General Surgery

Question 1

Define acute abdomen

Answer 1

An acute abdomen refers to a recent, rapid onset of urgent abdominal or pelvic pathology, usually presenting with abdominal pain.

Question 2

Differentials for generalised abdominal pain

Answer 2

Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis

Question 3

Differentials of RUQ pain

Answer 3

Biliary colic
Acute cholecystitis
Acute cholangitis

Question 4

Differentials epigastric pain

Answer 4

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm

Question 5

Differentials for central abdominal pain

Answer 5

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

Question 6

Differentials for right iliac fossa pain

Answer 6

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

Question 7

Differentials for left iliac fossa pain

Answer 7

Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion

Question 8

Differentials for suprapubic pain

Answer 8

Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis

Question 9

Differentials for loin to groin pain

Answer 9

Renal colic (kidney stones)
Ruptured abdominal aortic aneurysm
Pyelonephritis

Question 10

Differentials for testicular pain

Answer 10

Testicular torsion

Epididymo-orchitis

Question 11

What is peritonitis?

Answer 11

Peritonitis refers to inflammation of the peritoneum, the lining of the abdomen.

Question 12

What are the signs of peritonitis

Answer 12

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

Question 13

What is the cause of localised peritonitis?

Answer 13

underlying organ inflammation, for example, appendicitis or cholecystitis

Question 14

What is the cause of generalised peritonitis?

Answer 14

perforation of an abdominal organ releasing the contents into the peritoneal cavity and causing generalised inflammation of the peritoneum.

Question 15

What is spontaneous bacterial peritonitis?

Answer 15

spontaneous infection of ascites in patients with liver disease. This is treated with broad-spectrum antibiotics and carries a poor prognosis.

Question 16

Initial ABCDE approach

Answer 16

A – Airway: Ensure the patient’s airway is patent and secure.
B – Breathing: Assess the breathing, respiratory rate and oxygen saturations. Listen to the lungs. Provide oxygen if required.
C – Circulation: Assess the blood pressure, heart rate, heart sounds and perfusion (e.g., capillary refill time). Gain IV access (wide-bore cannulae are better), take bloods and provide an IV bolus of fluid if required.
D – Disability: Assess the consciousness level using AVPU or GCS scoring systems. Check the blood glucose level.
E – Exposure: Finish the full assessment, including examination of the abdomen.

Question 17

Indications for FBC pre-operative

Answer 17

indication of bleeding (drop in Hb) and infection / inflammation (raised WBC).

Question 18

Indications for U&Es pre-operative

Answer 18

indication of electrolyte imbalance and kidney function (useful prior to CT scans, as they require a contrast injection that can damage kidneys).

Question 19

Indications for amylase pre-operative

Answer 19

indication of inflammation of the pancreas in acute pancreatitis.

Question 20

Indications for INR pre-operative

Answer 20

International normalised ratio (INR) gives an indication of the synthetic function of the liver and is essential in establishing their coagulation prior to procedures.

Question 21

Indications for serum calcium pre-operative

Answer 21

Serum calcium is required to score acute pancreatitis and for other reasons (e.g., clotting and cardiac function).

Question 22

Indications for ABG pre-operative

Answer 22

analysis will show the lactate (an indication of tissue ischaemia) and pO2 (used for scoring in acute pancreatitis).

Question 23

Indications for group and save pre-operative

Answer 23

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

Question 24

Indications for AXR pre-operative

Answer 24

provide evidence of bowel obstruction by showing dilated bowel loops.

Question 25

Indications for erect CXR pre-operative

Answer 25

demonstrate air under the diaphragm when there is an intra-abdominal perforation.

Question 26

Indications for abdominal USS pre-operative

Answer 26

useful in checking for gallstones, biliary duct dilatation and gynaecological pathology.

Question 27

Initial management for acute abdomen

Answer 27

1. ABCDE assessment
2. Alert seniors of unwell patients: escalating to the registrar, consultant and critical care as required
3. NBM if surgery may be required or they have features of bowel obstruction
4. NG tube in cases of bowel obstruction
5. IV fluids if required for resuscitation or maintenance
6. IV antibiotics if infection is suspected
7. Analgesia as required for pain management
8. Arranging investigations as required (e.g., bloods, group and save and scans)
9. VTE risk assessment and prescription if indicated
10. Prescribing regular medication on the drug chart if they are being admitted (some may need to be withheld)