Gastroenterology 2 Flashcards

Question

What is the classic triad presentation for mesenteric ischaemia?

Answer 1

The typical presentation is with a “classic triad” of: * Central colicky **abdominal pain** after eating (starting around 30 minutes after eating and lasting 1-2 hours) * **Weight loss** (due to food avoidance, as this causes pain) * **Abdominal bruit** may be heard on auscultation

Answer 2

* Increased age * Family history * Smoking * Diabetes * Hypertension * Raised cholesterol

Answer 3

Diagnosis is by CT angiography.

Answer 4

* Reducing modifiable risk factors (e.g., stop smoking) * **Secondary prevention** (e.g., statins and antiplatelet medications) * **Revascularisation** to improve the blood flow to the intestines

Answer 5

* **Endovascular procedures** first-line (i.e. percutaneous mesenteric artery stenting) * **Open surgery** (i.e endarterectomy, re-implantation or bypass grafting)

Answer 6

Acute mesenteric ischaemia is typically caused by a **rapid blockage** in blood flow through the superior mesenteric artery. This is usually caused by a **thrombus** (blood clot) stuck in the artery, blocking blood flow. The blood clot may be a thrombus that has developed inside the artery or an embolus from another site that has got stuck in the artery

Answer 7

A key risk factor is **atrial fibrillation**, where a thrombus forms in the left atrium, then mobilises (thromboembolism) down the aorta to the superior mesenteric artery, where it becomes stuck and cuts off the blood supply.

Answer 8

Patients can go on to develop shock, peritonitis and sepsis.

Answer 9

metabolic acidosis

Answer 10

enlarged anal vascular cushions.

Answer 11

constipation and straining painless, bright red bleeding- the blood is **not** mixed with the stool Sore / itchy anus Feeling a lump around or inside the anus

Answer 12

They are also more common with pregnancy, obesity, increased age and increased intra-abdominal pressure (e.g., weightlifting or chronic coughing)

Answer 13

They often occur in pregnancy, most likely due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax the connective tissues.

Answer 14

The anal cushions are specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular. They are supported by smooth muscle and connective tissue. They help to control anal continence, along with the internal and external sphincters. The blood supply is from the rectal arteries.

Answer 15

* 1st degree: no prolapse * 2nd degree: prolapse when straining and return on relaxing * 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back * 4th degree: prolapsed permanently

Answer 16

* **External (prolapsed) haemorrhoids** are visible on inspection as swellings covered in mucosa * **Internal haemorrhoids** may be felt on a PR exam (although this is generally difficult or not possible) * They may appear (**prolapse**) if the patient is asked to “bear down” during inspection

Answer 17

is required for proper visualisation and inspection of haemorrhoids. This involves inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa.

Answer 18

Anal fissures Diverticulosis Inflammatory bowel disease Colorectal cancer Haemorrhoids

Answer 19

* Anusol (contains chemicals to shrink the haemorrhoids – “astringents”) * Anusol HC (also contains hydrocortisone – only used short term) * Germoloids cream (contains lidocaine – a local anaesthetic) * Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only)

Answer 20

* Increasing the amount of fibre in the diet * Maintaining a good fluid intake * Using laxatives where required * Consciously avoiding straining when opening their bowels

Answer 21

* Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply) * Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy) * Infra-red coagulation (infra-red light is applied to damage the blood supply) * Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)

Answer 22

**Haemorrhoidal artery ligation** involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply. **Haemorrhoidectomy** involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence. **Stapled haemorrhoidectomy** involves using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal. The staples remain in place long-term.

Answer 23

Thrombosed haemorrhoids are caused by **strangulation** at the base of the haemorrhoid, resulting in **thrombosis** (a clot) in the haemorrhoid. This can be very painful.

Answer 24

Intussusception is a condition where the bowel “invaginates” or “telescopes” into itself. Picture the bowel folding inwards. This thickens the overall size of the bowel and narrows the lumen at the folded area, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel.

Answer 25

It typically occurs in infants 6 months to 2 years and is more common in boys.

Answer 26

It is associated with various conditions: * Concurrent viral illness * Henoch-Schonlein purpura * Cystic fibrosis * Intestinal polyps * Meckel diverticulum

Answer 27

* Severe, colicky abdominal pain * Pale, lethargic and unwell child * **“Redcurrant jelly stool”- look out for this** * Right upper quadrant mass on palpation. This is described as **“sausage-shaped” - look out for this** * Vomiting * Intestinal obstruction

Answer 28

The typical child in the exam will have had a viral upper respiratory tract infection preceding the illness and will have features of intestinal obstruction (vomiting, absolute constipation and abdominal distention). Ultrasound is the initial investigation of choice.

Answer 29

Diagnosis is made mainly by ultrasound scan or contrast enema.

Answer 30

**Therapeutic enemas** can be used to try to reduce the intussusception. Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position. **Surgical reduction** may be necessary if enemas do not work. If the bowel becomes **gangrenous** (due to a disruption of the blood supply) or the bowel is **perforated**, then **surgical resection** is required.

Answer 31

* Obstruction * Gangrenous bowel * Perforation * Death

Answer 32

fourth most prevalent cancer in the UK

Answer 33

There are a number of factors that increase the risk of colorectal cancer: * Family history of bowel cancer * Familial adenomatous polyposis (FAP) * Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome * Inflammatory bowel disease (Crohn’s or ulcerative colitis) * Increased age * Diet (high in red and processed meat and low in fibre) * Obesity and sedentary lifestyle * Smoking * Alcohol

Answer 34

autosomal dominant

Answer 35

adenomatous polyposis coli (APC). which is a tumour suppressor gene

Answer 36

Patients have their entire large intestine removed prophylactically to prevent the development of bowel cancer (panproctocolectomy).

Answer 37

Lynch syndrome

Answer 38

DNA mismatch repair (MMR) genes.

Answer 39

colorectal cancer.

Answer 40

The red flags that should make you consider bowel cancer are: * Change in bowel habit (usually to more loose and frequent stools) * Unexplained weight loss * Rectal bleeding * Unexplained abdominal pain * Iron deficiency anaemia (microcytic anaemia with low ferritin) * Abdominal or rectal mass on examination

Answer 41

* Over 40 years with abdominal pain and unexplained weight loss * Over 50 years with unexplained rectal bleeding * Over 60 years with a change in bowel habit or iron deficiency anaemia

Answer 42

**Iron deficiency anaemia** on its own without any other explanation (i.e. heavy menstruation) is an indication for a “two week wait” cancer referral for **colonoscopy** and **gastroscopy** (“top and tail”) for GI malignancy. This is because GI malignancies such as bowel cancer can cause microscopic bleeding (not visible in bowel movements) that eventually lead to iron deficiency anaemia.

Answer 43

look very specifically for the amount of human haemoglobin in the stool. FIT replaced the older stool test called the faecal occult blood (FOB) test, which detected blood in the stool but could give false positives by detecting blood in food (e.g., from red meats).

Answer 44

FIT tests can be used as a test in general practice to help assess for bowel cancer in specific patients who do not meet the criteria for a two week wait referral, for example: * Over 50 with unexplained weight loss and no other symptoms * Under 60 with a change in bowel habit

Answer 45

In England, people aged 60 – 74 years are sent a home FIT test to do every 2 years. If the results come back positive they are sent for a colonoscopy.

Answer 46

People with risk factors such as **FAP, HNPCC** or **inflammatory bowel disease** are offered a colonoscopy at regular intervals to screen for bowel cancer.

Answer 47

Colonoscopy is the gold standard investigation. Sigmoidoscopy CT colonography Staging CT scan Carcinoembryonic antigen (CEA)- tumour marker

Answer 48

Dukes’ Classification

Answer 49

Dukes A – confined to mucosa and part of the muscle of the bowel wall Dukes B – extending through the muscle of the bowel wall Dukes C – lymph node involvement Dukes D – metastatic disease

Answer 50

T for Tumour: TX – unable to assess size T1 – submucosa involvement T2 – involvement of muscularis propria (muscle layer) T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa T4 – spread through the serosa (4a) reaching other tissues or organs (4b)

Answer 51

N for Nodes: NX – unable to assess nodes N0 – no nodal spread N1 – spread to 1-3 nodes N2 – spread to more than 3 nodes

Answer 52

M for Metastasis: M0 – no metastasis M1 – metastasis

Answer 53

Surgical resection Chemotherapy Radiotherapy Palliative care

Answer 54

Surgery involves: * Identifying the tumour (it may have been tattooed during an endoscopy) * Removing the section of bowel containing the tumour, * Creating an end-to-end anastomosis (sewing the remaining ends back together) * Alternatively creating a stoma (bringing the open section of bowel onto the skin)

Answer 55

involves removal of the **caecum, ascending and proximal transverse colon.**

Answer 56

involves removal of the **distal transverse** and **descending colon.**

Answer 57

involves removing the sigmoid colon (may be called a sigmoid colectomy).

Answer 58

involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus

Answer 59

involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.

Answer 60

is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.

Answer 61

* Bleeding, infection and pain * Damage to nerves, bladder, ureter or bowel * Post-operative ileus * Anaesthetic risks * Laparoscopic surgery converted during the operation to open surgery (laparotomy) * Leakage or failure of the anastomosis * Requirement for a stoma * Failure to remove the tumour * Change in bowel habit * Venous thromboembolism (DVT and PE) * Incisional hernias * Intra-abdominal adhesions

Answer 62

Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including: * Urgency and frequency of bowel movements * Faecal incontinence * Difficulty controlling flatulence

Answer 63

Serum carcinoembryonic antigen (CEA) CT thorax, abdomen and pelvis

Answer 64

Volvulus is a condition where the bowel twists around itself and the mesentery that it is attached to

Answer 65

The bowel gets its blood supply from the mesentery (through the mesenteric arteries).

Answer 66

a **closed-loop bowel obstruction,** where a section of bowel is isolated by obstruction on either side.

Answer 67

Sigmoid volvulus Caecal volvulus

Answer 68

Sigmoid volvulus

Answer 69

caecal volvulus

Answer 70

* Neuropsychiatric disorders (e.g., Parkinson’s) * Nursing home residents * Chronic constipation * High fibre diet * Pregnancy * Adhesions

Answer 71

the signs and symptoms are akin to bowel obstruction, with: * Vomiting (particularly **green bilious vomiting**) * Abdominal distention * Diffuse abdominal pain * Absolute constipation and lack of flatulence

Answer 72

**Abdominal x-ray** can show the **“coffee bean” sign** in **sigmoid volvulus**, where the dilated and twisted sigmoid colon looks like a giant coffee bean. **A contrast CT** scan is the investigation of choice to confirm the diagnosis and identify other pathology.

Answer 73

The _initial management_ is the same as with bowel obstruction (**nil by mouth, NG tube and IV fluids**). _Conservative management_ with endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis) _Surgical management_ involves: * **Laparotomy** (open abdominal surgery) * **Hartmann’s procedure** for sigmoid volvulus (removal of the rectosigmoid colon and formation of a colostomy) * **Ileocaecal resection** or **right hemicolectomy** for caecal volvulus

Answer 74

Meconium ileus Hirschsprung’s disease Oesophageal atresia Duodenal atresia Intussusception Imperforate anus Malrotation of the intestines with a volvulus Strangulated hernia

Answer 75

* Persistent vomiting. This may be **bilious**, containing bright green bile. * Abdominal pain and distention * Failure to pass stools or wind * Abnormal **bowel sounds.** These can be **high pitched** and **“tinkling”** early in the obstruction and **absent** later.

Answer 76

abdominal xray- dilated loops of bowel proximal to the obstruction and absence of air in the rectum.

Answer 77

A pilonidal sinus is a small hole or tunnel in the skin at the top of the buttocks, where they divide (the cleft). It does not always cause symptoms and only needs to be treated if it becomes infected.

Answer 78

Abx Incision and drainage Wide excision and open healing Excision and wound closure, often with flattening of the groove between the buttock Endoscopic ablation for a pilonidal sinus

Answer 79

A ruptured spleen is an emergency medical condition that occurs when the capsule-like covering of the spleen breaks open, pouring blood into your abdominal area. Depending on the size of the rupture, a large amount of internal bleeding can occur. Your doctor may refer to a ruptured spleen as a "splenic rupture.

Answer 80

scar-like tissue inside the body that bind surfaces together

Answer 81

an abnormal connection between two epithelial surfaces

Answer 82

the sensation of needing to open bowels without being able to produce stools (often accompanied by pain)

Answer 83

pancreaticoduodenectomy) – removal of the head of the pancreas, duodenum, gallbladder and bile duct

Answer 84

open cholecystectomy

Answer 85

liver transplant, Whipple procedure, pancreatic surgery or upper GI surgery

Answer 86

liver transplant

Answer 87

a general laparotomy, allows good access to abdominal organs

Answer 88

laparotomy (midline usually used instead)

Answer 89

renal transplant

Answer 90

Appendix surgery: Battle incision (paramedian) – **open appendicectomy** Gridiron incision / McBurney incision (oblique) – **open appendicectomy** Lanz incision (transverse) – **open appendicectomy** Rutherford Morrison incision (extended version of gridiron) – **open appendicectomy and colectomy**

Answer 91

Caesarean section: Pfannenstiel incision – **curved incision two fingers width above the pubic symphysis** Joel-Cohen incision – **straight incision that is slightly higher (this is the recommended incision)**

Answer 92

involves several 5-10mm incisions to allow th

Answer 93

Necrotizing fasciitis (NECK-re-tie-zing FASH-e-i-tis) is a rare bacterial infection that spreads quickly in the body and can cause death. Accurate diagnosis, rapid antibiotic treatment, and prompt surgery are important to stopping this infection

Answer 94

There are many types of bacteria that can cause the “flesh-eating disease” called necrotizing fasciitis. Public health experts believe group A Streptococcus (group A strep) are the most common cause of necrotizing fasciitis

Answer 95

Biliary colic Acute cholecystitis Acute cholangitis

Answer 96

Acute gastritis Peptic ulcer disease Pancreatitis Ruptured abdominal aortic aneurysm

Answer 97

Ruptured abdominal aortic aneurysm Intestinal obstruction Ischaemic colitis Early stages of appendicitis

Answer 98

Acute appendicitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion Meckel’s diverticulitis

Answer 99

Diverticulitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion

Answer 100

Lower urinary tract infection Acute urinary retention Pelvic inflammatory disease Prostatitis

Answer 101

Renal colic (kidney stones) Ruptured abdominal aortic aneurysm Pyelonephritis

Answer 102

Testicular torsion Epididymo-orchitis

Answer 103

* **Guarding** – involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below * **Rigidity** – involuntary persistent tightness / tensing of the abdominal wall muscles * **Rebound tenderness** – rapidly releasing pressure on the abdomen creates worse pain than the pressure itself * **Coughing test** – asking the patient to cough to see if it results in pain in the abdomen * **Percussion tenderness** – pain and tenderness when percussing the abdomen

Answer 104

s essential prior to theatre in case the patient requires a blood transfusion.

Answer 105

Initial management involves: * **ABCDE assessment** * **Alert seniors** of unwell patients: escalating to the registrar, consultant and critical care as required * **Nil by mouth** if surgery may be required or they have features of bowel obstruction * **NG tube** in cases of bowel obstruction * **IV fluids** if required for resuscitation or maintenance * **IV antibiotics** if infection is suspected * **Analgesia** as required for pain management * **Arranging investigations** as required (e.g., bloods, group and save and scans) * **Venous thromboembolism** risk assessment and prescription if indicated * **Prescribing regular medication** on the drug chart if they are being admitted (some may need to be withheld)

Answer 106

* Taking **consent** for surgery (by someone suitably qualified) * Review by an **anaesthetist** * Putting on the **theatre list** * **Crossmatch** units of blood if required

Answer 107

The peak incidence of appendicitis is in patients aged **10 to 20 years.** It can occur at any age but is less common in young children and adults over 50 years.

Answer 108

The appendix is a small, thin tube arising from the **caecum**. It is located at the point where the three **teniae coli** meet (the teniae coli are longitudinal muscles that run the length of the large intestine). There is a single opening to the appendix that connects it to the bowel, and it leads to a dead end. Pathogens can get trapped due to obstruction at the point where the appendix meets the bowel. Trapping of pathogens leads to infection and inflammation. The inflammation may proceed to **gangrene** and **rupture.** When the appendix ruptures, faecal contents and infective material are released into the peritoneal cavity. This leads to peritonitis, which is inflammation of the peritoneal lining.

Answer 109

The key presenting feature of appendicitis is abdominal pain. This typically starts as **central abdominal pain** that moves down to the **right iliac fossa (RIF)** within the first 24 hours, eventually becoming localised in the RIF. On palpation of the abdomen, there is tenderness at **McBurney’s point.** McBurney’s point refers to a specific area one third of the distance from the **anterior superior iliac spine (ASIS)** to the umbilicus. Other classic features are: * Loss of appetite **(anorexia)** * Nausea and vomiting * Low-grade fever * **Rovsing’s sign** (palpation of the left iliac fossa causes pain in the RIF) * **Guarding** on abdominal palpation * **Rebound tenderness** in the RIF (increased pain when suddenly releasing the pressure of deep palpation) * **Percussion tenderness** (pain and tenderness when percussing the abdomen) Rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix.

Answer 110

Diagnosis is based on the **clinical presentation** and **raised inflammatory markers.** Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An **ultrasound scan** is often used in female patients to exclude ovarian and gynaecological pathology. Ultrasound can also be useful in children, where a CT scan is less appropriate due to the dose of radiation. Appendicitis is mostly a **clinical diagnosis** (meaning it is based on signs and symptoms rather than diagnostic tests). Where the diagnosis is unclear, a period of observation may be used, with repeated examinations over time to see whether the symptoms resolve or worsen. When a patient has a **clinical presentation** suggestive of appendicitis, but investigations are negative, the next step is to perform a **diagnostic laparoscopy** to visualise the appendix directly. The surgeon can proceed to an appendicectomy during the same procedure, if indicated.

Answer 111

Ectopic Pregnancy Ovarian Cysts Meckel’s Diverticulum Mesenteric Adenitis

Answer 112

An appendix mass occurs when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa. This is typically managed conservatively with supportive treatment and antibiotics, followed by appendicectomy once the acute condition has resolved.

Answer 113

Patients with suspected appendicitis need emergency admission to hospital under the surgical team. Removal of the inflamed appendix (appendicectomy) is the definitive management for acute appendicitis. **Laparoscopic surgery** is associated with fewer risks and faster recovery compared to open surgery.

Answer 114

* Bleeding, infection, pain and scars * Damage to bowel, bladder or other organs * Removal of a normal appendix * Anaesthetic risks * Venous thromboembolism (deep vein thrombosis or pulmonary embolism)

Answer 115

Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops. It may be referred to as paralytic ileus or adynamic ileus.

Answer 116

is a term used to describe a functional obstruction of the large bowel, where patients present with intestinal obstruction, but no mechanical cause is found. This is less common than ileus affecting the small bowel.

Answer 117

There is a long list of things that can make the bowel unhappy, leading to ileus. Common causes are: * Injury to the bowel * Handling of the bowel during surgery * Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia) * Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia) The most common time you will see ileus is following abdominal surgery. This usually resolves with supportive care within a few days.

Answer 118

The signs and symptoms are akin to bowel obstruction, with: * Vomiting (particularly **green bilious vomiting)** * Abdominal distention * Diffuse abdominal pain * Absolute constipation and lack of flatulence * Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)

Answer 119

The ileus will usually resolve with treatment of the underlying cause. Management involves supportive care. Supportive care involves: * Nil by mouth or limited sips of water * NG tube if vomiting * IV fluids to prevent dehydration and correct the electrolyte imbalances * Mobilisation to helps stimulate peristalsis * Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function

Answer 120

Hernias occur when there is a weak point in a cavity wall, usually affecting the muscle or fascia. This weakness allows a body organ (e.g., bowel) that would normally be contained within that cavity to pass through the cavity wall.

Answer 121

* A soft lump protruding from the abdominal wall * The lump may be reducible (it can be pushed back into the normal place) * The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity) * Aching, pulling or dragging sensation

Answer 122

is where the hernia cannot be reduced back into the proper position (it is irreducible). The bowel is trapped in the herniated position. Incarceration can lead to obstruction and strangulation of the hernia.

Answer 123

A Richter’s hernia is a very specific situation that can occur in any abdominal hernia. This is where only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity. They can become strangulated, where the blood supply to that portion of the bowel wall is constricted and cut off. Strangulated Richter’s hernias will progress very rapidly to ischaemia and necrosis and should be operated on immediately.

Answer 124

Maydl’s hernia refers to a specific situation where two different loops of bowel are contained within the hernia.

Answer 125

**Conservative management** Conservative management involves leaving the hernia alone. This is most appropriate when the hernia has a wide neck (low risk of complications) and in patients that are not good candidates for surgery due to co-morbidities. **Tension-free repair (surgery)** Tension-free repair involves placing a mesh over the defect in the abdominal wall. The mesh is sutured to the muscles and tissues on either side of the defect, covering it and preventing herniation of the cavity contents. Over time, tissues grow into the mesh and provide extra support. This has a lower recurrence rate compared with tension repair, but there may be complications associated with the mesh (e.g., chronic pain). **Tension repair (surgery)** Tension repair involves a surgical operation to suture the muscles and tissue on either side of the defect back together. Tension repairs are rarely performed and have been largely replaced by tension-free repairs. The hernia is held closed (to heal there) by sutures applying tension. This can cause pain and there is a relatively high recurrence rate of the hernia.

Answer 126

* Femoral hernia * Lymph node * Saphena varix (dilation of saphenous vein at junction with femoral vein in groin) * Femoral aneurysm * Abscess * Undescended / ectopic testes * Kidney transplant

Answer 127

The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum). In males, the inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the **scrotum.** In females, the round ligament is attaches to the uterus and passes through the deep inguinal ring, inguinal canal and then attaches to the **labia majora.**

Answer 128

Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle. The hernia protrudes directly through the abdominal wall, through Hesselbach’s triangle (not along a canal or tract like an indirect inguinal hernia). Pressure over the deep inguinal ring will not stop the herniation.

Answer 129

R – Rectus abdominis muscle – medial border I – Inferior epigastric vessels – superior / lateral border P – Poupart’s ligament (inguinal ligament) – inferior border

Answer 130

Femoral hernias involve herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament, at the top of the thigh. The opening between the peritoneal cavity and the femoral canal is the femoral ring. The femoral ring leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of: * Incarceration * Obstruction * Strangulation

Answer 131

F – Femoral vein laterally L – Lacunar ligament medially I – Inguinal ligament anteriorly P – Pectineal ligament posteriorly

Answer 132

S – Sartorius – lateral border A – Adductor longus – medial border IL – Inguinal Ligament – superior border

Answer 133

N – Femoral Nerve A – Femoral Artery V – Femoral Vein Y – Y-fronts C – Femoral Canal (containing lymphatic vessels and nodes)

Answer 134

ncisional hernias occur at the site of an incision from previous surgery. They are due to weakness where the muscles and tissues were closed after a surgical incision. The bigger the incision, the higher the risk of a hernia forming. Medical co-morbidities put patients at higher risk due to poor healing. Incisional hernias can be difficult to repair, with a high rate of recurrence. They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.

Answer 135

Umbilical hernias occur around the umbilicus due to a defect in the muscle around the umbilicus. Umbilical hernias are common in neonates and can resolve spontaneously. They can also occur in older adults.

Answer 136

An epigastric hernia is simply a hernia in the epigastric area (upper abdomen).

Answer 137

A Spigelian hernia occurs between the lateral border of the **rectus abdominis muscle and the linea semilunaris**. This is the site of the spigelian fascia, which is an **aponeurosis** between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain. There may not be a noticeable lump. An **ultrasound scan** can help establish the diagnosis. Spigelian hernias generally have a narrower base, increasing the risk of incarceration, obstruction and strangulation.

Answer 138

Obturator hernias are where the abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvis. They occur due to a defect in the pelvic floor and are more common in women, particularly in older age, after multiple pregnancies and vaginal deliveries. They are often asymptomatic but may present with irritation to the obturator nerve, causing pain in the groin or medial thigh. Howship–Romberg sign refers to pain extending from the inner thigh to the knee when the hip is internally rotated and is due to compression of the obturator nerve. It can also present with complications of: * Incarceration * Obstruction * Strangulation * **CT or MRI** of the pelvis can establish the diagnosis. It may be found incidentally during pelvic surgery.

Answer 139

An hiatus hernia refers to the herniation of the stomach up through the diaphragm. The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place. A narrow opening helps to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus. When the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus.

Answer 140

Type 1: Sliding Type 2: Rolling Type 3: Combination of sliding and rolling Type 4: Large opening with additional abdominal organs entering the thorax

Answer 141

**Sliding hiatus hernia** is where the stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax. **Rolling hiatus hernia** is where a separate portion of the stomach (i.e. the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus

Answer 142

Heartburn Acid reflux Reflux of food Burping Bloating Halitosis (bad breath)

Answer 143

Chest x-rays CT scans Endoscopy Barium swallow testing

Answer 144

* Conservative (with medical treatment of gastro-oesophageal reflux) * Surgical repair if there is a high risk of complications or symptoms are resistant to medical treatment Surgery involves laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Answer 145

Stomas are artificial openings of a hollow organ (for example the bowel). The bowel or urinary system is artificially opened onto the surface of the abdomen, allowing faeces or urine to drain, bypassing the distal portions of the bowel or urinary tract. A specially adapted bag (stoma bag) is fitted around the stoma to collect the waste products and is emptied as required.

Answer 146

A colostomy is where the large intestine (colon) is brought onto the skin. Colostomies drain more solid stools, as much of the water is reabsorbed in the remaining large intestine. They can be flatter to the skin (compared with ileostomies which have a spout), as the solid contents are less irritating to the surrounding skin. They are typically located in the left iliac fossa (LIF).

Answer 147

An ileostomy is where the end portion of the small bowel (ileum) is brought onto the skin. Ileostomies drain more liquid stools, as the fluid content is normally reabsorbed later, in the large intestine. They have a spout, which allows them to drain directly into a tightly fitting stoma bag without the contents coming into contact with the surrounding skin. They are typically located in the right iliac fossa (RIF).

Answer 148

A gastrostomy involves creating an artificial connection between the stomach and the abdominal wall. This can be used for providing feeds directly into the stomach in patients that cannot meet their nutritional needs by mouth. Percutaneous endoscopic gastrostomy (PEG) refers to when the gastrostomy is fitted by an endoscopy procedure

Answer 149

A urostomy involves creating an opening from the urinary system onto the skin. They have a spout and are typically located in the right iliac fossa (RIF). All patients with stomas should have training on how to manage the stoma and have regular follow-up with a specialist stoma nurse.

Answer 150

An end colostomy is created after the removal of a section of the bowel, where the end part of the proximal portion of the bowel is brought onto the skin. Faeces are able to drain out of the end colostomy into a stoma bag. The other open end of the remaining bowel (the distal part) is sutured and left in the abdomen. It may be reversed at a later date, where the two ends are sutured together creating an anastomosis. End colostomies are permanent after resection of **abdomino-perineal resection (APR)** because the entire rectum and anus have been removed. These are usually located in the lower left abdomen. End ileostomies are permanent after a **panproctocolectomy** (total colectomy with removal of the large bowel, rectum and anus), for example in the treatment of **inflammatory bowel disease or familial adenomatous polyposis (FAP).** An alternative to this is to create an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back on itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” is then attached to the anus and collects stools prior to the person passing a motion.

Answer 151

A loop colostomy or loop ileostomy is a temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery. They may be called a “**covering” or “defunctioning**” loop colostomy or ileostomy, as they allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function. They are usually reversed around 6-8 weeks later. The bowel is partially opened and folded so that there are two openings on the skin side-by-side, attached in the middle. “Loop” refers to it being the two ends (proximal and distal) of a section of small bowel being brought out onto the skin. The proximal end (the productive side) is turned inside out to form a spout to protect the surrounding skin. This distal end is flatter. This allows you to distinguish between the proximal and distal portions of the bowe

Answer 152

* Psycho-social impact * Local skin irritation * Parastomal hernia * Loss of bowel length leading to high output, dehydration and malnutrition * Constipation (colostomies) * Stenosis * Obstruction * Retraction (sinking into the skin) * Prolapse (telescoping of bowel through hernia site) * Bleeding * Granulomas causing raised red lumps around the stoma

Answer 153

F – Fat F – Fair F – Female F – Forty

Answer 154

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction. Exams may test this mechanism, so it is worth remembering.

Answer 155

obstruction . Obstruction may be caused by a gallstone in the bile duct or an external mass pressing on the bile ducts (e.g., cholangiocarcinoma or tumour of the head of the pancreas).

Answer 156

**biliary obstruction** in presence of right upper quadrant pain and/or jaundice Raised alkaline phosphatase can also be caused by **liver or bone malignancy, primary biliary cirrhosis, Paget’s disease** of the bone and many other things.

Answer 157

In patients with **cholestasis** (e.g., due to gallstones), ALT and AST can increase slightly, with a higher rise in ALP (“an obstructive picture”).

Answer 158

If ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with **hepatocellular injury** (“a hepatitic picture”).

Answer 159

US Ultrasound can be helpful in identifying: * Gallstones in the gallbladder * Gallstones in the ducts * Bile duct dilatation (normally less than 6mm diameter) * Acute cholecystitis (thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder) * The pancreas and pancreatic duct

Answer 160

A magnetic resonance cholangio-pancreatography (MRCP) is an MRI scan with a specific protocol that produces a detailed image of the biliary system. It is very sensitive and specific for biliary tree disease, such as stones in the bile duct and malignancy. MRCP is used in a number of scenarios for gaining a detailed picture of the biliary system, such as identifying biliary strictures or congenital abnormalities. With gallstone disease, MRCP is typically used to investigate further if the ultrasound scan does not show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction.

Answer 161

An endoscopic retrograde cholangio-pancreatography (ERCP) involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system. The main indication for ERCP is to clear stones in the bile ducts. ERCP allows the operator to: * Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures) * Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow) * Clear stones from the ducts * Insert stents to improve bile duct drainage (e.g., with strictures or tumours) * Take biopsies of tumours

Answer 162

Excessive bleeding Cholangitis (infection in the bile ducts) Pancreatitis

Answer 163

Cholecystectomy involves surgical removal of the gallbladder. It is indicated where patients are symptomatic of gallstones, or the gallstones are leading to complications (e.g., acute cholecystitis). Stones in the bile ducts can be removed before (by ERCP) or during surgery. Laparoscopic cholecystectomy (keyhole surgery) is preferred to open cholecystectomy (with a right subcostal “Kocher” incision), as it has less complications and a faster recovery. Complications of cholecystectomy include: * Bleeding, infection, pain and scars * Damage to the bile duct including leakage and strictures * Stones left in the bile duct * Damage to the bowel, blood vessels or other organs * Anaesthetic risks * Venous thromboembolism (deep vein thrombosis or pulmonary embolism) * Post-cholecystectomy syndrome

Answer 164

Post-cholecystectomy syndrome involves a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder. Symptoms often improve with time. Symptoms include: * Diarrhoea * Indigestion * Epigastric or right upper quadrant pain and discomfort * Nausea * Intolerance of fatty foods * Flatulence

Answer 165

Acute cholecystitis refers to inflammation of the gallbladder, which is caused by a blockage of the cystic duct preventing the gallbladder from draining. It is a key complication of gallstones, and the majority of cases (around 95%) are caused by gallstones (calculous cholecystitis). Gallstones may be trapped in the **neck of the gallbladder or in the cystic duct.** In a small number of cases, the dysfunction in gallbladder emptying is caused by something other than gallstones (**acalculous cholecystitis**). One scenario where this may occur is in patients on total parental nutrition or having long periods of fasting (for example in ICU for other serious conditions), where the gallbladder is not being stimulated by food to regularly empty, resulting in a build-up of pressure.

Answer 166

Fever Nausea Vomiting Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate) Right upper quadrant tenderness Murphy’s sign Raised inflammatory markers and white blood cells

Answer 167

* Place a hand in RUQ and apply pressure * Ask the patient to take a deep breath in * The gallbladder will move downwards during inspiration and come in contact with your hand * Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration *

Answer 168

* Thickened gallbladder wall * Stones or sludge in gallbladder * Fluid around the gallbladder Magnetic resonance cholangiopancreatography (MRCP) may be used to visualise the biliary tree in more detail if a common bile duct stone is suspected but not seen on an ultrasound scan (e.g., bile duct dilatation or raised bilirubin).

Answer 169

* Nil by mouth * IV fluids * Antibiotics (as per local guidelines) * NG tube if required for vomiting **Endoscopic retrograde cholangio-pancreatography (ERCP)** can be used to remove stones trapped in the common bile duct. **Cholecystectomy** (removal of the gallbladder) is usually be performed during the acute admission, within 72 hours of symptoms. In some cases, it may be delayed for 6-8 weeks after the acute episode to allow the inflammation to settle.

Answer 170

Sepsis Gallbladder empyema Gangrenous gallbladder Perforation

Answer 171

Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder. Management involves IV antibiotics and one of two main options: * Cholecystectomy (to remove the gallbladder) * Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

Answer 172

Acute cholangitis is infection and inflammation in the bile ducts. It is a surgical emergency and has a high mortality due to sepsis and septicaemia. There are two main causes of acute cholangitis: * Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct) * Infection introduced during an ERCP procedure

Answer 173

The most common organisms are: * Escherichia coli * Klebsiella species * Enterococcus species

Answer 174

Right upper quadrant pain Fever Jaundice (raised bilirubin)

Answer 175

Patients need acute management of sepsis and acute abdomen, including: * Nil by mouth * IV fluids * Blood cultures * IV antibiotics (as per local guidelines) * Involvement of seniors and potentially HDU or ICU An **endoscopic retrograde cholangio-pancreatography (ERCP)** is required to remove stones blocking the bile duct. It involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system. A number of procedures can be performed during an ERCP: * **Cholangio-pancreatography**: retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system * **Sphincterotomy**: making a cut in the sphincter to dilate it and allow stone removal * **Stone removal:** a basket can be inserted and pulled through the common bile duct to remove stones * **Balloon dilatation**: a balloon can be inserted and inflated to treat strictures * **Biliary stenting**: a stent can be inserted to maintain a patent bile duct (for strictures or tumours) * **Biopsy**: a small biopsy can be taken to diagnose obstructing lesions **Percutaneous transhepatic cholangiogram (PTC)** involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts. The drain relieves the immediate obstruction. A stent can be inserted to give longer-lasting relief of obstruction. This is an option for patients that are less suitable for ERCP, or where ERCP has failed.

Answer 176

Gallstones Alcohol Post-ERCP

Answer 177

I – Idiopathic G – Gallstones E – Ethanol (alcohol consumption) T – Trauma S – Steroids M – Mumps A – Autoimmune S – Scorpion sting (the one everyone remembers) H – Hyperlipidaemia E – ERCP D – Drugs (furosemide, thiazide diuretics and azathioprine)

Answer 178

Severe epigastric pain Radiating through to the back Associated vomiting Abdominal tenderness Systemically unwell (e.g., low-grade fever and tachycardia)

Answer 179

Initial investigations are required as with any presentation of an acute abdomen. Importantly these need to include those required for calculating the Glasgow score: * FBC (for white cell count) * U&E (for urea) * LFT (for transaminases and albumin) * Calcium * ABG (for PaO2 and blood glucose) * **Amylase** is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function. **Lipase** is also raised in acute pancreatitis. It is considered more sensitive and specific than amylase. **C-reactive protein (CRP)** can be used to monitor the level of inflammation. **Ultrasound** is the initial investigation of choice in assessing for gallstones. **CT abdomen** can assess for complications of pancreatitis (such as necrosis, abscesses and fluid collections). It is not usually required unless complications are suspected (e.g., the patient is becoming more unwell).

Answer 180

0 or 1 – mild pancreatitis 2 – moderate pancreatitis 3 or more – severe pancreatitis

Answer 181

P – Pa02 \< 8 KPa A – Age \> 55 N – Neutrophils (WBC \> 15) C – Calcium \< 2 R – uRea \>16 E – Enzymes (LDH \> 600 or AST/ALT \>200) A – Albumin \< 32 S – Sugar (Glucose \>10)

Answer 182

Patients with acute pancreatitis can become very unwell rapidly. They require admission to supportive management. Moderate or severe cases should be considered for management on the **high dependency unit (HDU) or intensive care unit (ICU).** Management involves: * Initial resuscitation (ABCDE approach) * IV fluids * Nil by mouth * Analgesia * Careful monitoring * Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy) * Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area) * Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections) Most patients will improve within 3-7 days.

Answer 183

Necrosis of the pancreas Infection in a necrotic area Abscess formation Acute peripancreatic fluid collections Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis Chronic pancreatitis

Answer 184

* Chronic epigastric pain * Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract * Loss of endocrine function, resulting in a lack of insulin, leading to diabetes * Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile * Formation of pseudocysts or abscesses

Answer 185

**Abstinence** from alcohol and smoking is important in managing symptoms and complications. **Analgesia** can be used to manage the pain, although it can be severe and difficult to manage. **Replacement pancreatic enzymes** (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins. **Subcutaneous insulin** regimes may be required to treat diabetes. **ERCP** with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct. **Surgery** may be required by specialist centres to treat: * Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue) * Obstruction of the biliary system and pancreatic duct * Pseudocysts * Abscesses

Answer 186

The liver can regenerate as an organ. Therefore, it is possible to take a portion of the organ from a living donor, transplant it into a patient and have both regenerate to become two fully functioning organs. This is known as a living donor transplant.

Answer 187

Indications for liver transplant can be split into two categories: acute liver failure or chronic liver failure. They may also be used in specific cases of hepatocellular carcinoma. **Acute liver failure** usually requires an immediate liver transplant, and these patients are placed on the top of the transplant list. The most common causes are acute viral hepatitis and paracetamol overdose. **Chronic liver failure** patients can wait longer for their liver transplant and are put on a standard transplant list. It is normal for it to take around 5 months for a liver to become available.

Answer 188

Significant co-morbidities (e.g., severe kidney, lung or heart disease) Current illicit drug use Continuing alcohol misuse (generally 6 months of abstinence is required) Untreated HIV Current or previous cancer (except certain liver cancers)

Answer 189

The liver transplant surgery is carried out in a specialist transplant centre. It involves a **“rooftop”** or **“Mercedes Benz”** incision along the lower costal margin for open surgery. The liver is mobilised away from the other tissues and excised. The new liver, biliary system and blood supply is then implanted and connected.

Answer 190

Avoid alcohol and smoking Treating opportunistic infections Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis) Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients

Answer 191

Abnormal LFTs Fatigue Fever Jaundice