs of coeliac disease?

Answer 3

Muscle wasting (buttocks)
Arthralgia
Delayed puberty
Mouth ulcers
Dermatitis herpetiformis
Peripheral oedema + ascites

Question 4

What investigations are carried out for coeliac disease?

Answer 4

-Coeliac immunology screen: Reintroduce gluten into diet 6weeks before test- tTG (IgA)- 1st LINE
Endomysial Ab
-Bloods: FBC (↓Hb), ↓Folate, macrocytic anaemia, unexplained Fe deficiency (Fe absorbed in the duodenum)
-Endoscopic s.bowel biopsy= CONFIRMATION

Question 5

What is usually seen on a coeliac biopsy?

Answer 5

Mainly jejunum + duodenum
Diffuse villous atrophy
↑IE lymphocytes in LP
Crypt hyperplasia

Question 6

How is coeliac disease managed?

Answer 6

Dietary: AVOID wheat, rye, oats & barley

Question 7

What are the complications of coeliac disease?

Answer 7

Coeliac crisis

T-Cell lymphoma

Question 8

What is a coeliac crisis?

Answer 8

Life-threatening dehydration due to diarrhoea + malabsorption

Question 9

What are the 2 types of inguinal hernia?

Answer 9

DIRECT: Post abdo wall via defect in Hesselbach’s triangle
INDIRECT: Internal ring → external inguinal ring due to patent processes vaginalis

Question 10

Where to inguinal hernias pass with regards to the inferior epigastric vessels?

Answer 10

D =MEDIAL to inferior epigastric vessels

I = LATERAL to inferior epigastric vessels

Question 11

What are risk factors for an inguinal hernia?

Answer 11

Male
Chronic cough
Obesity
Constipation
Urinary obstruction
Heavy lifting
Prev abdo surgery

Question 12

How does an inguinal hernia present?

Answer 12

Intermittent swelling in groin/scrotum- emphasised by coughing
Sudden pain
Thickened spermatic cord (M)
Thickened round lig (F)

Question 13

How is an inguinal hernia investigated?

Answer 13

Abdo Ex
External genital Ex
Transillumination
USS

Question 14

How is an inguinal hernia managed?

Answer 14

Conservative: ↓weight, stop smoking, analgesia
Sustained compression
Surgery: Mesh repair- reinforces posterior wall

Question 15

What are the complications of an inguinal hernia?

Answer 15

Irreducible/incarcerated: Reduce for 24-48hrs then surgery
Strangulation
Small bowel obstruction
Hydrocele

Question 16

How is a hydrocele treated?

Answer 16

Self-limiting

Surgery if present 18-24m

Question 17

How does a femoral hernia occur?

Answer 17

Bowel segment enters femoral canal
Downward pointing mass in upper medial thigh/ above inguinal ligament
Often irreducible → strangulation

Question 18

What is the main risk factor for a femoral hernia?

Answer 18

Female

Question 19

What are the boundaries of the femoral canal?

Answer 19

ANT: Inguinal lig
MED: Lacunar lig
LAT: Femoral vein
POST: Pectineus

Question 20

How does a femoral hernia present?

Answer 20

Herniated mass pointing down leg
Appears on coughing/straining
Disappears when supine/relaxed

Question 21

How is a femoral hernia managed?

Answer 21

EVERYONE = repair (due to risk of strangulation)

Dissect sac & close

Question 22

What are the features of an umbilical hernia?

Answer 22

Congenital
Infantile = spont resolves
Adult = Ascites/preg/obesity

Question 23

How is an umbilical hernia managed?

Answer 23

Child + <1cm: Watch &wait (most close by 5)
>1.5cm or >4yo: Mayo repair
Close defect w/stitches

Question 24

How is an incisional hernia repaired?

Answer 24

Mesh

Question 25

How does an incisional hernia occur?

Answer 25

Tissue pushes through a prev scar/wound
More common if scar in the past that has not healed well
Usually <2yrs from op