Mixed II

Question 1

A 50-year-old woman presents with a five day history of right upper quadrant pain. The pain has become constant and associated with nausea. She has a pyrexia and tenderness in the right upper quadrant.

Answer 1

Acute cholecystitis

Question 2

A 90-year-old patient develops acute distension of the abdomen. He has a dense hemiplegia from a stroke two weeks previously. He is confused. His abdomen is grossly distended and he has not passed stool or flatus for two days. A plain abdominal x ray shows dilated loops of large bowel.

Answer 2

Colonic pseudo-obstruction
Colonic pseudo-obstruction may follow acute medical events such as pneumonia, myocardial infarction or hypoxia. It is associated with electrolyte abnormalities that may accompany an acute illness.

Mechanical large bowel obstruction must be excluded by rectal examination, rigid sigmoidoscopy, plain x ray (there may be gas in the rectum) and CT scan.

Initial treatment is with fluids, correction of electrolyte abnormalities, avoidance of opiate analgesia and nasogastric aspiration (if there is also small bowel dilation). There may be a place for a rectal tube, enemas and an octreotide infusion.

If these measures fail, intravenous neostigmine may be effective. The next step is colonoscopic decompression. Surgery is the last resort.

Question 3

A 35-year-old woman has an appendicectomy for perforated appendicitis. Ten days later she becomes unwell with a swinging fever and a high white blood cell count.

Answer 3

Pelvic abscess
Rectal examination may confirm the clinical diagnosis. Ultrasound and/or CT scan will establish the size of the abscess and whether any other collection is present. Drainage may be spontaneous, surgically per rectum or under radiological control.

Question 4

Three days after a right hemicolectomy for carcinoma of the caecum, a 68-year-old patient begins vomiting and has abdominal distension. The abdomen is not tender and there are no bowel sounds. Passage of a nasogastric tube produces large volumes of aspirate.

Answer 4

Paralytic ileus
The management of post-operative ileus is primarily conservative. Normally an ileus resolves in three to four days. Small bowel motility returns in about 24 hours, then gastric motility after three to four days.

If the ileus persists, nasogastric aspiration is essential to prevent gastric dilatation and the risk of aspiration pneumonitis. The patient should have intravenous fluids and correction of any electrolyte imbalance plus minimal oral fluids.

Mechanical obstruction (abscess, haematoma, internal hernia, early adhesions) should be excluded by ultrasound or CT scan. A small bowel water soluble contrast examination may demonstrate a mechanical obstruction and may also relieve the ileus.

Question 5

An 18-year-old motorcyclist is brought to the Emergency department after being hit by a car. He has a tachycardia and hypotension. Abdominal examination shows left upper quadrant tenderness. A diagnostic peritoneal lavage is performed. The aspirate is blood stained.

Answer 5

Ruptured spleen
The peritonitis results from irritation of the parietal peritoneum resulting in acute abdominal pain.

The quadrants of the abdomen represent close anatomical reference to the site of inflammation.

Referred pain can help identify sites of origin such as left shoulder tip pain in left subdiaphragmatic irritation.

Question 6

These calculi develop in a quarter of all patients who develop gout. They have an acidic urine and the management involves reducing purine intake, alkalinising the urine and taking allopurinol.

Answer 6

Uric acid
Most uric acid stones are in patients who do not have gout. Other causes include

Myeloproliferative disorders
Chronic diarrhoea
Patients with an ileostomy
Excessive meat eating.

Question 7

A 60-year-old lady presents with a renal colic. Her urinalysis and culture reveal an alkaline urine and Proteus mirabilis infection. An ultrasound scan and intravenous pyelogram reveal a staghorn calculus.

Answer 7

Triple phosphate
Urinary infection with urea splitting organisms, usually Proteus species, produces an alkaline urine. This increases the precipitation of calcium phosphate and magnesium ammonium phosphate.

Question 8

A pathologist is sent a stone retrieved from the urine. It is laminated and has areas of black staining. Urinalysis reveals hypercalciuria.

Answer 8

Calcium oxylate
In many patients, investigation fails to find any disorder of calcium metabolism. If an abnormality is present it may be dietary, absorptive, resorptive or of tubular origin.

Only about 2-3% of patients with calcium stones have hyperparathyroidism.

Question 9

The patient has the presence of lysine, arginine, ornithine and cystine in the urine. The disorder is autosomal recessive. The treatment includes urinary alkalinisation and penicillamine.

Answer 9

Cystine
In this condition there is a defect in the tubular reabsorption of cystine, orthinine, arginine and lysine (COAL). Stone formation is far more common in those who are homozygotes for the condition.

Question 10

A 19-year-old patient attends her GP with a renal colic. She informs her GP that she has a hereditary disease and that her mother had this problem.

Answer 10

Cystine
Although an autosomal recessive condition the heterozygotes may still have an increased incidence of cystine stone formation. There are a number of phenotypes and the expression of the cystinuria gene is very variable.

Most patients have no underlying abnormality to account for stone formation.

The abnormalities that cause stones to form involve

Abnormal constituents in the urine
Stasis
Infection.

Question 11

These lesions previously used to occur most commonly in Eastern Europeans. They are purple in colour and tend to be multiple. With the increase in AIDS they have been found increasingly on mucosal surfaces.

Answer 11

Kaposi’s sarcoma
Kaposi’s sarcoma used to be found more frequently in Eastern Europeans but are now recognised as an AIDS defining illness. They are purple papular lesions and can be found in the skin and on mucosal surfaces.

Question 12

The lesions arise from skeletal muscle. They most commonly affect children and can be found in the head, neck, trunk and limbs.

Answer 12

Rhabdomyosarcoma
Rhabdomyosarcoma arises from skeletal muscle. It is the most common soft tissue sarcoma in children with a peak incidence between 2 and 5 years. About 70% of cases are under 10-years-old. There is smaller peak between12 and 18 years.

Question 13

These lesions are very common and rarely become malignant. They are usually asymptomatic but may be multiple and painful.

Answer 13

Lipoma
Lipomas are characterised by soft rubbery tissue and can sometimes transilluminate. When multiple, familial (and often tender) the condition is Dercum’s disease/syndrome.

Question 14

These are rare tumours which may be part of a genetic syndrome. They are composed of highly vascularised fibrous tissue and they are not malignant. Recurrence is common and most frequently found in the abdominal wall.

Answer 14

Desmoid tumours

Question 15

These lumps arise following trauma. The cells regenerate in a disorganised manner. They are often found in amputation stumps and may produce pain.

Answer 15

Neuroma
When examining lumps, the site, size, consistency and colour are important to assess.

The regional lymph nodes must always be examined since malignant tumours may have spread along lymphatic drainage.

The risk of painful neuromas after amputation may be reduced by cutting (not tying) nerves as short as possible and keep the ends away from scar tissue.

Question 16

A 44-year-old lady with a family history of multiple endocrine neoplasia type 2a develops a lump palpable in the thyroid gland. She has experienced diarrhoea and undergoes total thyroidectomy with ipsilateral modified block dissection of the neck.

Answer 16

Medullary

Medullary cancers arise from the parafollicular C cells and synthesise calcitonin.

Question 17

A 75-year-old lady with a long history of Hashimoto’s thyroiditis develops a rapidly growing goitre.

Answer 17

Lymphoma

Lymphomas are rare, whilst squamous and sarcoma are even rarer with a poor prognosis.

Question 18

A 45-year-old lady from an endemic goiterous region has a solitary tumour of the thyroid that has spread haematogenously to the lung and bone. Histological examination of the tumour reveals capsular invasion and vascular spread. No nodes are involved.

Answer 18

Follicular

Follicular carcinoma represents 15% of all thyroid malignancies but occurs in an older age group.

Question 19

A 70-year-old lady presents to her GP with a hard fixed mass in the neck with hoarseness of her voice. A local debulking procedure is performed and a tracheostomy sited.

Answer 19

Anaplastic

Anaplastic tend to occur in the elderly and have a rapid progression with death ensuing within a year.

Question 20

A 25-year-old lady presents to her GP with a two lumps in her neck which she has noticed in the last two weeks. The most prominent lump is palpable in the lateral margin of the anterior triangle of the neck. She is investigated fully by a thyroid specialist who informs her that she requires surgery. She undergoes a total lobectomy with “berry picking” of individual lymph nodes.

Answer 20

Papillary
Thyroid neoplasms may present as a solitary nodule and must be distinguished from benign conditions by performing a history, examination, ultrasound scan and fine needle aspiration cytology.

The most common benign tumours are follicular adenomas whilst papillary represent 70% of all thyroid cancers.

Question 21

During the acute (EBB) phase following 40% deep dermal burns.

Answer 21

Increased utilisation of non-esterified fatty acids

Question 22

Where the patient’s traumatic insult is overwhelming.

Answer 22

Anaerobic metabolism

Question 23

In the delayed (FLOW) phase, one week after multiple trauma.

Answer 23

Increased nitrogen loss

Question 24

During the flight and fright early response to injury.

Answer 24

Increased adrenaline levels in the serum

Question 25

A 42-year-old lady develops hypoxaemia unresponsive to oxygen therapy on the intensive care unit following severe sepsis from pancreatitis.

Answer 25

Endothelial damage
The early metabolic responses to trauma reflect the appreciation of danger with the flight, fright and fight response with predominantly adrenaline release.

Following injury the tissues become damaged and there is a change in the homeostatic mechanisms that compensate for fluid loss.

Plasma hormone levels change with mobilisation of energy reserves and alterations in fuel utilisation. Initiation of acute phase protein responses occur with elevation in adrenocorticotropic hormone (ACTH), antidiuretic hormone (ADH) and aldosterone.

During the more prolonged flow phase which can occur over weeks, increases in metabolic rate occur and insulin resistance, increased skeletal muscle breakdown and loss of lean body mass result in creating nitrogen loss.

During the recovery phase catabolism occurs with subsequent fat restoration.

If failure to respond appropriately to trauma occurs due to organ failure, loss of oxygen delivery and anaerobic metabolism ensues with necrobiosis and death.

Question 26

A 62-year-old lady with jaundice and a pyrexia, with suspected stones present in the biliary tree undergoing endoscopic retrograde cholangiopancreatography with the intention to remove the stones with a retrieval basket. Her white blood count is elevated and her bilirubin serum level is five times normal.

Answer 26

One week course of antibiotics rather than three doses

Question 27

A 56-year-old gentleman admitted for an anterior resection of the rectum for adenocarcinoma of the mid-rectum. He was diagnosed with colonoscopy and has no evidence of metastases. He had subacute bacterial endocarditis five years ago and is diabetic.

Answer 27

Three doses of prophylactic antibiotics to cover bowel organisms

Question 28

A 78-year-old lady with osteoarthritis admitted for elective total hip replacement.

Answer 28

Use of laminar air flow in the operating theatre

Question 29

A 23-year-lady undergoing excision of a lipoma from the right forearm. She has no co-existing medical problems and is to be discharged the same day.

Answer 29

Conventional sterile technique only

Question 30

An 80-year-old previously fit gentleman who has been admitted as an emergency with an acute abdomen. He was found to have marked diverticulosis on a barium enema x ray taken two years previously, but had been asymptomatic for the last year. On this admission he has peritonitis and is taken to theatre for a Hartmann’s procedure.

Answer 30

One week course of antibiotics rather than three doses
There is no evidence that sterile adhesive drapes, bowel preparation, prolonged antibiotic prophylaxis, laminar flow theatres or antegrade colonic lavage reduce the incidence of wound infections in bowel surgery.

The organisms that are responsible for wound infections in surgery of the gastrointestinal tract are usually endogenous (Escherichia coli, Bacteroides fragilis, etc.) and not from the skin. Recent evidence implicates bacterial translocation through the bowel wall into the lympho-vascular circulation to the wound.

In orthopaedic operations the high flow of air in laminar air flow theatres combined with prophylactic antibiotics produces wound infection rates comparable with the wearing of gas extraction suits by the surgeons and no touch techniques.

Question 31

A 60-year-old lady presents with a renal colic. Her urinalysis reveals Proteus splitting organisms and an alkaline urine. Ultrasound scan and intravenous pyelogram reveal a staghorn calculus.

Answer 31

Triple phosphate

Question 32

A 19-year-old patient attends her GP with a renal colic. She informs her GP that she has a hereditary disease and that her mother had this problem.

Answer 32

Cystine

Question 33

These calculi represent a quarter of all patients who develop gout. They have an acidic urine and the management involves reducing purine intake and alkalinising the urine and taking allopurinol.

Answer 33

Uric acid

Question 34

A pathologist is sent a stone retrieved from the urine. It is laminated and has areas of black staining. Urinalysis reveals hypercalciuria.

Answer 34

Calcium oxalate

Question 35

The patient has the presence of lysine, arginine, ornithine and cystine in the urine. The disorder is autosomal recessive. The treatment includes urinary alkalinisation and penicillamine.

Answer 35

Cystine
About 80% of calculi in the United Kingdom are composed of Ca, mainly calcium oxalate; 5% are uric acid; 2% are cystine; and the remainder are magnesium ammonium phosphate (or infection calculi).

Most patients have no underlying abnormality to account for stone formation. The abnormalities that cause stones to form involve abnormal constituents in the urine, stasis or infection.

Oxalate and cystine stones are radio-opaque and urate stones are lucent.

Primary oxaluria may present with familial renal calculi but this disorder is extremely rare and is associated with childhood renal colic and failure in adolescence. However, familial cystinuria may present with renal colic in young patients and is a familial cause of renal colic.

The patient with aminoaciduria has cystinuria which is autosomal recessive.

Question 36

Highly efficient ‘N95’ masks should be used in association with plume evacuators.

Answer 36

Atmospheric contamination
N95 masks filter 95% of 0.3 micron paricles. Laser surgery causes tissue vapourisation which can cause alveolar damage and is possibly mutagenic.

Question 37

Patients undergoing laser surgery to the perianal area should have moistened drapes or a radiopaque, saline-soaked rectal swab.

Answer 37

Fire risk
Methane gas (flatus) may be ignited by laser surgery and cause a localised burn. It is important that drapes are not dry and unintentional leakage of gas avoided.

Question 38

Prominent signs should be placed on theatre doors indicating that lasers are being used.

Answer 38

Eye damage
Other theatre staff should be aware of the possibility of laser surgery and wear the appropriate eye goggles before entering.

Question 39

A 25-year-old male presents with severe upper abdominal pain following an alcohol binge. On examination he is tachycardic and hypotensive. Following catherisation he has a urine output of less than 15 mls per hour. His serum amylase is 2432.

Answer 39

Third space loss
This man has acute pancreatitis. Sequestration of fluid from his pancreas has resulted in a third space loss. This explains the elusive loss of extracellular fluid.

Question 40

A 22-year-old female has recently undergone a total colectomy and formation of end ileostomy for ulcerative colitis refractory to medical treatment. She complains of an output from her ileostomy in excess of 3 litres daily. She is clinically dehydrated.

Answer 40

Extracellular fluid depletion
ECF depletion is the most common abnormality of body fluids. It results from excessive or abnormal fluid loses with diminished intake. Decreased urine output and increased specific gravity are the best simple indicators.

Question 41

A 34-year-old female with known polycystic kidneys has presented with right flank pain. On examination she is pale and clammy, has a tachycardia and is hypotensive. A full blood count reveals haemoglobin of 7.1 g/dl with an MCV within the normal range.

Answer 41

Intravascular depletion
This woman has had a spontaneous haemorrhage into a renal cyst. Bleeding has been extensive and has resulted in a decrease in the intravascular volume.

Question 42

A 7-year-old boy presents with a three day history of bright red blood per rectum and no other symptoms. Digital rectal examination is normal.

Answer 42

Juvenile polyp
Juvenile polyps may present with bleeding or sometimes prolapse if in the rectum.

A Meckel’s diverticulum represents the remnant of the vitello-intestinal duct. Approximately 2-3% of the population have a Meckel’s diverticulum but only a minority of these will present clinically. A Meckel’s may become inflamed (may mimic acute appendicitis) or present with bright red rectal bleeding. Bleeding results from ectopic acid-pepsin-secreting gastric mucosa being present in the diverticulum (the reason for this is unclear). Bleeding can occur at any age but is most frequent under the age of 5.

Question 43

A 6-month-old girl with a 24 hour history of distress, crying, abdominal distension, vomiting and dark blood per rectum.

Answer 43

Intussusception
Intussusception is the invagination of a portion of the intestine into its own lumen. This condition can present at any age but is most common in boys under the age of one year. Most intussusceptions are ileocolic.

Clinically the infant presents with acute severe colicky abdominal pain and vomiting. Initially the stool is normal with the classical ‘recurrent jelly’ stool (blood and mucus) usually being passed after the first 24 hours. Abdominal palpation may reveal a sausage-shaped mass. Rectal examination will reveal blood. The diagnosis is confirmed by abdominal ultrasound or contrast study.

Question 44

A 25-year-old woman presents with severe PR pain on defecation and associated bright red blood per rectum.

Answer 44

Anal fissure
Anal fissures result in a tear of the distal anal mucosa and are therefore extremely painful. Fissures are mostly seen at the 6 and 12 o’clock positions. The patient presents with pain and bleeding following passing stool. They result from high resting tone of the internal sphincter causing ischaemia of the mucosa. The ischaemic mucosa is prone to breakdown. (Do not forget to think about child abuse and look for bruising or any other evidence of trauma)

First line therapy is stool softeners and topical nitrates (reduces resting tone). Surgery (lateral sphincterotomy) is reserved for refractory cases.

Question 45

A 30-year-old man presents with painless, bright red blood per rectum and a history of constipation.

Answer 45

Haemorrhoids

Degeneration of the vascular cushions of the anus results in prolapse and the symptoms of haemorrhoids. Haemorrhoids may be complicated by thrombosis and acutely painful prolapse. Grading is clinical into

Bleeding alone (first degree)
Prolapse that spontaneously reduce (second degree)
Prolapse requiring reduction (third degree) and
Irreducible (fourth degree).
Assessment of the rest of the colon is necessary if there are any atypical features. Treatment may be conservative, injection scelotherapy (bleeding haemorrhoids), rubber band ligation (prolapsing haemorrhoids) and operative (symptomatic external haemorrhoids).