Gen Emergency Surgery Flashcards
1
Q
1. An 85-year-old woman presents with a 6-hour history of severe sudden onset central abdominal pain. Her heart rate is 110 beats per minute and irregularly irregular. Her blood pressure is 132/94 mmHg and temperature is 38.1°C. Abdominal examination reveals a generally soft but distended and tender abdomen with no audible bowel sounds. Per rectal examination reveals guaiac-positive stool. What is the most likely diagnosis? A Abdominal aortic aneurysm B Acute pancreatitis C Mesenteric ischaemia D Myocardial infarction E Peptic ulcer disease
A
- C Mesenteric ischaemia
Acute mesenteric ischaemia is a serious condition with a high morbidity and mortality. It can also be notoriously difficult to diagnose. CT of the abdomen with arterial contrast may show thickened loops of small bowel or thrombus in the involved arteries (coeliac axis, superior mesenteric artery or inferior mesenteric artery) (Figure 1.1).
Figure 1.1 CT of small bowel ischaemia.
A 10-year retrospective review of cases in the USA revealed 95% of cases presented with abdominal pain, and 44% had nausea. Vomiting and diarrhoea occurred in 35% of cases, tachycardia in 33%, and 16% had per rectal bleeding. Atrial fibrillation is strongly associated with mesenteric ischaemia as embolic cause accounts for 28% of cases and half of these patients are fibrillating.
Park WM, Gloviczki P, Cherry KJ Jr, et al. Contemporary management of acute mesenteric ischemia: Factors associated with survival. J Vasc Surg 2002; 35:445–452.
Answers 31
2
Q
- In patients who present with acute pancreatitis, which factor is least likely to independently predict the development of complications?
A Age > 55 years
B APACHE II score > 8 points in the first 24 hours of admission
C C-reactive protein > 150 mg/L after 48 hours in hospital
D Glasgow score > 3
E Obesity
A
- A Age > 55 years
Age above 55 years alone is not predictive of the development of complications. Complications in acute pancreatitis occur more commonly in patients with clinical obesity. Complications are also more common in those patients with severe pancreatitis. This can be based on scoring systems (an APACHE II score > 8 in the first 24 hours after admission or a Glasgow coma score > 3). Severe pancreatitis also includes any organ failure which continues beyond 48 hours and a C-reactive protein > 150 mg/L. In both cases complications are more likely to occur.
UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005; 54:1–9.
3
Q
- An 8-week-old infant is diagnosed with a congenital diaphragmatic hernia (CDH). What is the most common cause of a CDH?
A Anterior defect (Morgagni hernia)
B Central tendon defect
C Defect in the pleuroperitoneal fold
D Enlarged oesophageal hiatus
E Posterolateral defect (Morgagni hernia)
A
- C A defect in the pleuroperitoneal fold
A defect in the pleuroperitoneal fold may result in a posterolateral Bochdalek hernia which is the most common congenital diaphragmatic hernia, accounting for more than 95% of cases. The majority of Bochdalek hernias (78%) occur on the left side of the diaphragm, 20% on the right, and they are rarely bilateral. Unlike Morgagni herniae, Bochdalek herniae tend not to have a hernia sac. Morgagni herniae occur through the anterior space of Larrey.
Brown SR, Horton JD, Trivette E, et al. Bochdalek hernia in the adult: demographics, presentation, and surgical management. Hernia 2011; 15:23–30.
4
Q
- A 27-year-old man presents with colicky pain in his left flank and urine dipstick reveals the presence of haematuria. A plain abdominal radiograph reveals a
- 5 × 0.5 cm opacification in his bladder which is thought to represent a passed calculus.
What is this calculus most likely to be composed of?
A Calcium oxalate
B Calcium phosphate
C Mixed oxalate/phosphate
D Ammonium magnesium phosphate (struvite)
E Uric acid
A
- A Calcium oxalate
Statistically, this stone is most likely to be composed of calcium oxalate as this comprises 40% of ureteric calculi. Mixed oxalate/phosphate occurs in 20%, calcium phosphate and ammonium magnesium phosphate (struvite) stones both occur in 15% of patients and uric acid in 10%.
Stones containing calcium, such as calcium oxalate and calcium phosphate, are easiest to detect by radiography. Although 90% of urinary calculi have been considered to be radiopaque, the sensitivity and specificity of kidney, ureters, and bladder radiography alone remains poor (with sensitivity of 45–59% and specificity of 71–77%).
Levine JA, Neitlich J, Verga M, et al. Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced helical CT. Radiology 1997; 204:27–31.
5
Q
- A 6-year-old boy with abdominal pain is admitted to the paediatric surgical ward for investigation and treatment. He is known from a previous admission to have a Meckel’s diverticulum and his attending doctors wonder if it is the cause of his current symptoms.
Which of the following is not a recognised presentation of a Meckel’s diverticulum?
A Gastrointestinal haemorrhage
B Incidental mesenteric lesion found at laparoscopy/laparotomy
C Intussusception
D Perforation
E Symptomatic inguinal hernia
A
- B Incidental mesenteric lesion found at laparoscopy/laparotomy
Meckel’s diverticulae are classically 5 cm (2 inch) long pulsion diverticulae which are normally found approximately 60 cm (2 feet) from the ileocaecal valve on the antimesenteric border of the ileum. They occur in approximately 2% of the population and hence the ‘Rule of 2s applies’. They represent an embryological remnant of the vitello-intestinal duct. Most patients are asymptomatic although the Meckel’s divertican cause symptoms due to inflammation, bleeding or perforation. It can also present as the lead point for an intussusception or as the contents of an indirect inguinal hernia sac, in the eponymous Littre’s hernia.
Thurley PD, Halliday KE, Somers JM, et al. Radiological features of Meckel’s diverticulum and its complications. Clin Radiol 2009; 64:109–118.
6
Q
- A 3-week-old neonate presents with dehydration and bilious vomiting. A contrast study reveals a duodenojejunal junction lying on the right side of the abdomen.
What is the most appropriate definitive management?
A Hydrostatic reduction B Insertion of nasogastric tube C Intravenous fluids and antiemetics D Laparotomy E Review at 6 months of age to determine the need for intervention
A
- D Laparotomy
This patient has intestinal malrotation. This is a congenital condition occurring 1 in 500 live births, which can have serious complications. Malrotation occurs when there is a failure of embryological gut development and rotation, whereby the root of the mesentery remains narrow and the caecum occupies a non-rotated position in the right upper quadrant
In the normal physiological state, starting from a straight tube, the embryological gut undergoes a complex series of rotations between 4–12 weeks culminating in the duodenojejunal flexure lying on the left side of the abdomen and the caecum positioned in the right iliac fossa.
There is a subsequent tendency for the bowel to twist around the mesentery and this combined with the development of adhesive Ladd’s bands can lead to ischaemic bowel and perforation. As such early diagnosis is important to facilitate early laparotomy and avoid dangerous sequelae.
Operative repair involves division of the Ladd’s band, appendicectomy, widening of the mesentery and relocation of the colon. A laparoscopic form of this procedure has evolved with the contrived acronym ‘LADD’ (Laparoscopic Appendicectomy and Duodenocolic Dissociation).
Millar AJW, Rode H, Brown RA, Cywes S. The deadly vomit: malrotation and midgut volvulus. Pediatr Surg Int 1987; 2:172–176.
Lessin MS, Luks FI. Laparoscopic appendectomy and duodenocolonic dissociation (LADD) procedure for malrotation. Pediatr Surg Int 1998; 13:184–185.
Williams H. Green for danger! Intestinal malrotation and volvulus. Arch Dis Child Educ Pract Ed 2007; 92:87–91.
7
Q
- A 4-year-old infant is diagnosed with a symptomatic choledochal cyst.
What is the most appropriate treatment?
A Cyst gastrostomy B Cyst jejunostomy C Excision with Roux-en-Y hepaticojejunostomy D Primary excision of the lesion E Surveillance (endoscopic)
A
- C Excision with Roux-en-Y hepaticojejunostomy
Choledochal cysts are congenital dilations of the intra- and/or extrahepatic bile duct(s). They can be asymptomatic or present with components of the classic triad of jaundice, abdominal pain and right upper quadrant mass.
They can present in children or adults and have been classified by Todani et al (1977) into types I–V (Figure 1.3):
• Type I: dilation of all or part of common bile duct (CBD; this is the commonest form, representing 80–90% of all choledochal cysts).
• Type II: solitary cystic diverticulum extending from the CBD.
• Type III: arising from the duodenal CBD at its junction with the pancreatic duct.
• Type IV: cystic dilatations of the intra- and extrahepatic biliary tree.
• Type V: cystic dilatations of the intrahepatic biliary tree only.
Children with choledochal cysts fare differently from adults as long-term complications are less common. The management of choledochal cysts used to involve internal drainage with cystoduodenostomy or cystoduodenotomy, but these procedures had a tendency to fail and up to 5% developed adenocarcinoma. The surgical treatment of choice is excision of the lesion and formation of a hepaticojejunostomy.
Todani T, Watanabe Y, Narusue M, et al. Congenital bile duct cysts: Classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst. Am J Surg 1977; 134:263–269.
Shimotakahara A, Yamataka A, Yanai T, et al. Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy for biliary reconstruction during the surgical treatment of choledochal cyst: which is better? Pediatr Surg Int 2005; 21:5–7.
8
Q
- A 21-year-old previously healthy male arts student presents with a 2-day history of lower abdominal pain and loss of appetite. He is pyrexial and has a tender palpable mass in his right iliac fossa. Haematology reveals a pyogenic leukocytosis and a CT demonstrates a 13 × 15 cm walled-off abscess adjacent to a large complex inflammatory mass involving an inflamed appendix.
What is the most appropriate management plan?
A Conservative management (analgesia, intravenous fluid and antibiotics)
B Conservative management, followed by interval appendicectomy at 6–8 weeks
C Laparoscopy and washout
D Laparoscopic appendicectomy
E Percutaneous drainage of the abscess and intravenous antibiotics
A
- E Percutaneous drainage of abscess and intravenous antibiotics
In patients with an appendix mass there is a degree of clinical equipoise with regards to the specific management. The main treatment decisions are between:
• Immediate appendicectomy
• Conservative management with interval appendicectomy
• Conservative management alone.
The presence of an appendix abscess mandates either surgical or radiological drainage. In this patient’s case there is a complex inflammatory mass and, as such, a surgical procedure would not be advisable.
Paull DL. Bloom GP. Appendiceal abscess. Arch Surg 1982; 117:1017–1019.
Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg 2007; 246:741–748.
Brown CV, Abrishami M, Muller M, Velmahos GC. Appendiceal abscess: immediate operation or percutaneous drainage? Am Surg 2003; 69:829–832.
Lasson A, Lundagårds J, Lorén I, Nilsson PE. Appendiceal abscesses: primary percutaneous drainage and selective interval appendicectomy. Eur J Surg 2002;168:264–269.
9
Q
- A 70-year-old man with arteriopathy undergoes a barium enema and feels light-headed afterwards. Routine biochemistry reveals a serum potassium of 2.8 mmol/L.
Which medication is least likely to be causative?
A Amphotericin B B Barium C Furosemide D Salbutamol E Trimethoprim
A
- E Trimethoprim
Trimethoprim is associated with hyperkalaemia. It inhibits the activity of the epithelial sodium channel resulting in elevated serum potassium. The four other drugs listed here as answer options are all associated with hypokalaemia rather than hyperkalaemia. Exposure to barium in the enema, antifungal treatment with amphotericin, diuretic therapy such as furosemide, and inhalers such as salbutamol, may all cause low potassium.
Perazella MA. Trimethoprim Is a potassium-sparing diuretic like amiloride and causes hyperkalemia in high-risk patients. Am J Therapeutics 1997; 4:343–8.
Nyirenda MJ, Tang JI, Padfield PL, Seckl JR. Hyperkalaemia BMJ 2009; 339:1019–1024.
Answers 35
10
Q
- A 45-year-old woman with haematemesis is admitted to accident and emergency in hypovolaemic shock. She undergoes resuscitation including administration of packed red cells. The blood transfusion centre will not release certain blood products unless a ‘massive bleeding’ protocol is initiated.
Which of the following is not a definition of massive bleeding?
A Blood loss of half the patient’s circulating volume in a 3-hour period
B Blood loss of the patient’s circulating volume in a 24-hour period
C Ongoing blood loss of 100 mL/min
D Transfusion of 4 units of red cells in 4 hours with continued bleeding
E Transfusion of 10 units of packed red cells in a 24-hour period
A
- C Ongoing blood loss of 100 mL/min
Massive bleeding is defined as:
• Blood loss of half the patient’s circulating volume in a 3-hour period
• Blood loss of the patient’s circulating volume in a 24-hour period
• Ongoing blood loss of > 150 mL/min
• Transfusion of four units of packed red cells in a 4-hour period with continued
bleeding
• Transfusion of 10 units of packed red cells in a 24-hour period.
A patient meeting such criteria should stimulate the activation of the local ‘massive transfusion protocol’. This should alert the transfusion service to provide prompt delivery of packed red cells and suitable clotting products.
British Committee for Standards in Haematology, Stainsby D, MacLennan S, et al. Guidelines on the management of massive blood loss. Br J Haematol 2006; 135:634–41.
Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg 2009; 209:198–205.
11
Q
- A 43-year-old previously well woman presents with pain, swelling and erythema in the anorectal area.
What is the most appropriate management?
A CT of abdomen and pelvis B Examination under anaesthesia and drainage of pus C Flexible sigmoidoscopy D Intravenous antibiotics E MRI of perineum
A
- B Examination under anaesthesia (EUA) and drainage of pus
Anorectal sepsis is a common presenting symptom which can present acutely as an abscess with erythema, pain and swelling or chronically as a fistula-in-ano. The peak incidence of perianal abscesses are in the third decade. Management of a perianal abscess is of simple incision and drainage of underlying pus, whereas fistulotomy of a low fistula or insertion of a draining seton can be used if a fistula-in-ano is evident.
MacKay GJ, Dorrance HR, Molloy RG (eds). Colorectal Surgery. Oxford: Oxford University Press, 2010: 274. Philips RKS (ed). Colorectal Surgery: A Companion to Specialist Surgical Practice, 4th edn. Philadelphia: Saunders, Elsevier, 2009: 227.
12
Q
- A 65-year-old man with severe pancreatitis is intubated and ventilated in the intensive care unit. His intra-abdominal pressure is measured using a catheter in his bladder connected to manometry.
Which one of the following describes the pressure effect seen in abdominal compartment syndrome?
A Bladder pressure of 16–25 mmHg does not present with oliguria
B Bladder pressure of 16–25 mmHg does not require decompression
C Bladder pressure of 26–35 mmHg results in increased cardiac output
D Bladder pressure of > 35 mmHg does not cause anuria
E Bladder pressure of < 15 mmHg normally has clinical signs
A
- B A bladder pressure of 16–25 mmHg does not require decompression
As intra-abdominal pressure rises, so too does bladder pressure. Between 16 and 25 mmHg is grade 2 intra-abdominal hypertension, which normally manifests as oliguria. Recommended management at this stage includes fluid resuscitation and if the pressure rises beyond the critical threshold of 25 mmHg, abdominal decompression is required (Table 1.1).
Papavramidis TS, Marinis AD, Pliakos, et al. Abdominal compartment syndrome – Intra-abdominal hypertension: Defining, diagnosing, and managing. J Emerg Trauma Shock 2011; 4:279–291
13
Q
- An 84-year-old man presents repeatedly with abdominal distension due to a sigmoid volvulus.
Which one of the following statements does not apply to the management of sigmoid volvulus?
A Following detorsion, volvulus recurs in 50–90% of cases
B Following sigmoid resection, volvulus recurs in 0% of cases
C Sigmoidoscopic decompression successfully reduces volvulus in 70–80% of
cases
D Spontaneous detorsion of volvulus is common
E Therapeutic barium enema can successfully reduce a volvulus
A
- D Spontaneous detorsion of volvulus is common
Sigmoid volvulus has a characteristic inverted U-shape on plain abdominal X-ray (Figure 1.4). The management of sigmoid volvulus is relief of the obstruction, normally by sigmoidoscopic decompression. This technique is successful in 70–80% of cases. A rectal tube can be left in situ to reduce the chance of recurrence. Despite a successful result, volvulus recurs in 50–90% of patients, and as such this technique should be considered as a temporising measure only.
Following further medical assessment and resuscitation, a decision can be made to proceed to definitive surgery (removal of the sigmoid colon). This may also be indicated if the volvulus recurs, or cannot be decompressed.
Other therapeutic options include barium or water-soluble contrast enemas.
This technique results in detorsion of the volvulus in approximately 5% of adults, although better results have been achieved in children. Spontaneous reductions in all patients are rare and occur in only two per cent of patients.
Ballantyne GH. Review of sigmoid volvulus: history and results of treatment. Dis Colon Rectum 1982; 25:494–501.
Reilly PMJ, Jones B, Bulkley GB. Volvulus of the colon. In: Cameron JL (ed). Current Surgical Therapy. St Louis: Decker Inc 1992: 170–174.
14
Q
- Which of the following is most likely to shift the oxygen haemoglobin dissociation curve to the left?
A Decreased pH B Extreme altitude C Increased 2,3-diphosphoglycerate concentration D Increased PaCO2 E Increased temperature
A
- B Extreme altitude
The oxygen haemoglobin dissociation curve represents the relationship
between the partial pressure of oxygen and the oxygen saturation. The affinity of haemoglobin for oxygen increases as further molecules of oxygen are bound. This results in a sigmoid-shaped curve until no further oxygen can be bound.
When this curve is shifted to the left, this represents a higher affinity of haemoglobin for oxygen at that given pressure. Conversely, when this curve is shifted to the right this represents lower affinity and consequently oxygen is released to the tissues more readily.
The curve is shifted to the right by acidosis (decreased pH), increased temperature, increased 2,3-diphosphoglycerate and raised CO2. This is analogous to exercising muscles and means that more oxygen is made available to the tissues. At extreme altitude the oxygen haemoglobin dissocation curve shifts to the left because there is much less CO2 in the blood (Figure 1.5).
15
Q
- Prothrombin complex concentrate is a haematological product, which is used for patients with ongoing bleeding.
Which of the following statements does not describe prothrombin complex concentrate?
A Contains clotting factors II, VII, VIII and IX
B Contains protein C and protein S
C Has a faster mode of action than fresh frozen plasma
D It is used for perioperative prophylaxis of bleeding in acquired deficiency of
the prothrombin complex coagulation factors
E Is used for reversal of warfarin when rapid correction is required
A
- A Contains clotting factors II, VII, VIII and IX
Prothrombin complex concentrate contains clotting factors II, VII, IX and X (the vitamin K-dependent factors). It also contains protein C and protein S. It is indicated for treatment, and perioperative prevention, of bleeding in patients with (acquired or congenital) deficiency of factors II, VII, IX or X, or if purified specific coagulation factors are not available.
Lubetsky A. Efficacy and safety of a prothrombin complex concentrate (Octaplex) for rapid reversal of oral
anticoagulation. Thrombosis Research 2004; 113:371–378
16
Q
- A 27-year-old woman sustains multiple rib fractures in a road traffic accident. When is an urgent thoracotomy not indicated?
A Cardiac tamponade
B Chest drainage of 300 mL blood in the first hour and 250 mL/h in the next few
hours
C Flail chest with evidence of haemothorax
D Immediate chest drainage of >1500 mL of blood
E Widening of the mediastinum to >8 cm
A
- C Flail chest with evidence of haemothorax
Indications for an urgent thoracotomy include:
• A defect in the chest wall
• A great vessel injury demonstrated on angiography
• A large ongoing air leak (despite adequate drainage)
• A large unevacuated clotted haemothorax
• A traumatic (sepal or valvular) injury to the heart
• Cardiac tamponade
• Chest drainage > 1500 mL (or > 200 mL drainage per hour)
• Diaphragm laceration
• Oesophageal injury
• Widening of the mediastinum > 8 cm
Bodai BI. Emergency thoracotomy in the management of trauma. JAMA 1983; 8; 249:1891–1896.
Feliciano DV, Rozycki GS. Advances in the diagnosis and treatment of thoracic trauma. Surg Clin North Am 1999; 79:1417–1429.
Shields, TW, Locicero J, Reed CE (eds). General Thoracic Surgery, Volume 1, 7th edn. Philadelphia: Lippincott, Williams and Wilkins 2009: 898
17
Q
- A 65-year-old man presents with left iliac fossa pain, pyrexia and raised white cell count 20 × 1000 per mm3 and C-reactive protein of 200 mg/L.
What is the most appropriate investigation?
A Abdominal X-ray
B Barium enema
C Colonoscopy
D CT of abdomen and pelvis
E Flexible sigmoidoscopy
A
- D CT of abdomen and pelvis
Diverticular disease is its complicated form can present with a patient showing clinical signs of sepsis and will require treatment with intravenous antibiotics. In severe sepsis combination antibiotics should be prescribed. In an unwell patient a CT of abdomen and pelvis can provide information as to the cause of the sepsis, i.e. confirming or refuting the suspected diagnosis as well as providing further details, such as any underlying absesses which may be ameniable to radiological drainage. A CT may also show any evidence of fistulation, obstruction or perforation, which may require more aggressive management.
MacKay GJ, Dorrance HR, Molloy RG and O’Dwyer PJ. Colorectal Surgery. Oxford: Oxford University Press, 2010: 298.
Philips RK. Colorectal Surgery: A Companion to Specialist Surgical Practice. Philadelphia: Saunders, 4th edn, 2009: 112.
18
Q
- A 23-year-old woman is referred by the gastroenterology team with tachycardia, hypotension and generalised colonic tenderness. She has had 5 days of intravenous (IV) steroids and her bowel movements have decreased from
12 to 6 bloody stools per day.
What is the most appropriate management?
A Colonoscopy and biopsies B Continue IV steroids C Cyclosporin D Infliximab E Subtotal colectomy and ileostomy
A
- E Subtotal colectomy and ileostomy
This patient has severe acute colitis and is systemically unwell. The treatment
is an emergency subtotal colectomy and end ileostomy. She has failed medical management. Although there are a number of classifications for acute colitis, Truelove and Witts’ classification (Table 1.2) provides a straightforward method of classification for such patients.
Jakobovits SL and Travis SPL. Acute Severe Colitis. British Medical Bulletin 2006; 75, 76:131–144.
19
Q
- A 78-year-old woman is admitted with a dense right-sided weakness. She has reduced consciousness but is moving her left arm and both legs normally. She is confused and disorientated but opens her eyes in response to vocal stimuli and follows commands.
What is this patient’s score on the Glasgow coma scale?
A 10
B 11
C 12
D 13
E 14
A
- D 13
The Glasgow coma scale (GCS) is a 15-point scale for assessing and recording a patient’s conscious state (Table 1.3). It is composed of eye opening, best motor and verbal response.
20
Q
- ABO compatibility is advisable for the transfusion of blood products. Which of the following products does not require ABO compatibility?
A Cryoprecipitate B Fresh frozen plasma C Haemoglobin solution D Packed red cells E Platelets
A
- C Haemoglobin solution
Solutions of free haemoglobin do not have the antigenic characteristics of the blood groups, and they therefore do not require compatibility testing. ABO incompatibility can reduce the expected platelet count increment by 10−30%.
Remy B, Deby-Dupont G, Lamy M. Red blood cell substitutes: fluorocarbon emulsions and haemoglobin solutions. British Medical Bulletin 1999; 55:277–298.
21
Q
- A 24-year-old woman is involved in a road traffic accident where she sustains a splenic injury.
Which of the following statements describes the classification of splenic injury?
A Grade I injury describes an intraparenchymal haematoma under 5 cm in diameter
B Grade II injury describes a capsular tear under 1 cm deep
C Grade III injury describes a subcapsular haematoma under 50% of the surface
area
D Grade III injury describes a capsular laceration 1–3 cm deep in the parenchyma
E Grade IV injury describes a laceration producing major devascularisation
(> 25% of spleen)
A
- E Grade IV injury describes a laceration producing major devascularisation (> 25% of spleen)
Grade IV injury describes a laceration producing major devascularisation equivalent to over 25% of the spleen.
Grade I splenic injuries include subcapsular haematomas (of < 10% of the surface area) and capsular lacerations < 1 cm deep. Grade II splenic injuries include subcapsular haematomas (of < 50% of the surface area) and intraparenchymal haematomas
< 5 cm. They also include capsular tears between 1 and 3 cm deep. Grade III splenic injuries include expanding subcapsular or intraparenchymal haematomas, ruptured haematomas, and any lacerations > 3 cm (or involving trabecular vessels). Grade IV injuries describe segmental, or hilar, vessel lacerations or major devascularisation. Grade V injuries refer to a completely shattered or devascularised spleen.
Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen and liver. J Trauma 1994; 38:323–324.
22
Q
- A72-year-oldmanpresentswithfreshrectalbleeding.HeundergoesCTangiography, which fails to localise the bleeding source and continues to bleed.
What is the most appropriate investigation?
A Barium enema B CT of chest, abdomen and pelvis C Colonoscopy D Flexible sigmoidoscopy E Upper gastrointestinal endoscopy and proctoscopy
A
- E Upper gastrointestinal endoscopy and proctoscopy
Acute colonic bleeding is a common problem and can manifest in a broad spectrum of clinical signs. The incidence increases with age and in the majority it resolves without intervention. However, in approximately 15% of cases bleeding will continue, resulting in haemodynamic instability. CT angiography has been shown in porcine models to detect bleeding rates of < 0.3 mL/min, but endoscopic visualisation of the upper gastrointestinal tract with endoscopy and proctoscopy should be first line investigations. Haemorrhoids must be excluded as a cause.
MacKay GJ, Dorrance HR, Molloy RG, O’Dwyer PJ. Colorectal Surgery. Oxford: Oxford University Press, 2010: 393.
Laing CT, Tobias T, Rosenblum DI, et al. Acute gastrointestinal bleeding: emerging role of multidetector CT angiography and review of current imaging techniques. Radiographics 2007; 27:1055–1070.
23
Q
- A 55-year-old man presents to the surgical department with acute colonic bleeding.
Which of the following statements is most appropriate?
A Angiodysplasia is a rare cause
B Diverticular bleeding is the most common cause accounting for approximately
50% of cases
C For angiography to successfully identify the bleeding source, the blood loss
must be above 10 mL/min
D Rectal causes preclude the need for proximal investigation
E The incidence of bleeding post polypectomy is as high as 30%
A
- B Diverticular bleeding is the most common cause accounting for approximately 50% of cases
In the elderly population the commonest cause of massive colonic bleeding is diverticular disease, (up to 50% of cases) closely followed by angiodysplasia (40%) . The incidence of bleeding post polypectomy is < 2%.
Avots–Avotins KV, Waugh DE. Colonic bleeding in the elderly. Clin Geriatr Med 1985;1(2):433–443.
MacKay GJ, Dorrance HR, Molloy RG, O’Dwyer PJ. Colorectal Surgery. Oxford: Oxford University Press, 2010: 390.
Ginsberg G. Risks of Colonoscopy and Polypectomy. Tech Gastrointest Endosc 2008; 10:7–13.
24
Q
- A 74-year-old woman attends her general practitioner (GP) complaining of absolute constipation and abdominal distension. The GP is concerned about the possibility of large bowel obstruction.
Which of the following statements describes the features of large bowel obstruction?
A Colonic volvulus is the most common cause
B Colonoscopy is the most appropriate first line investigation
C If the ileocaecal valve is incompetent a closed loop obstruction will develop
D Nausea and vomiting are early clinical symptoms
E Signs of peritonitis suggest ischaemia or perforation
A
- E Signs of peritonitis suggest ischaemia or perforation
Large bowel obstruction is a common surgical emergency. Mechanical causes account for > 60%, colonic tumours account for 20% and volvulus 5%. Nausea and vomiting are late signs as the obstruction is distal in the gastrointestinal tract. CT has largely replaced other investigations as it can distinguish between different pathologies and, if the obstruction is the result of a malignant cause, it will provide information on staging.
MacKay GJ, Dorrance HR, Molloy RG, O’Dwyer PJ. Colorectal Surgery. Oxford: Oxford University Press, 2010: 393.
25
Q
- An 88-year-old woman with severe chronic obstructive pulmonary disease presents with abdominal distension. A CT shows an obstructing apple core lesion of the sigmoid colon. She is also noted to have bilobar liver metastases.
What is the most appropriate first line management?
A Caecostomy B Colonic stenting C Hartmann’s procedure D Sigmoid colectomy E Subtotal colectomy and end ileostomy
A
- B Colonic stenting
This is a frail patient with significant comorbidities, which would make any surgery very high risk. Even a loop colostomy is associated with significant morbidity and
a small mortality rate. Stenting of the obstructing colonic lesion can achieve the same functional result as surgical decompression without the need for an operation and defunctioning colostomy. It can be used to allow time for work-up to definitive surgery or in an elderly patient, such as this, can provide good palliation.
Lamah M, Mathur P, McKeown B, et al The use of rectosigmoid stents in the management of acute large bowel obstruction. J R Coll Surg Edinb 1998; 43:318–321.
26
Q
- A 72-year-old man with refractory hypotension is commenced on dopamine in the intensive care unit.
Which of the following statements describes dopamine?
A In high doses it causes peripheral vasodilatation
B In low doses it increases renal blood flow
C It decreases cardiac output
D It decreases splanchnic blood flow
E It is able to cross the blood-brain barrier
A
- B In low doses it increases renal blood flow
Dopamine has varying dose-related effects due to α1-, β1- and dopaminergic activity:
Low dose effects (at doses < 2 μg/kg/min) are predominantly renal. There is increased renal, cerebral, coronary and mesenteric blood flow with vasodilation because of agonistic action on dopamine receptors in these vascular beds.
Intermediate dose effects (at doses 2–10 μg/kg/min) are predominantly cardiac. β1-agonist activity results in increased cardiac contractility and heart rate. The increased cardiac output and increased dopaminergic activity results in increased mesenteric perfusion. Slight α1-adrenergic activity may lead to a degree of peripheral vasoconstriction.
High dose effects (at doses 10–20 μg/kg/min) are vasoconstrictive and cardiac. α1-Adrenergic activity causes marked peripheral vasoconstriction and a rise in blood pressure. There can also be renal and mesenteric vasoconstriction. At very high doses (> 20 μg/kg/min) the overriding adrenergic activity may cause extreme vasoconstriction, which can suppress dopaminergic renal vasodilation and deleteriously affect the renal and peripheral circulation.
Holmes CL, Walley KR. Bad medicine: low-dose dopamine in the intensive care unit. Chest 2003; 123:1266–1275.
Dopamine in cardiac failure and shock. BMJ 1977; 17:1563–1564.
27
Q
- A 22-year-old girl has a suspicious lesion on her right shoulder that requires
excision biopsy.
Which of the following statements describes the excision margins for malignant skin lesions?
A In pTis melanoma (in situ) an excision margin of 1 cm is recommended
B In pT1 melanoma (0–1 mm thickness) an excision margin of 2 cm is
recommended
C In pT4 melanoma (> 4 mm thickness) an excision margin of 2 cm is
recommended
D With primary basal cell carcinoma lesions < 2 cm in diameter, an excision
margin of 0.5–1.0 cm is recommended
E With squamous cell carcinoma lesions under 2 cm, a margin of 1 cm is
recommended
A
- C In pT4 melanoma (> 4 mm thickness) an excision margin of 2 cm is recommended
For surgical excision of melanomatous lesions:
• In pTis (melanoma in situ) an excision margin of 2–5 mm is recommended
• In pT1 melanoma (0–1 mm thickness) an excision margin of 1 cm is
recommended
• In pT2 melanoma (1–2 mm thickness) an excision margin of 1–2 cm is recommended
• In pT3 melanoma (2–4 mm thickness) an excision margin of 2 cm is recommended
• In pT4 melanoma (> 4 mm thickness) an excision margin of 2 cm is recommended
In patients with squamous cell carcinoma, a 4 mm margin is sufficient to remove microscopic tumor in over 95% of well-differentiated tumours which are < 2 cm
in diameter. A wider margin of 6–10 mm is required for lesions > 2 cm in diameter, less-differentiated, or in high-risk locations (such as the scalp, ears, eyelids, nose, or lips).
In cases of primary basal cell carcinoma (BCC), a 3 mm surgical margin adequately clears the tumour in 85% of patients with lesions under 2 cm. However, increasing the excision margin to 4–5 mm increases the peripheral clearance rate to 95%.
In instances of recurrent BCC, margins of 5–10 mm have been recommended.
Balch CM, Buzaid AC, Soong SJ, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol 2001; 19:3635–3648.
Brodland DG, Zitelli JA. Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol 1992; 27:241–248.
Burg G, Hirsch RD, Konz B, Braun-Falco O. Histographic surgery: accuracy of visual assessment of the margins of basal-cell epithelioma. J Dermatol Surg Oncol 1975; 1:21–24.
Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch Dermatol 1987; 123:340–344.
28
Q
- A 60-year-old man presents with large volume haematemesis. After resuscitation an endoscopy reveals bleeding varices in the fundus of the stomach with no other abnormalities seen.
What is the most appropriate initial treatment?
A Balloon tamponade B Band ligation C Blood pressure regulation D Injection of cyanoacrylate glue E Transjugular intrahepatic portosystemic shunt
A
- D Injection of cyanoacrylate glue
Unlike oesophageal varices, bleeding from gastric varices is difficult to treat using band ligation because of difficult deployment in a retroflexed scope position. There are few controlled studies of medical therapy for gastric variceal bleeding and most evidence is extrapolated from what is known regarding the management of oesophageal varices.
The best endoscopic therapy for fundal gastric variceal bleeding is injection of cyanoacrylate glue which hardens on contact with blood. Following healing, when the mucosa sloughs away the overlying glue ‘cap’ will also be shed. Complications include infection and embolism of glue particles (which are fortunately very rare). The glue can also harden inside the scope and this can damage the equipment.
Feldman M, Friedman LS, Brandt LJ (eds). Sleisenger and Fordtran’s Gastrointestinal and Liver disease, 9th edn. Philadelphia: Saunders, 2010.
29
Q
- A 66-year-old man has long-standing portal hypertension due to alcohol abuse. He is investigated on an outpatient basis for the development of varices.
Which of the following anatomical areas does not represent a site of portosystemic varices?
A Intrahepatic, between the portal vein and the inferior vena cava
B Lower oesophagus, between the left gastric vein and oesophageal branches of
the azygous vein
C Rectal, between the superior rectal vein and the pudendal vein
D Retroperitoneal, between the ovarian vessels and the renal veins
E Umbilical, between the obliterated umbilical vein and the left portal vein
A
- D Retroperitoneal, between the ovarian vessels and the renal veins
Retroperitoneal varices occur between the mesenteric vessels and renal (or gonadal, or iliac) veins. However, in patients with infrarenal inferior vena cava obstruction, the ovarian (gonadal) vessels act as a collateral drainage for the systemic circulation by facilitating drainage form the internal iliac vessels to the left renal vein and the cava itself. However, this does not involve a portosystemic anastomosis. Other sites of collateralisation (between the portal and systemic circulations) include:
• The rectum, where the superior rectal from inferior mesenteric vein anastamoses with the middle and inferior rectal veins/pudendal vein.
• The paraumbilical region, where the left portal/paraumbilical vein anastomoses with the vestigial umbilical vein/superficial epigastric and caput medusa may result.
• The distal esophagus, where the left gastric vein anastomoses with oesophageal branches of the azygous vein.
• Intrahepatic, between the portal vein and the inferior vena cava.
30
Q
- Which of the following pathogens are not eradicated by alcohol based hand gels?
A Clostridium difficile B Escherichia coli C Extended spectrum β-lactamase D Klebsiella species E Methicillin-resistant Staphylococcus aureus
A
- A Clostridium difficile
Alcohol-based hand rubs are less effective on soiled hands and are ineffective against
C. difficile infection. Unfortunately, the hand rub is unable to kill the bacterial spores. World Health Organization (WHO). WHO Guidelines on Hand Hygiene in Health Care: First Global Patient
Safety Challenge: Clean care is safer care. Geneva: WHO, 2009: 242–245.
31
Q
- A 47-year-old woman presents to the emergency department with generalised weakness, fatigue and light headedness. Her routine blood gases show: pH 7.34, pO2 9.4 kPa, pCO2 4.4 kPa, HCO3 22 mmol/L. Serum biochemistry includes Na+ 131 mmol/L, K+ 5.1 mmol/L, and plasma glucose 3.4 mmol/L.
What is the most likely diagnosis? A Addison’s disease B Chronic renal failure C Diabetic ketoacidosis D Exacerbation of chronic obstructive pulmonary disease E Myasthenia gravis
A
- A Addison’s disease
This patient has biochemical evidence of metabolic acidosis with low bicarbonate, sodium and glucose and an elevated serum potassium. The normal range for serum glucose is 4–7 mmol/L (70–125 mg/dL).
Addison’s disease (or adrenocortical insufficiency) results in reduced synthesis of mineralocorticoids and glucocorticoids. As a result of decreased glucocorticoid effects, there is a reduction in serum blood glucose. Because of decreased circulating cortisol, the kidney cannot excrete free water and hyponatraemia develops. Metabolic acidosis develops because of low aldosterone levels causing sodium
loss in the urine, with H+ retention in the serum. Low aldosterone also leads to hyperkalaemia. Clinical symptoms which develop are mainly due to the low blood sugar (hypoglycaemic autonomic effects) and low sodium (hypotension).
Ten S, New M, Maclaren N. Addison’s disease. J Clin Endocrinol and Metabl 2001; 86:2909–2922.
32
Q
- A 47-year-old man has an open appendicectomy. Subsequently a 2.5 cm carcinoid tumour with clear resection margins is diagnosed on histopathology.
What is the most appropriate management?
A Chemotherapy B Colonoscopy C No further management required D Right hemicolectomy E Subtotal colectomy and ileorectal anastomosis
A
- D Right hemicolectomy
The patient requires a right hemicolectomy as the carcinoid of the appendix is > 2 cm in diameter. A right hemicolectomy shoud be considered if the appendix tumour is large (1–2 cm) or invades the serosa. If a right hemicolectomy is to be performed then a regional lymphadenectomy should also be considered.
Ramage JK, et al. Guidelines for Management of Gastroenteropancreatic Neuroendocrine (including carcinoid) tumours. Gut 2005; 54(Suppl IV): iv1–iv16.
33
Q
- A study is performed to assess whether there is a correlation between the time a patient waits for colonoscopy (irrespective of outcome) and the overall satisfaction rating for the in-hospital experience. Waiting time is divided into four ascending groups and satisfaction is scored on a continuous rating scale from 1 to 100.
Which statistical test should be used to examine for any association? A Two-sided t-test B ANOVA test C Kruskal–Wallis test D Linear regression analysis E Mann–Whitney U test
A
- C Kruskall–Wallis test
When answering a statistical question, it is important to select the correct test (Table 1.4). In this example, a test for an association between two continuous variables is sought. Satisfaction scores (notoriously difficult to attain reliability) are very unlikely to have normal distribution, and so median scores are applicable. Therefore, without assuming equal variances or normal distribution in the data,
the Kruskal–Wallis test can be applied; where normal distribution and mean values are applied, ANOVA would be the correct test. The Mann–Whitney U test compares medians in two sets of continuous data; the 2-sided t-test compares means and the linear regression analysis is applicable in determining the contribution of multiple factors to one continuous outcome variable.
Table 1.4 provides a simple overview for comparative statistical tests that should be easily remembered.
Kirkwood BR, Sterne JAC. Non-parametric methods based on ranks. In: Kirkwood BR, Sterne JAC (eds). Essential Medical Statistics, 2nd edn. Oxford: Wiley-Blackwell, 2004: 345.
34
Q
- A controlled study is set up to address whether or not patients having single incision laparoscopic cholecystectomy have similar outcomes to standard laparoscopic cholecystectomy. The primary outcome measure is complication rate, estimated at 5% for the standard procedure. To detect a difference of 2.5%, in either direction, it is decided that 200 patients require to be recruited to both arms of the study, with a power of 80%.
Which statement best describes the application of statistical principles?
A A significant difference (p-value = 0.05) has a likelihood of being due to chance in 1 in 20
B All patients should be offered either procedure by the clinician
C If early results show inferiority, the trial continues to allow conclusions to be
drawn
D If there is low recruitment, there is a risk of a type I error
E The study will be underpowered to detect this difference
A
- A A significant difference (p-value = 0.05) has a likelihood of being due to chance in 1 in 20
A type I (α) error describes the likelihood of wrongly rejecting the null hypothesis. A p-value of 0.05 describes the chance that a seemingly positive finding is actually due to luck alone, and in fact, no real difference exists (0.05 is equivalent to 1 in 20 mathematically).
It is clear that a power calculation has been carried out, based on the desired power and relevant difference which we wish to detect. The methodology described is
that of a randomised controlled trial. In specially designed, pragmatic studies,
either surgeon and/or patient preference may be accounted for, although this is
not generally the case in controlled trials. Early stopping rules always apply, with patient safety paramount. If there is clearly a higher rate of complication with the new intervention, a trial is not justified, as the whole basis for its carrying one out is that of clinical equipoise and uncertainty. If a trial is underpowered, there may be too few subjects to correctly identify a real difference. This is a false negative or falsely retaining the null hypothesis, and represents a type II (β) error.
Kirkwood BR, Sterne JAC. Non-parametric methods based on ranks. In: Kirkwood BR, Sterne JAC (eds). Essential Medical Statistics, 2nd edn. Oxford: Wiley-Blackwell, 2004: 425.
35
Q
- A surgeon would like to know whether patients with thyroid goitres are more or less likely to have been exposed to irradiation during their early years, than those patients without goitres.
What is the best study design for this purpose?
A Case–control study B Environmental study C Longitudinal cohort study D Meta-analysis of the literature E Randomised trial of exposure
A
- A Case–control study
Here, we have a condition which we wish to link with a previous exposure. The question may be answered with a population level, longitudinal cohort study, following up children and recording details of any exposure, with rates of goitre later in life, to generate relative risk data. However, this is wholly impractical. It is more straightforward to answer this question by comparing two sets of odds ratios, to attribute the likelihood that someone with a condition has had a certain exposure, compared to the likelihood that someone free of the exposure has the condition. This does not imply causality, but degrees of relationship can be ascertained, and may provide justification for larger scale, longitudinal studies. Thus, the two sets
of patients have different odds ratios generated. A randomised trial of exposure is simply unethical. An environmental study may act as a hypothesis-generating study during the early stages of studies. A meta-analysis may address the question, but would be unspecific to this surgeon’s own population. It also traditionally pertains only to randomised controlled trials.
Bhopal R. Concepts of Epidemiology: Integrating the Ideas, Theories, Principles and Methods of Epidemiology, 2nd edn. Oxford: Oxford University Press, 2008.
36
Q
- A surgeon would like to set up a randomised double-blind controlled trial, examining the efficacy of laparoscopic fundoplication (comparing partial and total wrap). The outcomes are defined and a power calculation performed, and the centre is ready to start recruitment.
Which factor is not essential to the validity of the trial?
A Adopting a recognised method for patient allocation and stratification
B Blinding the patients
C Blinding the surgical team
D Ensuring it represents a more general population
E Having randomisation conducted through a remote site
A
- D Ensuring it represents a more general population
Although external validity describes the applicability of trial data to the broader population, it is widely acknowledged that participants in randomised controlled trials (RCTs) are not typical patients. These patients self-select (selection bias) as being more interested/motivated around their healthcare issues, and their treatment will be different, regardless of protocols. The Hawthorne effect describes the
change in behaviour, and potential outcomes, experienced by both participants and clinicians involved in trials, by the very fact they are aware of being studied. The other options simply describe best practice to ensure internal validity in any RCT, and so all must apply for the results to be valid and reliable in themselves.
McCarney R, Warner J, Iliffe S, et al. The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol. 2007; 7: 30.
37
Q
- A 95-year-old man is admitted from a nursing home with diarrhoea and is
subsequently diagnosed with colitis secondary to Clostridium difficile.
Which of the following statements describes Clostridium difficile infection?
A Cephalosporins are rarely associated with the diagnosis
B First line medical therapy is intravenous metronidazole
C Its presentation is consistently more severe than other forms of gastroenteritis
D Patients with prolonged hospital stays are at particular risk
E Vancomycin is a frequent risk factor
A
- D Patients with prolonged hospital stays are at particular risk
Although vancomycin is rarely associated with Clostridium difficile diarrhoea,
it is more often used as a second line treatment, after oral metronidazole. Prolonged hospital admissions (and in particular, stays in the intensive care
unit), are independently associated Clostridium difficile infection. The clinical presentation of this chapter ranges from mild diarrhoea, to severe pancolitis with pseudomembranes, sepsis and perforation. Examples of this are shown in the endoscopic (Figure 1.6) and postoperative (Figure 1.7) images. A low index of clinical suspicion is required for adequate infection control.
Starr J. Clostridium difficile associated diarrhoea: diagnosis and treatment. BMJ 2005; 331:498–501.
38
Q
- A 22-year-old girl is admitted with collapse and dehydration. She is suspected of being chronically malnourished.
Which of the following statements describes malnutrition assessment in the acute hospital setting?
A Every malnourished patient should have trace elements checked prior to commencing on supplements
B Formal diagnosis of malnutrition may be made with body mass index (BMI) ≤ 18 kg/m2
C Only patients with clinical or biochemical signs of malnutrition require nutritional screening at admission
D Obese patients do not require nutritional screening
E The Malnutrition Universal Screening Tool calculates risk by patient’s
reduction in BMI.
A
- B Formal diagnosis of malnutrition may be made with BMI ≤ 18 kg/m2
Guidelines state that nutritional screening should be offered to all patients at the point of admission and if a clinical concern arises at any time, then subsequently repeated weekly for inpatients. A routine method to accomplish this is the Malnutrition Universal Screening Tool (MUST) (Table 1.5), based on the patient’s body mass index (BMI), degree of unintentional weight loss, and effect of acute disease. This was developed to ensure a reliable, thorough and reproducible screening technique. Obese patients, as defined by BMI > 30, may still be malnourished in terms of loss
of lean muscle mass, particularly in the acute illness phase. BMI ≤ 18 (or 20 with associated > 5% weight loss over 3–6 months), or weight loss > 10% in the same period are diagnostic. Patients require baseline trace elements to be checked only prior to commencement of parenteral feeding.
Elia M. The ‘MUST’ report: Nutritional screeing for adults: a multidisciplinary responsibility. Redditch: Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition (BAPEN), 2003.
National Institute of Clinical Excellence (NICE). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32). London: NICE, 2006. Available at: http://www.nice. org.uk/CG32.
39
Q
- Which of the following statements does not describe evidence based medicine?
A Absolute risk reduction: effect of an intervention minus effect observed in controls
B Number needed to treat: effectiveness of an intervention (equivalent to 1 ÷ absolute risk reduction).
C Odds ratio: likelihood of being exposed to a risk factor
D Prevalence: risk of developing a new condition within a specified period
E Relative risk: likelihood of an outcome, relative to an exposure status
A
- D Prevalence: risk of developing a new condition within a specified period
This describes incidence not prevalence. Odds ratios and relative risks are frequently confused. Odds ratios pertain to retrospective data, working back from an event
to assess the likelihood of having been exposed to a risk factor. They cannot be used to describe aetiology with certainty, and are useful in hypothesis generation and epidemiological studies. Relative risk ratios are calculated over prospective, longitudinal data, and reliably inform the strength of the relationship between exposure and outcomes. The absolute risk reduction is a numerical calculation, subtracting the risk rate in the control group from that in a study group. This may then be used to calculate the number needed to treat, which indicates the number of patients who require exposure to an intervention in order for any one patient to benefit. This is useful in economic modelling. See Straus et al (2010) for a readable guide to putting these numbers into practice.
Straus SE, Richardson WS, Glasziou P, et al. Evidence Based Medicine: How to Practice and Teach EBM. 4th edn, London: Churchill Livingstone, 2010.
40
Q
- Which of the following statements describes nutritional support?
A Enteral nutrition supplements reduce the risk of refeeding syndrome after a period of starvation
B Oral nutritional supplements reduce the risk of infection and length of hospital stay
C Parenteral nutrition is more effective than enteral at reducing infection in malnourished patients
D Parenteral nutrition should be considered in all patients with a significant degree of malnutrition
E Usual nutritional support should include adequate calories (total energy of 25–35 kcal/kg/day)
A
- E Usual nutritional support should include adequate calories (total energy 25–35 kcal/kg/day)
The daily calorie requirement must be adjusted for any acute illness episode, with 0.8–1.5 g protein/kg/day recommended. There is evidence to support the use of oral supplements towards improved outcomes, with absolute risk reduction of infection of 10% in one systematic review. When comparing enteral and parenteral nutrition in the same series, enteral nutrition was superior. However, overall quality of evidence is too poor to make definitive recommendations.
Parenteral nutrition should only be considered when the gut is:
• Unusable
• Insufficient to achieve adequate absorption
• Inaccessible
• Non-functional
• Leaking
Otherwise, enteral feeding is always the route of choice. It generally offers better outcomes and fewer complications. In the context of starvation or malnutrition, refeeding syndrome may emerge on recommencement of feeding, particularly with enteral supplementation. This is a metabolic disturbance with rapid electrolyte imbalance, driven largely by a change in basal metabolic rate and insulin levels.
It requires careful biochemical monitoring, and dietary phosphate and vitamin supplementation is usually prescribed to prevent this.
Koretz RL, Avenell A, Lipman TO, Braunschweig CL, Milne AC. Does enteral nutrition affect clinical outcome? A systematic review of the randomised trials. American Journal of Gastroenterolgy 2007; 102:412–29.
41
Q
- A 22-year-old boy is seriously injured in a road traffic accident and following discussion with his family, is being considered as an organ donor.
Which of the following is not a precondition for the diagnosis of brainstem death?
A A PaCO2 of > 7 kPa has been documented
B All underlying metabolic or pharmacological causes have been excluded
C If neuromuscular blockade has been administered, a return to normal state
has been demonstrated
D Tests are performed by two doctors trained in the technique on two separate
occasions
E There is no papillary reflex to light (cranial nerves II and III)
A
- A PaCO2 of > 7 kPa has been documented
The PaCO2 need rise only to 6–6.5 kPa to confirm brainstem death. The other criteria are accurate. In the UK, brainstem death is defined as complete, irreversible loss of brainstem function, made according to well-defined criteria and preconditions, with reversible causes of apnoeic coma excluded, and brainstem areflexia and persistent apnoea confirmed. The cranial nerve reflexes tested are set out in Table 1.6.
Pallis C, Harley DH. ABC of Brain Stem Death, 2nd edn. London: BMJ Books, 1996.
42
Q
- Which of the following statements describes the limitations of day case surgery?
A Diabetic patients can easily be managed on a day case list
B Obese patients (BMI >30) should be excluded from day case lists
C Patients must have a responsible carer accompanying them for 24–48 hours
postoperatively
D Patients must have a telephone in the discharge destination
E The procedure should have a low incidence of postoperative complications
A
- B Obese patients (BMI >30) should be excluded from day case lists
Obese patients were originally excluded from day case surgery lists, with BMI limits
varying considerably between units. A BMI of 30–40 was used as a cut-off, but
increasingly even super-obese patients are being managed as day cases. It is now
deemed acceptable to make this judgement on an individual patient basis. The
other statements correctly describe defined criteria. Full details are available from
the anaesthesic guidelines for day case surgery.
Verma R, Alladi R, Jackson I, et al. Day case and short stay surgery: 2. Anaesthesia, 2011; 66:417–434.
43
Q
- A 3-week-old neonate presents with crying and vomiting and malrotation is suspected.
Which of the following statements describes malrotation of the gut?
A The caecum fails to descend to a subhepatic position during embryological
development
B It is frequently associated with other congenital abnormalities
C The diagnosis is based on is bilious vomiting in the first few days of life
D There is normal gas pattern on plain X-ray and the diagnosis requires a
contrast study
E With neonatal bilious vomiting, definitive surgery may be deferred until
nutritional issues are addressed
A
- A The caecum fails to descend to a subhepatic position
during embryological development
Malrotation (Figure 1.2), although commonly presenting in the first few months
of life, may also present at a later stage, with 0.2% presenting much later in
adulthood. Presenting in the neonatal period and the first few months of life, it
constitutes a surgical emergency, and although baseline evaluation of biochemical
and haematological indices are recommended, they should not delay surgery.
Radiological investigations typically show a gasless abdomen, with a little stomach
gas an isolated feature; contrast studies make the definitive diagnosis, normally
demonstrating a ‘corkscrew’ duodenum with the duodenojejunal flexure lying to the
right of the midline. It is normally an isolated abnormality and the child will go on
lead a normal life following surgical correction.
Youngson GG. Emergency abdominal surgery in infancy and childhood. In: Jones PF, Krukowski ZH,
Youngson GG (eds). Emergency Abdominal Surgery 3rd edn, Boca Raton: CRC Press, 1998.
44
Q
- A 4-year-old infant presents with the passage of ‘redcurrant’ stool. The paediatric
surgeons are suspicious of intussusception.
Which of the following statements describes intussusception in the paediatric
population?
A At operation a resection of the affected bowel is always required
B It is caused by a congenital anatomical variant
C It can be treated by air enema without risk
D It most commonly affects the 4- to 6-year-old age group
E It most commonly occurs in an ileocolic segment of bowel
A
- E It most commonly occurs in an ileocolic segment
of bowel
The most common cause of paediatric intussusception is lymphoid hyperplasia in
the Peyer’s patches of the gut. The most prominent such tissue occurs along the
ileocaecal segment (Figure 1.8). Hence, this is not a congenital ‘lead point’ for the
intussusception as such. Other possible lead points include Meckel’s diverticulum
and duplication cysts, as well as B lymphoma of the gut. Intussusception most
commonly presents in the 2 months to 2 years age bracket. A high level of diagnostic
accuracy is achieved with abdominal ultrasound, which may demonstrate the ‘target’
sign of bowel within bowel.
Pneumostatic reduction is routinely attempted, unless the child already has signs
of perforation/peritonitis, in which case theatre is essential. Prior to pneumatic
reduction (‘air enema’), intravenous access and preparation for potential theatre
should be assured. If it fails, operative reduction is often achieved, without the need
to resect bowel.
Youngson GG. Emergency abdominal surgery in infancy and childhood. In: Jones PF, Krukowski ZH,
Youngson GG (eds). Emergency Abdominal Surgery, 3rd edn. Boca Raton: CRC Press, 1998: 82–135.
45
Q
- A 15-year-old boy is involved in a fight and sustains a stab wound to his right upper quadrant/epigastrium. On presentation to the emergency department he is lucid,
oxygenating, but complaining of abdominal pain, with a systolic blood pressure of 90mmHg, on his second litre of crystalloid. On examination, he has peritonitis and his blood pressure is not stabilising.
What is the most appropriate next step in the management plan?
A CT of the abdomen to delineate injuries
B Focused assessment with sonography for trauma scan to confirm fluid/gas in
the peritoneal cavity
C Laparotomy in emergency theatre
D Serum amylase level
E Urinary catheter insertion
A
- C Laparotomy in emergency theatre
This patient requires an urgent laparotomy (the advanced trauma life support
manual). He is haemodynamically unstable, with evidence of fluid loss (most likely
blood) and peritonitis, indicating significant intra-abdominal injury. Scans will delay
definitive management and may be dangerous in this context. No useful information
will be gleaned from a FAST scan to supplement the clear clinical signs. Delayed
pancreatitis is associated with blunt trauma to the same region. Catheterisation will
take place perioperatively, irrespective of the pathology.
American College of Surgeons. Abdominal Trauma in Advanced Trauma Life Support Manual, 6th edn.
Chicago: American College of Surgeons, 1997.
46
Q
- A 4-year-old infant presents with the passage of bloody stool and abdominal pain.
A provisional diagnosis of Meckel’s diverticulitis is made by a senior paediatrician.
Which of the following statements describes Meckel’s diverticulum?
A It lies 2 feet (60 cm) proximal to the ileocaecal valve
B It can be attached to the umbilicus
C It most commonly presents as an acute abdomen in the paediatric population
D It most commonly presents with peptic ulceration
E It should always be removed if identified incidentally at laparotomy or laparoscopy
A
- B It may be attached to the umbilicus
A Meckel’s diverticulum, the most common congenital abnormality of the
small intestine, may be attached to the umbilicus. There may be other potential
connections with a patent vitellointestinal duct with faecal fistula, or partial patency
of the duct as a sinus to the umbilicus, with potential ongoing secretions. The
presence of a Meckel’s may be undiagnosed lifelong, but it occurs in approximately
2% of the population. The three most common presentations include intestinal
obstruction (40–50%), peptic ulceration (25%) and acute inflammation (20%),
mimicking appendicitis. There is no indication to remove the lesion if discovered
incidentally at surgery for another condition.
Youngson GG. Emergency abdominal surgery in infancy and childhood. In: Jones PF, Krukowski ZH,
Youngson GG (eds). Emergency Abdominal Surgery, 3rd edn. CRC Press, 1998: 82–135.
47
Q
- Which of the following statements describes pyloric stenosis?
A Bilious vomiting is frequently associated with the diagnosis
B In over 50% cases, it presents in the first 2 weeks of life
C Infants present with a hypochloremic, hypokalemic metabolic alkalosis
D It most commonly presents in first born female infants
E Surgical correction must take place within the first 24 hours of presentation
A
- C Infants present with a hypochloremic, hypokalemic
metabolic alkalosis
Infantile hypertrophic pyloric stenosis is a common surgical problem, and often managed by the non-specialist paediatric general surgeon by way of Ramstedt’s pyloromyotomy (Figure 1.9). The precise aetiology remains unknown, but it tends to affect first-born males, some with a family history, at around 4–6 weeks of age. The vomiting is specifically non-bilious in nature. The child usually has been thriving, until insidious onset of vomiting, which then becomes projectile. The speed of presentation for medical help dictates the degree of metabolic disturbance, but the prolonged loss of gastric juices leads to an alkalosis, with potassium also lost in exchange for the kidney’s attempt to preserve chloride. Electrolyte correction, specifically of the hypochloraemia, and volume replacement must be carried out prior to surgical intervention, which may be delayed by a number of days if necessary. Recovery following the pyloromyotomy is normally straightforward.
Youngson GG. Emergency abdominal surgery in infancy and childhood. In: Jones PF, Krukowski ZH, Youngson GG (eds). Emergency Abdominal Surgery, 3rd edn. CRC Press, 1998: 82–135.
