General/Colorectal Surgery Questions Flashcards
A 23-year-old male medical student presents to the emergency department with severe right upper quadrant abdominal pain. He describes it as sharp and worse on inspiration. He has been feeling tired and short of breath in the last few days and has a cough productive of purulent, bloody sputum. He has a fever, tachycardia and tachypnoea. He has recently come back from a week-long holiday in which he admits to drinking 15 units of alcohol a day.
What is the most likely cause of his presentation?
Viral Hepatitis Alcoholic Hepatitis Gallstones Pancreatitis Pneumonia
Pneumonia
Lower lobe pneumonia may present with upper quadrant abdo pain
Although the patient is complaining of abdominal pain, the other symptoms point towards a diagnosis of pneumonia. There are signs of infection (fever, tachycardia, tachypnoea) along with shortness of breath and purulent, bloody sputum. This question highlights that pneumonia can sometimes cause abdominal pain; in particular, lower lobe pneumonia may be felt as upper quadrant abdominal pain.
The stoma bag is removed to examine the stoma site. There is feculant matter in the stoma bag. The stoma is pink and flush to the surface of the abdomen. There is no evidence of infection or dermatitis of the surrounding skin.
The wound is healing well and the stitches are removed.
Given the above information, what type of stoma does this patient have?
colostomy
nephrostomy
urostomy
ileostomy
colostomy
A colostomy is flush to the skin, as the enzymes in the colon are less alkaline than those in the small intestine and so are less damaging to the skin.
This patient has a colostomy (1). The information in the question that tells you this are the contents of the stoma bag, and the fact that the stoma is flush to the skin.
It is tempting to label stomas based on their anatomical site (e.g. ileostomies in the right iliac fossa), however this is not a foolproof method. As a general rule, an ileostomy is spouted to prevent the surrounding skin from coming into contact with the alkaline enzymes in the small intestine, whilst colostomies are flat (2).
A 62-year-old man with no significant past medical history presents with a right sided groin lump which he noticed whilst having a shower. It has been present for 2 weeks and disappears when he lies down. It never causes him any discomfort and there are no other gastrointestinal symptoms of note. Examination reveals an small reducible swelling in the right groin consistent with an inguinal hernia. What is the most appropriate management?
refer to vascular surgeon
routine referral for surgical repair
advise no action as will heal with time
routine referral for surgical repair
This patient has an asymptomatic inguinal hernia. Studies looking at conservative management tend to find that many patients become symptomatic and eventually have surgery anyway. As this patient is medically fit most clinicians would refer for surgical repair.
A 66-year-old lady presents with a tumour of the low rectum. There is a projection inferior to within 1cm of the dentate line.
APER OR
Anterior Resection?
APER (abdomino-perineal excision of rectum)
Low rectum
A 63-year-old man presents with a carcinoma of the upper rectum. Staging investigations demonstrate localised disease and he is not deemed to require and neo adjuvent therapy.
APER OR
Anterior resection?
Anterior resection
high rectum
A 67-year-old woman is brought to the Emergency Department with severe abdominal pain which has been worsening the past two days. In began in the lower left side of her abdomen and she has had diarrhoea with it. She has a past medical history of hypertension, chronic kidney disease and diverticular disease.
Her heart rate is 121 bpm, blood pressure is 132/81 mmHg, temperature is 38.2ºC and her oxygen saturation is 97% on air. Her abdomen is tender throughout and exhibits involuntary guarding throughout. Her bowel sounds are inaudible and she has rebound tenderness present throughout her abdomen.
Which of the following investigations would be best to confirm your diagnosis?
AXR Erect CXR Supine CXR US Abdo CT Abdo
Erect CXR
An erect chest x-ray is used to identify bowel perforation
A 22-year-old man presents with a 5 month history of episodic retrosternal chest pain together with episodes of dysphagia to liquids. An upper GI endoscopy is performed and no mucosal abnormality is seen.
A. Mallory Weiss Tear B. Hiatus hernia C. Squamous cell carcinoma of the oesophagus D. Adenocarcinoma of the oesophagus E. Peptic stricture F. Motility disorder
Motility disorder
Dysphagia that is episodic and varies between solids and liquids is more likely to represent a motility disorder.
A 76-year-old man presents with a 5 week history of progressive dysphagia. An upper GI endoscopy is performed and the surgeon notices changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed.
A. Mallory Weiss Tear B. Hiatus hernia C. Squamous cell carcinoma of the oesophagus D. Adenocarcinoma of the oesophagus E. Peptic stricture F. Motility disorder
Adenocarcinoma of the oesophagus
A short history of dysphagia together with food debris and Barretts changes makes adenocarcinoma the most likely diagnosis.
An obese 53-year-old man presents with symptoms of recurrent retrosternal discomfort and dyspepsia. This is typically worse at night after eating a large meal. On examination there is no physical abnormality to find
A. Achalasia B. Pulmonary embolus C. Dissection of thoracic aorta D. Boerhaaves syndrome E. Gastro-oesophageal reflux F. Carcinoma of the oesophagus G. Oesophageal candidiasis
GORD
symptoms are worse at night
A 22-year-old man is admitted with severe retrosternal chest pain and recurrent episodes of dysphagia. These occur sporadically and often resolve spontaneously. On examination there are no physical abnormalities and the patient seems well.
A. Achalasia B. Pulmonary embolus C. Dissection of thoracic aorta D. Boerhaaves syndrome E. Gastro-oesophageal reflux F. Carcinoma of the oesophagus G. Oesophageal candidiasis
Achalasia
Achalasia may produce severe chest pain and many older patients may undergo cardiac investigations prior to endoscopy.
what % of colorectal cancers are adenocarcinomas?
90%
what is the strongest RF for anal cancer?
HPV infection
A 65-year-old man with a history of ischaemic heart disease presents with sudden onset central abdominal pain radiating to his back. He is clammy and short of breath.
A. Myocardial infarction B. Colorectal cancer C. Duodenal ulcer D. Gastric ulcer E. Biliary colic F. Ruptured abdominal aortic aneurysm G. Acute pancreatitis H. Toxic megacolon I. Diverticulitis J. Intestinal obstruction
Ruptured abdominal aortic aneurysm
What type of ulcer is when pain is relieved by eating?
Duodenal ulcer
A 22-year-old woman presents with macroscopic haematuria. She is sexually active. She is known to have renal calculi and had a berry aneurysm clipped.
A. Interstitial nephritis B. Membranous glomerulonephritis C. Endometriosis D. Placenta percreta E. Adult polycystic kidney disease F. Renal vein thrombosis G. Urinary tract infection
Adult polycystic kidney disease 79%
APKD is associated with liver cysts (70%), berry aneurysms (25%) and pancreatic cysts (10%). Patients may have a renal mass, hypertension, renal calculi and macroscopic haematuria.
