Surgical abdomen Flashcards

Question

Management of incisional hernia conservcative/surgical

Answer 1

Surgery is not appropriate for all pt must ba;ance risk of op and recurrence with risk of obstruction/strangulation and pt cjoice usually broad neced therefore low risk of strangulation **Conservative:** * manage RF eg, constipation, cough * weight loss * elasticated coset or truss **surgical:** * pre-op * optimise cardioresp function * encourage weight loss * nylon mesh repair: open or lap

Answer 2

* **inspection:** * ****pt may be overweight * ask pt to lift head off bed and to cough * note any associated skin damage e.g. ulceration * note any overlying scars: may indicate recurrence * **Palpation:** * ****any tenderness * feel for presence of defect * try to assess sie * ask pt to cough while feeling for an impulse * if a lump is present, ask pt to reduce it

Answer 3

* Predisposing factors: pregnancy, ascites, obesity * pain * reducible * episodes of obstruction or strangulation * previous repairs

Answer 4

* acquired defect in linea alba just above or below the umbilicus * commoner in obese, middle aged pts * neck is commonly narrow * prone to befoming irreducible or strangulated * typically contain omentum **RF:** * obesity * pregnancy * ascites * fibroids * bowel distension

Answer 5

* surgery advised: high risk of strangulation * Treat concurrent medical problems * May repait: * mobilise sac and reduce contents * double breast linea alba +/- sublay mesh

Answer 6

* congenital defect in umbilical scar (cicatrix) * typically congenital 3% of live births RF: * afro-caribbean * trisomy 21 * congenital hypothyroidism recur in adults: pregnancy, ascites

Answer 7

* usually asymptomatic and resolves by 2-3 yrs * surgical repair advocated if no resolution by 3 yrs

Answer 8

* **Gastroschisis:** * ****protrusion of abdo contents through defect in abdo wall to the right of the umbilicus * not usually associated with other abnormalities * promps surgical repair after fluid resuscitation * **exomphalos:** * ****protrusion of abdo contents w/i in a 3 layered sac * commonly associated with other defects: * cardiac * anencephaly

Answer 9

* **inspection:** * ****midline lump above the umbilicus when the pt coughs or lifts head from bed * typically small: pea shaped * assoc scars? * Incisional hernia or previous repairs * **Palpations:** * any pain * feel for cough impulse * establish sie of defect * **Differential:** * incisional hernia: ?scar * Divarification of recti: *widening gap between recti muscles, not a hernia*

Answer 10

History: * predisposing factors: pregnancy * obesity * symptoms * reducible * episodes of obstruction/strangulation * previous repair s

Answer 11

* **features:** * ****abdnormal protrusion of abdominal contects through a defect in linea alba between xiphisternum and umbilicus * usually contains extraperitoneal fat or omentum * commoner in young (20s-50s) * **symptoms:** * ****may be aSx * may be confused for upper GI path * pain: may inicreas after meals or exercise * nause and early satiety * Abdominal bloating

Answer 12

* **conservative:** * manage RF e.g. constipation, cough * weight loss * **surgical:** * ****reduce hernial contents and excise sac * suture or mesh repair *

Answer 13

**set up:** best to examine pt standing (won't miss varicocele) **Inspection:** * skin: scar, erythema, blue tinge, ulcers * groid lumps or scars * ask pt to cough **Palpation:** 1. ***Can you get above it?*** can't get above an inguinoscrtal hernia 2. ***is it tender?*** * ******torted testis or hydatic of morgagni * epididymo-orchitis * strangulated hernia 3. ***is it palpable seperately?*** * ******No: * tumour * orchitis * hydrocele * Yes: * Varicocele * spermatocele/epididymal cyst 4. ***does it transluminate?*** * ******No: * tumour * testis * varicocele * spermatocele * Yes: * hydrocele * epididymal cyst ******

Answer 14

* Inspection: * swollen scrotum * palpation: * can get above it * cannot feel testis seperately * Firm/tense * Transluminates

Answer 15

* duration * pain, discomfort, other symptoms * previous testicular masses or infections * recent trauma * treatment so far * co-morbidities e.g. HF

Answer 16

*accumulation of fluid within the tunica vaginalis* TV: *remnant of the processus vaginalis that accompanied the testicle during its descent. forms one of the adult coverings of the testis*

Answer 17

* **vaginal:** accumulation in the tunica vaginalis that doesn't extend up the cord * **congenital:** proximal part of the processus has not obliterated and the sac communicates directly with the peritoneum * **infantile:** processus is obliterated at the deep ring but still extends up the cord * **hydrocele of the cord:** fluid accumulates around the ductus deferens. Can be hard to distinguish from inguinal hernia as it may extend proximal to the superficial ring. testicular tractin will pull it inferiorly (c.f. to inguinal hernia

Answer 18

* **primary:** * ****caused by a patent processus vaginalis * commonest type! * young men, large, tense * **secondary:** * vaginal type, can be caused by a variety of pathologies incl: * testicular tumours * epididymo-orchitis * trauma * torsion

Answer 19

US to exclude malignanacy!

Answer 20

* non-surgical: * watch and wait (ensure no Ca) * aspiration: symptom relief only as will accumulate * Surgical: * **lord's repair:** plication of tunical vaginalis * **jaboulay's repair:** eversion of sac

Answer 21

* **inspection:** * ****normal appearing scrotum * **palpation:** * ****can get above it * seperate from testis: typically above and behind * Firm * Transiluminates: *unless its a spermatocele*

Answer 22

* History: * duration * pain, discomfort, other Sx * treatment so far * Features: * retention cyst of tubule of the rete testis or epididymis * often multiple * may contain sperm: spermatocele (does not transluminate) * generally aSx

Answer 23

* non-surgical: * if the cyst isn't troublesome it shouldn't be removed due to risk of op damage and post-op fibrosis-\> SUBFERTILITY * surgical: * V large/painful cysts can be removed * excision of entire epididymis may be indicated to prevent to recurrence of painful cysts

Answer 24

* Inspection: * normal appearing scrotum * Palpation * pt must be standing * can get above mass * seperate from testes * feels like a bag of worms * doesn't transilluminate * may have palpable cough impulse * often disappear on lying

Answer 25

* History: * duration * pain, discomfort, other symptoms * Treatment so far * symptoms: * dragging sensation exacerbated by exertion * subfertility; commonest surgically correctable cause

Answer 26

* dilated veins of the pampiniform plexus * 98% L sided, 50% bilateral * primary; * occur in up to 15% of young men * often around puberty * anatomical cause ?nutcracker syndrome * secondary: * varicoceles suddenly appearing in older men can be sinister * retroperitoneal disease affecting the testicular V * e.g. genal cell carcinoma extending into L renal V * don't disappear when pt lies down

Answer 27

* Left testicular vein is more vertical where it joins the left renal vein cf to obliquity of R testicular V where it joins the IVC * LEft renal vein can be compressure by the colon * L testicular v is longer than R * left testicular V often lacks terminal valve to prevent backflow

Answer 28

* **non-surgical:** * ****scrotal support * transfermoral radiological embolisation of testicular vein * **surgical** * ****often advised as problem usually gets worse with age and can result in subfertility * palomo-operation: * high approach with transferse incision slightly above and medial to ASIS * vein exposed and ligated * inguinal approach: ligation of veins in inguinal canal * laparoscopic approach also possible

Answer 29

* Inspection: * Enlarged testis may be visible * Palpation: * Can get above mass * inseparable from testis * hard irrgular nodular * non-tender * doesn't transluminate * Completion * examine contralateal scrotum * abdo exam: hepatomegaly * Chest exam: thoracic mets * Examine for abdo lymphadenopathy * Differential: * testicular tumour * chronic infection-\> scarring (orchitis, TB) * chronic hydrocele (calcified)

Answer 30

* History * Pain, discomfort * SOB: lung mets * BAck pain: para-aortic node involvement * haematospermia * hydrocele * Hx: tumour/infection * Presentation: * commonest malignancy in men 15-45 yrs * painless lump or dull ache in one testis in young man * occasionally a history of trauma accompanying overlying mass * 10% present with acutely painful testis * haematospermia * 2ndary hydrocele

Answer 31

* 95% are germ cell tumours * 50% are pure cell populations: * pure seminomatous: 50% * non-seminomatous: ***teratoma*** is commones * Other types: * ***yolk sack***: commenest testicular tumour in children * choriocarcinoma * leydig or sertoli cell; may secrete oestrogens -\> gynaecomastia * **_lymphoma_**: NHL is commonest testicular mass \>60yrs

Answer 32

* Tumour markers AFP, bHCG, placental ALP * CxR: mets * US scrotum: diagnostic * CT abdomen: staging

Answer 33

* all testicular tumours are treated with orchidectomy * groin incision with early clamping of spermatic cord to prevent seeding seminoma * Early: DxT (radiotherapy) to para-aortic nodes * Late: DxT + combination chemo Teratoma * early: observation * Late: combincation chemo: * Bleomycin * Etoposide * cisPlatin

Answer 34

* a vascular compression disorder* * compression of the left renal vein between the superior mesenteric artery (SMA) and aorta*

Answer 35

Examination: * site * contents of bag * solid stool * semi-formed or liquid stool * urine * Appearance: * spout * lumens * rod * mucosal health * scar: NO scars suggests clonoscopy assisted trephine colostomy palpate: * palpate for parastomal hernia complete: * remove bag to closely inspect and digitate stoma: * no. of lumens * health of mucosa and surounding skin * strictures * prolapse * Eclonoscopy assisted trephine colostomy examine perineum

Answer 36

Artificial union between conduits or between a conduit and the outside

Answer 37

* Surgery * output * pain * complications * psychosexual function

Answer 38

* **Exteriorisation** * temporary: perforated or contaminated bowel e.g. hartmann's * permentant: e.g. AP resection * **Diversion** * protection of distal anastomosis * contamination e.g. faecal peritonitis * anatomical e.g. ileorectal anastomosis * acute crohn's: * urinary diversion following cystectomy * **Decompression**: bypass of distal obstructing lesion * **Feeding**: gastrostomy/jejunostomy * **lavage** e.g. appendicostomy

Answer 39

located in RIF Small bowel content is irritant therefore ileostomies = spouted ileal pouch–anal anastomosis (IPAA)

Answer 40

Explanation of indications and complications liaisn with stoma nurse to arrange siting Siting: * done with pt standing up to ensure pt can see stoma * Avoid: * bony prominences * skin folds/creases * waistline * old wounds * umbilicus * choose: * site that is accessible to pt * ideally below belt line for concealment * w/i the rectus (reduce risk of hernia or prolapse

Answer 41

* early: * h'gge * ischaemia * high output (can lead to hypokalaemia) * loperamide +/- codeine to thicken output * parastomal abscess * stoma retraction * Delayed: * parastomal hernia (on lat side) * obstruction; adhesions or hernia through lat space around stoma * dermatitis; ileostomy * stoma prolapse * stenosis or stricture * fistulae * psychosexual dysfunction

Answer 42

* aim for normal diet * good skin care and cleanliness * psychosexual support

Answer 43

1. tracheostomy 2. gastrostomy 3. jejunostomy 4. ileostomy 5. caecostomy 6. colostomy 7. urostomy

Answer 44

fashioned following total cystectomy 1. ileal conduit: incontinent * ureters attached to a portion of resected ileum which is exteriorised as a spouted stoma * bowel continuity mainstained by primary anatomosis * urine collected in bag 2. Indiana pouch: continent * pouch created 2 ft of resected ascdemnding colon and portion of ileum which includes the ileosaecal valve * ureters anastomosed to colonic end and ileal end exteriorised as spouted stoma * ileocaecal valve prevents urinary leak from pouch * Self catheterises to drain pouch

Answer 45

* **Examination:** * describe anatomical location and orientation * give correct technical name where possible * Well healed or recently formed? * incisional hernia; cough impulse? * wait to be asked for suggested surgeries!: * use anatomical knowledge + NAVY to suggest * **Look for:** * stoma and drain scars: bowel surgery * vasc access scars: AAA, graft

Answer 46

* Midline laparotomy * Aproach: * skin * camper's fascia * scarpa's fascia * linea alba * transversalis fascia * pre-peritoneal fat * peritoneum * use: * emergency: * perforated DU * trauma * ruptured AAA * hartmann's * elective: * colectomy * AAA * vasc bypass * Features: * good: * good access * bloodless line * minimal nerve and muscle injury * bad: * long midline scar * pain * closure: * PDS blunt J shaped feature en mass * jenkin's rule * length of suture = 4x length of incision * 1 cm bite, 1cm apart

Answer 47

* Right paramedian * use: not commonly used now as closure techniques have improved * location: 3cm lat to midline * aproach: rectus sheath opened and rectus displaced laterally slips back to cover the defect * bad: tme consuming

Answer 48

* Kocher's (subcostal) * R Open cholecystectomy, L Kocher's used for splenectomy

Answer 49

* Rooftop * Uses: * hepatobilary surgery: * liver transplant * whipple's; *remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct* * liver resection * gastric surgery * disadvantage: longer to close than a midline as the incision is closed in 3 layers * adaptability: modified to a mercedes ben incision

Answer 50

* pfannenstiel * use: * gynae surgery * lower UTI

Answer 51

* Two * **McBurney's:** oblique * **Lan:** Transverse * Anatomy: * skin * camper's fascia * scarpa's fascia * external oblique * Internal oblique * Transversus * Transversalis fascia * pre-peritoneal fat * peritoneum * use: appendectomy * Two types: BOTH, follow langer's lines * Lan: favoured hidden in skin creases * risk: of injury to ilioinguinal and iliohypogastric nerves may predispose to inguinal hernia

Answer 52

* Thoracoabdominal * Use: oesophagogastrectomy

Answer 53

* Transverse muscle splitting * Right hemicolectomy * disadv: limited acces to midline incision * adv: * reduced damage to rectus * segmental nerve supply means the muscle can be cut transversely without weakening

Answer 54

* Name; inguinal hernia incision * Use: * Open inguinal hernia repair * ORchidectomy * features: incision over the inguinal ligament follow's langer's lines * risk: high rates of chronic neuropathic pain

Answer 55

* Name/aka: Mc Evedy-modified/aka half pfanenstiel * Use: emergency femoral hernia * Advantage: allows inspection of peritoneal cavity with easy confersion to laparotomy if necessary

Answer 56

* Loin * Nephrectomy

Answer 57

* Vasc access * Use: * bypass * embolectomy * EVAR/TEVAR * Stent insertion * Fem endartectomy * angioplasty

Answer 58

Right hemicolectomy _Features_ * **Indication:** tx in the cecum and proximal part of ascending colon * **Scars:** * ****midline laparotomy * Transverse muscle splitting * Laparoscopic ports * **Stoma:** none * **Anastomosis:** ileocolic * **Differential:** midline laparotomy differential

Answer 59

**Extended Right hemicolectomy** Features * **Indication:** tumours in the distal ascending colon or transverse colon * **Scars:** * ****midline laparotomy * laparoscopic ports * **Stoma:** none * **Anastomosis**: ileocolic * **Differential:** midline laparotomy differential

Answer 60

**Left hemicolectomy** Features * **Indication:** tumours in the descending colon * **Scars:** * ****midline laparotomy * laparoscopic ports * **Stoma:** none * **Anastomosis**: colocolic * **Differential:** midline laparotomy differential

Answer 61

**Hartmann's procedure** Features * **Indication:** obstruction or perforation secondary to sigmoid tymour or diverticulitis * **Description:** * *****emergency procedure* * *sigmoid colectomy* * *proximal bowel exteriorised as an end colostomy* * *distal bowel oversewn to form a rectal stump* * *MAY be reversed after 3-6mo (\>50% of pts **ARE NOT reversed)*** * **Scars:** * ****midline laparotomy * may have previous stoma acr in LIF if it has been reversed * **Stoma:** single lumen colostomy in LIF * **Differential:** APR!

Answer 62

**Abdomino-perineal resection (APR)** Features * **Indication:** rectal Ca \<4-5cm from anal verge * **Description:** * ****sigmoid rectum and mesorectal nodes removed via abdominal incision * anus removed via perineal incision * **Scars:** * ****midline laparotomy * no anus * **Stoma:** single lumen colostomy in LIF * **Differential:** Hartmann's procedure; *look for patent anus*

Answer 63

**Anterior resection** Features * **Indication:** rectal Ca \>4-5cm from anal verge * **Description:** * ****excision of part of the rectum and sigmoid colon * may be high or low depending on site of tumour * + total mesorectal excision for tumours in the middle or lower 1/3 * rectal blood supply is poor!!: * THEREFORE **colorectal anastomosis** is convered by **_temporary_ loop** _ileostomy_ * **Scars:** * ****midline laparotomy * laparoscopic port scars * stoma OR SCAR in **RIF** * **Stoma:** double lumen loop ileostomy in RIF * **Differential:** * *****End ileostomy:* * **panproctocolectomy: UC, FAP * subtotal colectomy: acute severe UC * cystectomy + ileal conduit * *loop ileostomy:* * **Temporary diversion: * crohn's * anterior resection; alows healing of colorectal anastomosis

Answer 64

**Subtotal colectomy** Features * **Indication:** acute severe UC * **Description:** * ****all colon excised except distal sigmoid and rectum * **_temporary_** end ileostomy * Rectosigmoid stump *may* be exteriorised as mucus fisula * followed after 3mo by either: * completion protectomy + IPAA (ileal pouch anal anastomosis) or permenent end ileostomy * ileorectal anastomosis (IRA) * **Scars:** * ****midline laparotomy * laparoscopic port sites * **Stoma:** single lumen end ileostomy in RIF * **Differential:** * ****end ileostomy: * panprotocolectomy: UC, FAP * subtotal colectomy: acute severe UC * cystectomy and ileal conduit * Loop ileostomy * temporary diversion: anterior resection or crohn's

Answer 65

**Panproctocolectomy** Features * **Indication:** Uc or FAP * **Description:** * ****all colon, rectum and anus removed * permenant end ileostomy * **Scars:** * ****midline laparotomy * laparoscopic port sites * **Stoma:** single lumen end ileostomy in RIF * **Differential:** * end ileostomy: * panprotocolectomy: UC, FAP * subtotal colectomy: acute severe UC * cystectomy and ileal conduit * Loop ileostomy * temporary diversion: anterior resection or crohn's

Answer 66

* Inspection: * Peripheral * Gen: * Malnutrition/wt loss * cushingoid (steroid yse) * Hands: * clubbing * leukonychia * Beau's lines * eyes: * pale conjunctivae * iritis, episcleritis * Mouth: * aphthous ulcers * gingibal hypertrophy * legs: * erythema nodosmun * pyoderma gangrenosum * Abdomen: * Scars: * mutple and ?atypical =crohn;s * healed stoma site * Healed drain sites * Stomas (*or healed stoma sites*) * Enerocutaneous fistulae * Palpation: * Tenderness * RIF mass! * +/- hepatomegaly * completion: * inepect perineum for perianal disease * examine for extra-intestinal features * large joint monoarthritis * sacroileitis * bronchiectasis

Answer 67

* Symptoms * Wt. loss, fever, malaise * Abdominal pain * Diarrhoea, blood and/or mucus PR * Peri-anal disease: abscesses, fistulae * Extra-intestinal: EN, arthritis, iritis, gallstones, PSC * Therapy * Admissions * Medical therapy * Operations

Answer 68

Bloods * FBC: ↓Hb, ↑WCC * U+E: dehydration, ↓K * LFTs: ↓ albumin, deranged LFTs * Clotting: ↑INR * ↑ ESR, ↑ CRP: used to monitor activity Stool * Culture + CDToxin: exclude infective causes * Campy, Yersinia, Shigella, C. diff, TB * Faecal calprotectin Imaging * AXR * Toxic megacolon in UC * Bowel obstruction 2O to strictures in Crohn’s * Contrast studies * Ba or Gastrograffin enema in UC * Small bowel follow–through in Crohn’s * MRI: perianal disease in Crohn’s Endoscopy * Ileocolonoscopy + regional biopsy * Ix of choice * Safe in acute disease * Distinguish UC from Crohn’s * Assess disease severity * Wireless capsule endoscopy

Answer 69

**Truelove and Witts Criteria** * Symptoms * BMs \>6 x /d * Large PR bleed * Systemic Signs * ↑ HR \>90 * Pyrexia \>37.8 * Laboratory Values * ↓ Hb \<10.5g/dL * ESR \>30mm/Hr

Answer 70

**Acute Severe** * Megacolon: ≥6cm on AXR * Perforation: 30-40% mortality * Severe GI bleeding **Chronic** * Medical Mx failure * Malignancy * Maturation failure in children

Answer 71

**Acute Severe** * Obstruction 2O to stenosis * Perforation * Severe GI bleeding **Chronic** * Peri-anal disease: fistulae and abscesses * Intra-abdominal abscesses * Medical Mx failure: ***temporary*** defunction * Entero-cutaneous fistulae

Answer 72

Hepatobiliary * Fatty liver * Chronic hepatitis → cirrhosis * Gallstones * PSC (3% of **UC**) and cholangiocarcinoma

Answer 73

**Principles** * Curative intent * IPAA or IRA offer continence but suffer from ↑ **BMs**, **pouchitis** and risk of **malignancy**. **Subtotal colectomy c¯ end ileostomy ± mucus fistula** * Operation of choice for acute severe colitis * All colon excised except distal sigmoid and rectum. * Rectosigmoid stump may be exteriorised as mucus fistula * Followed after ~3mo by either: * Completion proctectomy + IPAA or end ileostomy * Ileorectal anastomosis (IRA) **Proctocolectomy and permanent ileostomy** * Rectum and anus excised c¯ all of colon * Only performed for pt. choice or when pt. is not suitable for restorative procedure * ↑ age * Impaired sphincter function **Restorative Proctocolectomy** * Proctocolectomy or completion proctectomy * Construction of ileal reservoir which is anastomosed to anus * Ileal pouch anal anastomosis (IPAA) * Usually covered by a diverting loop ileostomy * May check pouch anastomosis c¯ water soluble contrast

Answer 74

**Principles** * 80% need ≥1 operation in their life * Never curative * Must be as conservative as possible: avoid short gut syndrome **Procedures** 1. Ileocaecectomy 2. Drainage of intra-abdominal abscesses 3. Stricturoplasty 4. Colonic defunctioning for failed medical therapy 5. Occasionally a subtotal colectomy + permanent end ileostomy may be needed.

Answer 75

* Inspection: * Peripheral: * Cachexia * signs of CLD * look in sclera and at **frenulum (of tongue):** jaundice * Palpate for virchow's node * Abdo: * ascites * dilated abdo veins * umbilical/para-umbilical hernia * Palpation: * hepatomegaly * splenomegaly * palpable gallbladder * Completion: * check temp: obstruction complicated by infection * dipstick urine: bilirubin, urobilinogen, hb

Answer 76

**Post-hepatic**: * Dark urine, pale stools * Itching * Stones: RUQ pain or biliary colic * Malignancy * Wt. ↓ and ↓ appetite * Change in bowel habit: esp. steatorrhoea * Back pain Hepatic * EtOH intake * Foreign travel: Hep A * Blood transfusions, IVDU, Sex: Hep B and C * Sore throat: EBV * Drug Hx: OCP, Abx, neuroleptics, OTCs Pre-hepatic * Anaemia: tired, SOB, palpitations, ankle swelling * FH

Answer 77

*Yellow discoloration of the skin and mucus membranes caused by the accumulation of bile pigments.* * Normal BR = 3-17uM * Visible jaundice = **50uM** (**3** x ULN) * Very high levels usually have a hepatic cause

Answer 78

* *Urine:** ↑↑BR, no ***urobilinogen*** * *Bloods** * LFTs: ↑cBR ↑↑↑ALP, ↑AST/ALT, ↑GGT * Clotting: ↑ INR * Auto-Abs: AMA, pANCA, ANA Imaging * US * Underlying hepatic disease * Dilated ducts: \>6mm * Gallstones * Pancreatic mass or lymphadenopathy * MRCP * ERCP * CT: staging tumour

Answer 79

* *Pre-hepatic**: haemolysis after a transfusion * *Hepatic** * Halogenated anaesthetics * Sepsis * Intra- / post-operative hypotension **Post-hepatic:** Biliary injury: e.g. in Lap Chole

Answer 80

* Inspection * Peripheral * Hands and Arms * Clubbing * AV fistula * Eyes * Pallor * Jaundice * Neck * LNs: e.g. Virchow’s node Abdominal * Asymmetry * Scars: esp. Rutherford Morrison Palpation; *Differentiate mass before continuing c¯ rest of exam* * Site, size, shape * Consistency: firm, soft * Edge: well or poorly defined * Surface: smooth, irregular, nodular * Relations * Can you get above and below it? * Does it move c¯ respiration? * Attachment to skin * Attachment to abdominal muscles * Ask pt. to lift head while palpating * Cough impulse * Inguinal nodes Percussion * Resonant: e.g. bowel or retroperitoneal * Dull Auscultation * Bruits * Bowel sounds

Answer 81

* Duration of mass and how it has changed * Abdominal symptoms * Gynae symptoms * Systemic symptoms * Co-morbidities and previous operations

Answer 82

**Commonest** * Transplanted kidney * Caecal Ca * Crohn’s or Appendix mass or abscess * Incisional hernia (mass c¯ scar) **Skin and Soft Tissues** * Sebaceous cyst * Lipoma * Sarcoma **Gynaecological** * Ovarian tumour * Fibroid uterus **Male Reproductive System** * Undescended or ectopic testis ± tumour **Urological System** * Ectopic kidney * Bladder diverticulum **Blood Vessels** * External iliac or common iliac artery aneurysm * LNs

Answer 83

**US** * 1st line * Distinguish bowel mass from pelvic mass * ID any LNs and abnormal blood vessels **CT** * Best to view abdominal wall masses * Good to assess extent of intra-abdominal malignancy **MRI**:Good for pelvic masses **Other Ix** * Bloods: FBC, U+E, LFT * Mantoux * CXR, AXR * US / CT guided biopsy