GI and General II Flashcards
An 80-year-old man presented with large bowel obstruction. Following resuscitation, he underwent a laparotomy. A large carcinoma of the rectum was found, fixed to the lateral pelvic wall, with omental and peritoneal secondary deposits.
Transverse loop colostomy
Primary anastomosis can be performed at the time of emergency surgery if colonic lavage is carried out.
A 75-year-old male presented with 18 hours of acute abdominal pain. He was noted to have generalised peritonitis and free intra-peritoneal air on an erect chest x ray. At laparotomy, he was found to have widespread faecal peritonitis due to perforated sigmoid diverticular disease.
Hartmann’s procedure
When there is widespread faecal peritonitis the majority of surgeons would avoid an anastomosis as the risk of continued peritoneal infection and anastomotic leak is very high. The operation time would also be longer.
A 45-year-old man presents with known severe ulcerative colitis that has not responded to maximal medical therapy. He has had five days of bloody diarrhoea. Examination shows mild abdominal distension with generalised guarding. A plain abdominal x ray shows a colonic diameter of 7 cm.
Subtotal colectomy with ileostomy
The definition of toxic megacolon is non-obstructive, total or segmental colonic dilatation of 6 cm or more, associated with systemic toxicity. In acute toxic dilatation of the colon due to ulcerative colitis the treatment is subtotal colectomy and ileostomy.
Excision of the rectum and anus (panproctocolectomy) would add considerable time to the procedure and remove the possibility of creating a pouch in the future.
A 58-year-old lady undergoes an anterior resection for colorectal cancer. After radiological and pathological staging her disease is staged as a Dukes’ stage C.
What is the 5-year survival rate for this stage of disease?
(Please select 1 option)
35-40%
This lady is already one year post operative, so she is asking for her chance of five year survival. The overall five year survival for Dukes’ stage C colorectal cancer is around 40%.
Five year survival for the other Dukes’ stages are as follows:
Dukes’ A D around 10-15%.
A 76-year-old man is admitted on the surgical intake complaining of colicky lower abdominal pain, absolute constipation and abdominal distension of two days duration.
On examination he has a grossly distended soft abdomen. Plain abdominal x ray demonstrates large bowel dilation throughout the colon. Routine bloods are requested and he is placed nil by mouth.
What is the most appropriate next management step for this gentleman?
(Please select 1 option)
Barium enema
Barium small bowel follow through
Colonoscopy
Laparotomy
Water soluble contrast enema
Water soluble contrast enema This is the correct answerThis is the correct answer
This gentleman’s history, examination and x ray findings suggest large bowel obstruction. A water soluble contrast enema should be obtained to differentiate between a mechanical cause and pseudo-obstruction.
Barium examinations should be avoided as he may be likely to require urgent surgery.
As he has no signs of peritonitis immediate laparotomy is not indicated without further investigation.
You are called to see a 56-year-old patient in the emergency department who has been diagnosed with large bowel obstruction.
She reports longstanding constipation but the symptoms of abdominal pain and distension came on suddenly. There has been no bleeding or weight loss. Past medical history includes schizophrenia.
Which of the following is the most likely cause?
(Please select 1 option)
Adhesions
Crohn’s disease
Incarcerated hernia
Intussusception
Volvulus of sigmoid colon
Volvulus of sigmoid colon This is the correct answerThis is the correct answer
Volvulus, faeces and tumours are common causes of large bowel obstruction.
In this case the likely diagnosis given the long history of constipation and psychiatric illness and a short history of pain/distension in the absence of other gastrointestinal symptoms is sigmoid volvulus.
The other conditions listed tend to result in small bowel obstruction.
Rectus sheath haematoma
The history of a spontaneous mass within the rectus is typical of a haematoma. These haematomas are often seen in patients on anticoagulants and are seen following minor trauma such as coughing.
In this case the patient was more at risk to the antibiotic therapy upsetting INR control.
The haematomas should be managed conservatively with analgesia, volume replacement if necessary, and correction of any haemostatic abnormalities.
A 43-year-old woman presents to the emergency department with an eight hour history of severe right upper quadrant pain and vomiting. She says that the pain exacerbates on breathing and is radiating to her right scapula.
On examination, she is pale and mildly jaundiced. Her pulse rate is 104/min and temperature is 38.8°C. Abdominal examination reveals a tender mass over the right hypochondrium. She says that she used to get this type of pain following a fatty meal, although not this severe. Serum amylase is not elevated.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Cirrhosis of the liver
Gall stones
Acute cholecystitis is the acute inflammation of the gall bladder. Gallstones are the commonest cause for inflammation. They may obstruct the common bile duct which in turn prevents the flow of the bile. This leads to accumulation of bile and inflammation leading to an acutely inflamed gall bladder.
Build up of bile within the gall bladder also increases the pressure within the gall bladder, thus increasing the chance of perforation. Other risk factors for acute cholecystitis include
Alcohol abuse
Tumours of the gall bladder.
Acute cholecystitis is more common in females over 40 years of age who have a high BMI; the incidence increases with fertility.
The frequent signs and symptoms of acute cholecystitis include
Severe right hypochondrial pain which is exacerbated by breathing
Nausea and vomiting
Pyrexia.
A tender, inflamed gall bladder is frequently, but not always, palpable. Jaundice may or may not be present.
This condition has to be distinguished from biliary cholangitis, where the signs and symptoms of inflammation/infection are more severe; the gall bladder, however, is not palpable in isolated biliary cholangitis.
Pain associated with gall stones is typically seen after a fatty meal and the mere presence of gall stones do not present with signs of inflammation (for example, pyrexia).
The other differential diagnoses for acute cholecystitis include
Acute pancreatitis Peptic ulcer Appendicitis Pleurisy. Since the clinical diagnosis of acute cholecystitis may be difficult, an ultrasound scan or a cholescintigraphy may be necessary to clinch the diagnosis.
The immediate management of acute cholecystitis involves rest, intravenous antibiotics, and analgesia. Anti-emetics and naso-gastric tube (and nil by mouth) may be indicated in severe cases.
Once the acute symptoms have subsided cholecystectomy is the preferred line of management. However, if acute cholecystitis is complicated by perforations or gangrene, immediate removal of the gall bladder may become necessary.
A 43-year-old gentleman presents to the emergency department with severe stabbing type of pain over the epigastric region.
The pain started following episodes of repeated vomiting and it worsens on swallowing. He is a heavy drinker and has been consuming 10-15 units of alcohol every day for the past 20 years.
On examination, his blood pressure is 100/78 mmHg, and his pulse is 124/min and thready. Chest x ray reveals air in the mediastinum and in the subcutaneous tissues. There is no change in the anatomical contour of the diaphragm.
From the options below choose the most appropriate cause for this patient’s signs and symptoms.
(Please select 1 option)
Acute cholecystitis
Boerhaave’s syndrome
Diaphramatic rupture
Myocardial contusion
Traumatic haemothorax
Boerhaave’s syndrome is the spontaneous rupture of a non-diseased oesophagus, usually caused after episodes of vigorous vomiting. It is seen in patients who consume excessive amounts of alcohol. The dramatically raised intra-oesophageal pressure caused by vigorous vomiting (and associated failure of relaxation of the cricopharyngeal sphincter) may lead to sudden spontaneous rupture of the oesophagus.
It is vital to recognise this condition since delay in diagnosis is associated with high morbidity and mortality. The signs and symptoms include
Sudden pain in the thorax and epigastrium following forceful protracted vomiting
Pain radiating to the neck
Progressive dyspnoea
Tachypnoea
Cyanosis
Shock.
The x ray shows an abnormal left cardiac border with free fluid within the left hemithorax (pleural effusion).
Physical examination usually is non specific; however, subcutaneous emphysema may be present, palpable in the neck or chest. This sign may take an hour to develop after injury.
The triad of vomiting, chest pain, and subcutaneous emphysema is also known as ‘Mackler triad’; however, this should not always be relied on since only one or two of the above symptoms may be present in a majority of patients in the early stages.
Patients may appear acutely ill with tachycardia and tachypnoea. Fever, sepsis and gross hypotension may be seen in patients with delayed presentation.
Examination of chest may reveal decreased breath sounds on the side of perforation, usually the left. A crunching sound (known as Hamman’s sign) may be heard with each heartbeat in up to 20% of cases.
A 53-year-old man who is a heavy alcohol drinker presents to the Emergency Department with a 12 hour history of sharp, central abdominal pain and vomiting. He prefers to sit up as the pain is aggravated on lying flat.
On examination, he is mildly jaundiced, his temperature is 38.2°C, his pulse rate is 132/min and his blood pressure is 118/82 mmHg. Abdominal examination reveals periumbilical discolouration and maximal tenderness over the epigastric region.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Acute pancreatitis
Acute viral hepatitis
Crohn’s disease
Perforated duodenal ulcer
Pyelonephritis
The common causes for acute pancreatitis include
alcohol gallstones trauma hyperlipidaemia certain drugs, such as azathioprine. Pancreatitis is thought to result from early activation of pancreatic enzymes, producing auto-digestion of the pancreas and surrounding tissues. Exposure of trypsinogen to lysosomal enzymes (e.g. cathepsin B) may be the cause for early trypsin activation. Digestive enzyme release is amplified as acinar cells lyse, leading to a vicious cycle of inflammation and necrosis.
Central abdominal pain that starts at a low intensity and gradually becomes very painful is a very common presentation. The pain may radiate to the back and may be relieved by sitting forward. This is usually associated by nausea and vomiting. On examination, the patient may be tachycardic, pyrexial, jaundiced and may or may not manifest signs and symptoms of shock. There may be discolouration in the peri-umbilical region (Cullen’s sign). Blood test may reveal elevated inflammatory markers and a significantly raised serum amylase levels.
Management of acute pancreatitis includes
keeping the patient nil by mouth and insertion of nasogastric tube
intravenous fluids
analgesia
antibiotics
plasma expanders (if there is haemodynamic compromise).
Laparotomy may be indicated in selected patients in whom there is evidence of fulminant pancreatic necrosis. A CT scan may be needed prior to laparotomy.
Complications of acute pancreatitis include intra-abdominal infection, pseudocyst, renal failure and pancreatic necrosis.
A 53-year-old male is admitted via the Emergency department. His main presenting complaint is severe upper abdominal pain.
During the history taking he says he has lost his job within the last few months and his alcohol intake has been steadily increasing as a result. He is currently drinking over one bottle of vodka a day. His admission bloods show a serum amylase of 902 IU/L (50-150).
Which of the following blood tests is not part of the Glasgow criteria for assessing the severity of an attack of pancreatitis?
(Please select 1 option)
Albumin
Arterial blood gas
Calcium
CRP
LDH
CRP
The Glasgow criteria use nine variables to assess the severity of the pancreatitis. It can be easily remembered using the mnemonic PANCREAS:
P PO2 55 years - N Neutrophils (WCC) >15 ×109/L (4-11) C Calcium 16 mmol/L (2.5-7.5) E Enzymes LDH >600 U/L (10-250) A AST >125 U/L (1-31) Albumin 10 mmol/L (3.0-6.0) Three positive criteria indicate severe acute pancreatitis. The number of variables relates to the severity and mortality of the pancreatitis.
Although CRP is not part of the Glasgow scoring criteria, a raised level is an independent indicator of severity.
A 72-year-old female presents with vomiting, colicky abdominal pain and an absence of flatus. She has never had surgery to her abdomen. On examination her abdomen is distended, non-tender and tympanic to percussion. Plain abdominal radiograph reveals distended loops of small bowel, no air is seen in the colon. What is the most likely diagnosis? (Please select 1 option) Caecal carcinoma Duodenal carcinoma Gastric carcinoma Pancreatic carcinoma Rectal carcinoma
Caecal carcinoma
The commonest cause of bowel obstruction in an abdomen that has not previously been operated is colonic carcinoma. Colonic malignancy can present as an emergency or with chronic symptoms.
Tumours of the caecum and the ascending colon typically present with anaemia and no change in bowel habit, due to the liquid nature of the faeces. An obstructing caecal tumour usually causes obstruction of the ileocaecal valve resulting in a small bowel obstruction with a collapse of the distal colon.
Obstructing rectal tumours result in large bowel obstruction ± small bowel obstruction on the plain film.
Obstructing gastric tumours result in a gastric outlet obstruction producing a distended stomach.
Obstructing duodenal or pancreatic tumours result in high small bowel obstructions which usually do not result in the small bowel being visible on the plain film.
A 24-year-old male is found to have an inflamed non-perforated appendicitis at operation.
What is the most predictive symptom, sign or serological marker in appendicitis?
(Please select 1 option)
Low grade pyrexia
Nausea
Raised C reactive protein
Raised white cell count
Tenderness over the site of the appendix
Tenderness over the site of the appendix This is the correct answerThis is the correct answer
The diagnosis of appendicitis can be difficult even for the most experienced clinician.
Patients with appendicitis usually present with a typical pattern of symptoms and signs. Pain is usually one of the earliest symptoms. The pain is usually periumbilical initially (irritation of the visceral peritoneum due to early obstruction, dilatation and infection of the appendix) localising to the right iliac fossa (irritation of the parietal peritoneum due to spread of infection through the appendix) a few hours later.
After the initial pain, anorexia, nausea and occasionally vomiting may develop. Tenderness over the appendix is the hallmark of appendicitis. Tenderness is due to inflammation of the serosa of the appendix and overlying peritoneum.
Pyrexia tends to be a late sign and may be very elevated if the appendix is perforated.
Laboratory markers of infection are unreliable in appendicitis, as white cell count and C reactive protein only become raised when appendicitis is established.
A 55-year-old man presents having recently noticed a lump in his right groin which disappears when he is recumbent. It is accompanied by some discomfort. He has a chronic cough due to smoking. He has had an appendicectomy previously. What is the most likely diagnosis? (Please select 1 option) Epigastric hernia Femoral hernia Incisional hernia Inguinal hernia Spigelian hernia
Inguinal hernia is the most likely cause of a lump in the right groin in a patient of this age.
The hernia protrudes through the external inguinal ring. It may
Go unnoticed for quite some time
Cause an ache
Resolve on lying flat.
Femoral hernias are more common in females.
The anatomical site is inconsistent with an epigastric hernia; and an incisional hernia following appendicectomy would be very unusual.
This patient is at increased risk of hernias as he has a persistent cough due to his smoking.
A 40-year-old male presents with a history of intermittent, but slowly progressive dysphagia for both solids and liquids. He experiences pain on swallowing and has regurgitation of food swallowed several hours earlier. He has no heartburn but has anorexia and weight loss.
Ba swallow demonstrates proximal dilatation of the oesophagus and failure of relaxation of the lower oesophageal sphincter.
What should first line management consist of?
(Please select 1 option)
Amlodipine
Amyl nitrite
Intrasphincteric botulinum toxin
Oesophageal bouginage
Oesophageal myotomy
Oesophageal bouginage
The patient has achalasia of the cardia, which is a functional obstruction at the lower oesophageal sphincter caused by a failure of relaxation.
Balloon dilatation is first line management, but if this fails oesophageal cardiomyotomy (Heller’s operation) is the preferred treatment.
Drug therapy, such as botulinum toxin injections, does not achieve medium to long-term relief.
A 35-year-old female presents with acute severe abdominal pain associated with tachycardia, hypotension and tachypnoea.
Which of the following is likely concerning the finding of a raised serum amylase in this patient?
(Please select 1 option)
Could indicate a perforated duodenal ulcer
Is diagnostic of acute pancreatitis
Makes diabetic ketoacidosis less likely
Makes ectopic pregnancy less likely
Makes mesenteric ischaemia less likely
Perf DU
A raised serum amylase may occur in all these conditions.
A 32-year-old female who is known to have Crohn's disease presents with increased frequency of micturition. She is demonstrated to have sterile pyuria. Which is the most likely diagnosis? (Please select 1 option) Colo-vesical fistula Recto-vesical fistula Ileo-vesical fistula ileo-ureteric fistula Vesico-vaginal fistula
ileo-vesical fistula
In Crohn’s disease the most common origin of a fistula to the urinary tract is the ileum:
ileum - 64%
colon - 22%
rectum - 8%.
The most common urinary tract connection is the bladder:
bladder - 90%
ureter - 5%
urethra - 2%
urachus - 3%.
