The Abdomen Flashcards
An 8 year-old boy of Caribbean descent presents with periumbilical abdominal pain. He has vomited twice and is refusing fluids. His temperature is 38.1oC and blood tests are as follows: Haemoglobin 8 g/dl, WCC 13 x 109/l, with a neutrophilia. What is the most likely diagnosis?
Pancreatitis Sickle cell crisis Appendicitis Intussusception Spontaneous bacterial peritonitis
Anaemia is seldom seen in appendicitis and if present should prompt a search for an alternative underlying diagnosis.
Sickle cell anaemia is characterised by severe chronic haemolytic anaemia resulting from poorly formed erythrocytes. Painful crises result from vaso-occlusive episodes, which may occur spontaneously or may be precipitated by infection. Consider this diagnosis in all children of appropriate ethnic background.
With which of the conditions listed below is Boas’ sign classically associated?
Perforation of the thoracic oesophagus Acute cholecystitis Hepatocellular carcinoma Closed loop small bowel obstruction Acute diverticulitis
Boas’ sign refers to hyperaesthesia of the tip of the right scapula and is seen classically in association with acute cholecystitis.
What type of stoma is most likely to be encountered in a 56 year old man undergoing a low anterior resection for carcinoma of the rectum with a colorectal anastomosis?
Loop colostomy End colostomy End ileostomy Loop ileostomy Caecostomy
Loop ileostomy
Colonic resections with an anastomosis below the peritoneal reflection may have an anastomotic leak rate (both clinical and radiological) of up to 15%. Therefore most surgeons will defunction such an anastomosis to reduce the clinical severity of an anastomotic leak. A loop ileostomy will achieve this end point and is relatively easy to reverse. Loop colostomy is less popular in this setting as reversal can compromise the blood supply to the anastomosis.
A 23 year old lady is persistently vomiting following a laparoscopic appendicectomy for a perforated gangrenous appendicitis. Imaging shows some dilated small bowel loops. What is the most appropriate course of action?
Insertion of wide bore nasogastric tube Insertion of narrow bore nasogastric tube Administration of intravenous cyclizine Administration of metoclopramide Arrange a laparotomy
This patient is likely to have a paralytic ileus and the administration of anti emetic drugs in this situation achieves very little. It’s important to decompress the stomach and this can be achieved with a wide bore nasogastric tube.
A 78 year old lady is admitted with small bowel obstruction. On examination, she has a distended abdomen and the leg is held semi flexed. She has some groin pain radiating to the ipsilateral knee. What is the most likely diagnosis
Inguinal hernia Obturator hernia Lumbar hernia Spigelian hernia Incisional hernia
The groin swelling in obturator hernia is subtle and hard to elicit clinically. There may be pain in the region of sensory distribution of the obturator nerve. The defect is usually repaired from within the abdomen
A 25 year-old lady presents to her GP complaining of a two day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain and dyspareunia. What is the most likely cause?
Appendicitis Adnexial torsion Endometriosis Pelvic inflammatory disease Ruptured ectopic pregnancy
The most likely diagnosis is pelvic inflammatory disease. Right upper quadrant pain occurs as part of the Fitz Hugh Curtis syndrome in which peri hepatic inflammation occurs.
A 34 year old man undergoes a sub total colectomy to treat fulminant ulcerative colitis. What type of stoma is most likely to be fashioned?
End colostomy Loop colostomy End ileostomy Loop ileostomy End jejunostomy
A sub total colectomy involves the removal of the entire right, transverse, left and part of the sigmoid colon. The rectal stump is closed and an end ileostomy fashioned in the right iliac fossa.
A 45 year old man develops a colocutaneous fistula following reversal of a loop colostomy fashioned for the defunctioning of an anterior resection. Pre-operative gastrograffin enema showed no distal obstruction or anastomotic stricture. What is the best course of action?
Make the patient nil by mouth and commence total parenteral nutrition Provide local wound care and await spontaneous resolution Undertake a laparotomy and resect the fistula Construct a loop ileostomy Re-construct the loop colostomy
Provide local wound care and await spontaneous resolution
Colocutaneous fistulae may occur as a result of anastomotic leakage following loop colostomy reversal. In the absence of abdominal signs a laparotomy is not necessarily required. Signs of wound sepsis may require antibiotics. Because there is not any distal obstruction (note normal pre-operative gastrograffin enema) these fistulae will usually close spontaneously.
A 73 year old lady presents with peritonitis and tenderness of the left groin. At operation, she has a left femoral hernia with perforation of the anti mesenteric border of ileum associated with the hernia. What type of hernia is this?
Richters hernia Littres hernia Morgagni hernia Spigelian hernia Bochdalek hernia
When part of the bowel wall is trapped in a hernia such as this it is termed a Richters hernia and may complicate any hernia although femoral and obturator hernias are most typically implicated.
In which of the conditions described below is Rovsing’s sign most likely to be absent?
Locally advanced caecal cancer Para ileal appendicitis Right sided colonic diverticulitis Retrocaecal appendicitis Severe terminal ileal Crohns disease
Any advanced right iliac fossa pathology can result in a positive Rovsings sign. However, in retrocaecal appendicitis, it may be absent and this fact can contribute to a delayed diagnosis if undue weight is placed on the presence of the sign in making the diagnosis.
An 8 year old boy presents with a 4 hour history of right iliac fossa pain with nausea and vomiting. He has been back at school for two days after being kept home with a flu like illness. On examination, he is tender in the right iliac fossa, although his abdomen is soft. Temperature is 39.3oC. Blood tests show a CRP of 40 and a WCC of 8.1. What is the most appropriate course of action?
Abdominal MRI scan Abdominal CT scan Diagnostic laparoscopy Active observation Colonoscopy
The key point in the history is the preceding flu like illness and absence of abdominal signs. These make mesenteric adenitis the most likely diagnosis. The patient should have a period of active observation
A 6 day old child is suspected of having a malrotation and requires urgent abdominal exploration. What is the most appropriate surgical approach?
Midline abdominal incision Paramedian incision Transverse supra umbilical abdominal incision Transverse infra umbilical abdominal incision Battle incision
In young children, laparotomy is performed via transverse supra umbilical incision. Access via midline incisions is very poor and they should not be used.
A 4 year old girl is admitted with lethargy and abdominal pain. On examination, she is febrile, temperature 38.1oC, pulse rate is 150 and blood pressure is 100/60. Her abdomen is soft but there is some right sided peritonism. Her WCC is 14 and urinanalysis is positive for leucocytes but is otherwise normal. What is the best course of action?
Manage as urinary tract infection with oral antibiotics Manage as urinary tract infection with intravenous antibiotics Take to theatre for appendicectomy within 6 hours Undertake ultrasound scan Admit for serial clinical examination
Take to theatre for appendicectomy within 6 hours
Children with appendicitis do not localize in the same way as adults and often the diagnosis is difficult and all too often made late. The findings of right sided peritonism are ominous and the low grade fever and tachycardia and WCC are strongly suggestive of appendicitis. The findings of an isolated leukocytosis are suggestive of appendicitis over UTI. The diagnosis of appendicitis is clinical and undertaking imaging is not going to change management which should comprise appendicectomy, this should be undertaken promptly.
A 14 year old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative. What is the most likely underlying diagnosis?
Mittelschmerz Endometriosis Appendicitis Crohns disease Pelvic abscess
The timing of the pain and the fact that it is mid cycle makes Mittelschmerz the most likely cause.
A 12 month old child is brought to the clinic with a history of a right groin swelling. The parents have a photograph on their mobile phone which looks very much like an inguinal hernia. What is the best course of action?
Arrange an MRI scan Undertake an open inguinal hernia repair with mesh Undertake an open inguinal herniotomy Undertake a laparoscopic hernia repair with mesh Arrange a herniogram
Undertake an open inguinal herniotomy
Where the history is strongly suggestive and the parents have a clear image or even description, most surgeons would proceed without confirmatory imaging. Herniograms and MRI would require a GA in a child of this age and are not routine. Herniotomy is the usual procedure and no mesh is used.
A 1 day old infant is born with severe respiratory compromise. On examination, he has a scaphoid abdomen and an absent apex beat. Which of the following anomalies is most likely?
Situs inversus Morgagni hernia Necrotising enterocolitis Bochdalek hernia Cystic fibrosis
Bochdalek hernia
A hernia is the most likely diagnosis given the abdominal findings. The large hernia may displace the heart although true dextrocardia is not present. The associated pulmonary hypoplasia will compromise lung development.
A 75 year old lady is admitted with a 12 hour history of absolute constipation, vomiting and colicky abdominal pain. On examination, her abdomen is distended and she has right sided tenderness. Imaging demonstrates an obstructing hepatic flexure tumour with a caecal diameter of 11cm. What is the best course of action?
Undertake an immediate laparotomy Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later Administer antibiotics and intravenous fluids and schedule surgery for the following day Arrange a colonoscopy Administer oral sodium picosulphate
Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later
The sun should not rise and set on unrelieved large bowel obstruction! This patient has a competent ileocaecal valve. As a result lack of surgery would result in caecal perforation leading to faecal peritonitis with and associated high mortality rate.
An 11 month-old girl develops sudden onset abdominal pain. She has a high pitched scream and draws up her legs. Her BP is 90/40 mm/Hg, her pulse 118/min and abdominal examination is normal. What is the most likely diagnosis?
Mid gut volvulus Intussusception Appendicitis Mesenteric adenitis Spontaneous bacterial peritonitis
Intussusception should be considered in toddlers and infants presenting with screaming attacks
Which abdominal sign is described as being present when a patient with cholecystitis experiences pain on palpation of the right upper quadrant most marked on inspiration?
Murphy's sign Boas' sign Rovsing's sign Cullens sign Grey Turners sign
Murphy’s sign
Of the surgical incisions listed below, which is most suitable for a 45 year old female undergoing a first time renal transplant?
Abdominal midline Paramedian Battle Rutherford Morrison Pfannenstiel
A Rutherford Morrison incision is the traditional approach for a renal transplant and provides extra peritoneal access to the iliac vessels.
A 16 year old female presents to the emergency department with a 12 hour history of pelvic discomfort. She is otherwise well and her last normal menstrual period was 2 weeks ago. On examination, she has a soft abdomen with some mild supra pubic discomfort. What is the most likely underlying cause?
Ruptured ectopic pregnancy Degenerating fibroid Pelvic inflammatory disease Appendicitis Mittelschmerz
Mid cycle pain is very common and is due to the small amount of fluid released during ovulation. Inflammatory markers are usually normal and the pain typically subsides over the next 24-48 hours.
An 8 year old boy is examined by his doctor as part of a routine clinical examination. The doctor notices a smooth swelling in the right iliac fossa. It is mobile and he is otherwise well. What is the most likely underlying cause?
Meckels diverticulum Spigelian hernia Mesenteric cyst Appendix mass Liposarcoma
Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although rare, they most often occur in young children (up to 30% present before the age of 15). Many are asymptomatic and discovered incidentally
An 84 year old lady presents with a tender painful lump in the right groin and signs of small bowel obstruction. What is the most appropriate surgical incision to address this problem?
Lothessien McEvedy Midline abdominal Paramedian Kochers
A McEvedy incision is traditionally used to approach incarcerated femoral hernias. The disadvantage of the Lothessien approach is that it weakens the inguinal canal and predisposes to inguinal hernia formation. The other incisions would not usually address femoral hernias. Given the features of bowel obstruction, a low approach would be inappropriate.
A 19 year old lady is admitted with lower abdominal pain. On examination, she is diffusely tender. A laparoscopy is performed and at operation multiple fine adhesions are noted between the liver and abdominal wall. Her appendix is normal. What is the most likely diagnosis?
Mesenteric infarct Fitz Hugh Curtis Syndrome Perforated peptic ulcer Appendicitis Pancreatitis
This is Fitz Hugh Curtis syndrome in which pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions.
A 21 year old woman is admitted with a 48 hour history of worsening right iliac fossa pain. She has been nauseated and vomited twice. On examination, she is markedly tender in the right iliac fossa with localised guarding. Vaginal examination is unremarkable. Urine dipstick (including beta HCG) is negative. Blood tests show a WCC of 13.5 and CRP 70. What is the most appropriate course of action?
Open appendicectomy Laparotomy Abdominal ultrasound Laparoscopic appendicectomy Abdominal CT scan
Laparoscopic appendicectomy
The most likely diagnosis is appendicitis. The negative vaginal examination (and therefore by definition the absence of cervical excitation) makes pelvic inflammatory disease unlikely. Given the raised inflammatory markers, the correct course of action is to proceed with surgery. In females, there are considerable advantages of undertaking this laparoscopically as it allows evaluation of the pelvic viscera
Which of the following signs is seen in patients who have a significant retroperitoneal haemorrhage?
Boas' sign Pembertons sign Grey Turners sign Cullens sign Rovsing's sign
Bruising of the flank is described as Grey Turners sign
What type of stoma should be considered in a patient undergoing emergency operative intervention for large bowel obstruction as a result of a carcinoma 5cm from the anal verge?
End colostomy Loop colostomy End ileostomy Loop jejunostomy Loop ileostomy
Loop colostomy
Don’t confuse loop ileostomy and loop colostomy. A loop colostomy is the only safe option for an obstructing rectal cancer. Loop ileostomy in the context of rectal cancer is performed to mitigate the effects of anastomotic leak following a low anterior resection.
A 43 year old man has suffered from small bowel Crohns disease for 15 years. Following a recent stricturoplasty he develops an enterocutaneous fistula which is high output. Small bowel follow through shows it to be 15 cm from the DJ flexure. His overlying skin is becoming excoriated. What is the best course of action?
Undertake a further laparotomy and construct a proximal diverting stoma Commence high dose steroids Commence TPN and octreotide Undertake a laparotomy and resect the affected segment Perform a small bowel bypass procedure
Commence TPN and octreotide
This man has a high output and anatomically high fistula. Drying up the fistula with octreotide will not suffice, his nutrition is compromised and TPN will help.
Which of the following strategies is not employed in the management of bleeding oesophageal varices?
Endoscopic sclerotherapy Intravenous vasopressin Intravenous beta blockers Endoscopic rubber band ligation of varices Insertion of Sengstaken Blakemore tube
Intravenous beta blockers are not typically used to manage an acute event, their value lies in prophylaxis by lowering portal venous pressure.
A 22 year old man is operated on for a left inguinal hernia, at operation the sac is opened to reveal a large Meckels diverticulum. What type of hernia is this?
Richters hernia Morgagni hernia Littres hernia Spigelian hernia Bochdalek hernia
Littres hernia
Hernia containing Meckels diverticulum is termed a Littres hernia.
Which of the following agents increases the rate of emptying of the vagotomised stomach?
Metoclopramide Ondansetron Cyclizine Erythromycin Ciprofloxacin
Erythromycin increases the rate of gastric emptying and decreases GI transit times in general. This accounts for its side effect profile (diarrhea). It can be a useful agent in diabetic gastropathy.
A 25 year old builder presents with a reducible swelling in the right groin, it is becoming larger and has not been operated on previously. What is the best course of action?
Open inguinal herniotomy Laparoscopic inguinal herniotomy Open Bassini repair Laparoscopic Bassini repair Open Lichtenstein repair
The hernia can be repaired by either open or laparoscopic techniques. However, herniotomy is not performed as an isolated procedure in adults. The Bassini darn repair has a high recurrence rate. An open Lichtenstein repair using mesh is appropriate. There is a 0.77% recurrence rate with this technique. A Shouldice repair is an acceptable alternative if the surgeon is experienced
A 78 year old lady presents with colicky abdominal pain and a tender mass in her groin. On examination; there is a small firm mass below and lateral to the pubic tubercle. Which of the following is the most likely underlying diagnosis?
Incarcerated inguinal hernia Thrombophlebitis of a saphena varix Incarcerated femoral hernia Incarcerated obturator hernia Deep vein thrombosis
Femoral herniae account for <10% of all groin hernias. In the scenario the combination of symptoms of intestinal compromise with a mass in the region of the femoral canal points to femoral hernia as the most likely cause.
Which of the following is not a typical feature of acute appendicitis?
Neutrophilia Profuse vomiting Anorexia Low grade pyrexia Small amounts of protein on urine analysis
Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis or an ileus
A 75 year old man is admitted with sudden onset severe generalised abdominal pain, vomiting and a single episode of bloody diarrhoea. On examination, he looks unwell and is in uncontrolled atrial fibrillation. Although diffusely tender his abdomen is soft. What is the most likely diagnosis?
Pancreatitis Infective diarrhoea Ischaemic colitis Crohns disease Mesenteric infarction
Mesenteric infarction
Pain out of proportion to physical signs, AF and generalized abdominal pain suggest widespread infarction.
An 28 year old man presents with a direct inguinal hernia. A decision is made to perform an open inguinal hernia repair. Which of the following is the best option for abdominal wall reconstruction in this case?
Suture plication of the transversalis fascia using PDS only Suture plication of the hernial defect with nylon and placement of prolene mesh anterior to external oblique Suture plication of the hernia defect using nylon and re-enforcing with a sutured repair of the abdominal wall Sutured repair of the hernial defect with prolene and placement of prolene mesh over the cord structures in the inguinal canal Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures
Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures
During an inguinal hernia repair in males the cord structures will always lie anterior to the mesh
A 17 year old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal. What is the most likely cause?
Appendicitis Crohns disease Peptic ulcer disease Meckels diverticulum Irritable bowel syndrome
This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration. The iron deficiency anaemia makes a Meckels more likely than IBD.
Which of the following is not a typical feature of irritable bowel syndrome?
A change in the consistency of stools Abdominal pain relieved with defecation A change in frequency of defecation Abdominal bloating Pain at a single fixed site
Pain at a single fixed site
The pain or discomfort of IBS is typically migratory and variable in intensity. Pain at a fixed site is suggestive of malignancy.
Abdominal bloating is an extremely common feature.
A 2 month old infant is troubled by recurrent colicky abdominal pain and intermittent intestinal obstruction. On imaging, the transverse colon is herniated into the thoracic cavity, through a mid line defect. What is the most likely defect?
Bochdalek hernia Morgagni hernia Littres hernia Paraoesophageal hernia Hiatus hernia
Morgagni hernia may contain the transverse colon. Unless there is substantial herniation, pulmonary hypoplasia is uncommon. As a result, major respiratory compromise is often absent. Para oesophageal and hiatus hernias are very rare in children.
A 56 year old lady is admitted with colicky abdominal pain. A plain x-ray is performed. Which of the following should not show fluid levels on a plain abdominal film?
Stomach Jejunum Ileum Caecum Descending colon
Fluid levels in the distal colon are nearly always pathologica
A 53 year old man undergoes a reversal of a loop colostomy. He recovers well and is discharged home. He is readmitted 10 days later with symptoms of vomiting and colicky abdominal pain. On examination, he has a swelling of the loop colostomy site and it is tender. What is the most likely underlying diagnosis?
Haematoma Intra abdominal adhesions Anastomotic leak Anastomotic stricture Obstructed incisional hernia
In this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis
A 21 year old women presents with right iliac fossa pain. She reports some bloodstained vaginal discharge. On examination, she is afebrile and has a pulse rate of 97 bpm, normal blood pressure. She has diffuse lower abdominal tenderness. What is the most appropriate course of action?
Laparotomy Laparoscopy Abdominal and pelvic MRI scan Abdominal and pelvic CT scan Abdominal and pelvic USS
Abdominal and pelvic USS
The history of blood stained discharge and tenderness makes an ectopic pregnancy a strong possibility, a USS should be performed and a pregnancy test undertaken. If the beta HCG is high then an intra uterine pregnancy should be found. If it is not, then an ectopic pregnancy is likely and surgery should be considered.
A 56 year old lady presents with a large bowel obstruction and abdominal distension. Which of the following confirmatory tests should be performed prior to surgery?
Abdominal ultrasound scan Barium enema Rectal MRI Scan Endoanal ultrasound scan Gastrograffin enema
Gastrograffin enema
Patients with clinical evidence of large bowel obstruction, should have the presence or absence of an obstructing lesion confirmed prior to surgery. This is because colonic pseudo-obstruction may produce a similar radiological picture. A gastrograffin enema is the traditional test, as barium is too toxic if it spills into the abdominal cavity
A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination, he has some right iliac fossa tenderness and is febrile. What is the most likely cause?
Appendicitis Irritable bowel syndrome Inflammatory bowel disease Infective gastroenteritis Meckels diverticulum
The history of weight loss and intermittent diarrhea makes inflammatory bowel disease the most likely diagnosis.
A 78 year old man is walking to the bus stop when he suddenly develops severe back pain and collapses. On examination he has a blood pressure of 90/40 and pulse rate of 110. His abdomen is distended and he is obese. Though tender his abdomen itself is soft. What is the most likely diagnosis?
Ruptured abdominal aortic aneurysm Perforated peptic ulcer Appendicitis Mesenteric infarction Perforated diverticulitis
Ruptured abdominal aortic aneurysm
This will be a retroperitoneal rupture (anterior ones generally don’t survive to hospital).
A 28 year old man presents with a recurrent inguinal hernia on the left side of his abdomen and a newly diagnosed inguinal hernia on the right side. What is the best course of action?
Bilateral open Litchenstein repair Bilateral open inguinal herniotomy Bilateral laparoscopic inguinal herniotomy Bilateral laparoscopic TEP repair Bilateral open Shouldice repair
Bilateral laparoscopic TEP repair
Laparoscopic hernia repairs are specifically indicated where there are bilateral hernias or recurrence of a previous open repair.
Which of these factors does not increase the risk of abdominal wound dehiscence following laparotomy?
Jaundice Abdominal compartment syndrome Poorly controlled diabetes mellitus Administration of intravenous steroids Use of Ketamine as an anaesthetic agent
Ketamine does not affect healing. All the other situations in the list carry a strong association with poor healing and risk of dehisence
A 6 year old child presents with colicky abdominal pain, vomiting and the passage of red current jelly stool per rectum. On examination, the child has a tender abdomen and a palpable mass in the right upper quadrant. Imaging shows an intussusception. Which of the conditions below is least recognised as a precipitant?
Inflammation of Peyers patches Cystic fibrosis Meckels diverticulum Mesenteric cyst Mucosal polyps
Mesenteric cyst
Mesenteric cysts may be associated with intra abdominal catastrophes where these occur they are typically either intestinal volvulus or intestinal infarction. They seldom cause intussusception
Which one of the following is least likely to cause malabsorption?
Primary biliary cirrhosis Ileo-colic bypass Chronic pancreatitis Whipples disease Hartmans procedure
In a Hartmans procedure the sigmoid colon is removed and an end colostomy is fashioned. The bowel remains in continuity and no absorptive ability is lost.
A 63 year old man presents with a 48 hour history of right iliac fossa pain. On examination he has a low grade pyrexia and is tender with some voluntary guarding in the right iliac fossa. Some of his blood tests are reproduced below: Hb 81 WCC 13.8 Platelets 438 Albumin 22 CRP 24 What is the best course of action?
Undertake a laparotomy and right hemicolectomy Undertake a laparoscopic appendicectomy Arrange a CT scan Undertake an open appendicectomy Arrange a colonoscopy
Arrange a CT scan
This man’s investigations point to a more longstanding disease process (Hb and albumin), right sided colonic cancer being the most likely. For this reason a CT scan is a sensible option as it will adjust the surgical planning.
A 33 year old lady presented with jaundice secondary to common bile duct stones. A cholecystectomy and common bile duct exploration is performed and the bile duct closed over a T tube. Six weeks post operatively a T tube cholangiogram is performed and shows no residual stones. The T tube is removed and five hours after removal a small amount of bile is noted to be draining from the T tube site. What is the best course of action?
Await spontaneous resolution Arrange an MRCP Arrange an ERCP Return to theatre for CBD exploration Re-insert the T tube
Await spontaneous resolution
When the bile duct is closed over a T Tube the latex in the T tube encourages tract fibrosis. This actually encourages a fistula to develop. The result is that when the tube is removed any bile which leaks will usually drain through the tract. Provided that there are no residual stones in the duct the fistula will slowly close. Persistent high volume drainage may be managed with ERCP and sphincterotomy.
Which of the following anti emetic drugs targets the chemoreceptor trigger zone of the area postrema?
Metoclopramide Ondansetron Cisapride Cyclizine Domperidone
Ondansetron
5 HT3 blockers are most effective for many types of nausea for this reason.
A 10 year old girl has right iliac fossa pain and an appendicectomy is to be performed. What is the best incision for this procedure?
Paramedian Midline abdominal Kochers Lanz Gridiron
Lanz
Both Lanz and Gridiron incisions can be used to perform an open appendicectomy. However, a Lanz incision provides for a superior cosmetic scar and is more easily extended than a Gridiron incision.
A 21 year old man is admitted with a tender mass in the right groin, fevers and sweats. He is on multiple medical therapy for HIV infection. On examination, he has a swelling in his right groin, hip extension exacerbates the pain. What is the most likely cause?
Septic arthritis Psoas abscess Infected lymph node HIV related lymphadenopathy Femoral hernia
Psoas abscesses may be either primary or secondary. Primary cases often occur in the immunosuppressed and may occur as a result of haematogenous spread.
Which of the following interventions is most likely to reduce the incidence of intra abdominal adhesions?
Peritoneal lavage with cetrimide following elective right hemicolectomy Use of a laparoscopic approach over open surgery Use of talc to coat surgical gloves Performing a Nobles plication of the small bowel Using stapled rather than a hand sewn anastamosis
Laparoscopy results in fewer adhesions. When talc was used to coat surgical gloves it was a major cause of adhesion formation and withdrawn for that reason. A Nobles plication is an old fashioned operation which has no place in the prevention of adhesion formation. Use of an anastamotic stapling device will not influence the development of adhesions per se although clearly an anastamotic leak will result in more adhesion formation
In which of the following scenarios is a mucous fistula most likely to be encountered?
Following an elective right hemicolectomy and ileo-colic anastomosis Following an Ivor Lewis oesophagectomy Following an emergency sub total colectomy for severe colitis Following an abdomino perineal excision of the colon and rectum for rectal cancer Following a small bowel resection and primary anastomosis for incarcerated femoral hernia
Following an emergency sub total colectomy for severe colitis
A mucous fistula is a conduit between the skin and a redundant segment of bowel. They are typically constructed because the section of bowel that is exteriorized is at very high risk of breakdown. They are not the same as an end stoma, by definition they are usually seen in patients who have an end stoma. They are typically seen following a sub total colectomy where the distal sigmoid colon is deemed too friable to close and it then brought onto the skin as a mucous fistula.
A 24 year old man presents with a 10 day history of right sided abdominal pain. Prior to this he was well. On examination, he has a low grade fever and a mass palpable in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix. What is the best course of action?
Arrange a laparotomy and right hemicolectomy Perform a laparoscopic appendicectomy Perform an open appendicectomy Manage conservatively with antibiotics Arrange a colonoscopy
Manage conservatively with antibiotics
This man is likely to have an appendix mass. There is no history suggestive of inflammatory bowel disease. These are usually managed without surgery, especially in the absence of peritoneal signs. Broad spectrum antibiotics are required. In the past an interval appendicectomy was performed. This is rare now and in most cases the process resolves with fibrosis of the appendix.
A 15-month-old girl presents with a three day history of periorbital oedema. She is brought to hospital. On examination she has facial oedema and a tender distended abdomen. Her temperature is 39oC and her blood pressure is 90/45 mmHg. There is clinical evidence of poor peripheral perfusion. What is the most likely diagnosis?
Sickle cell crisis Intussusception Spontaneous bacterial peritonitis Henoch Schonlein purpura Appendicitis
Spontaneous bacterial peritonitis
The 15-month-old girl is a patient with nephrotic syndrome. Patients with this condition are at risk of septicaemia and peritonitis from Streptococcus pneumonia, due to the loss of immunoglobulins and opsonins in the urine.
Which of the following statements relating to a burst abdomen is false?
Is seen in 1-2% of modern laparotomies Is more common in faecal peritonitis Is less common when a 'mass closure' technique is used When it does occur is most common at 15 days Is similar in incidence regardless of whether 1/0 polydiaxone or 1/0 polypropylene are used
When it does occur is most common at 15 days
When it does occur, a burst abdomen is most common at 6 days and is usually the result of technical error when Jenkins rule is not followed and sutures are placed in the zone of collagenolysis. The choice of materials given above does not influence dehisence rates.
A 67 year old man is due to undergo a Whipples procedure to resect a pancreatic adenocarcinoma. What is the most appropriate surgical incision to address this?
Rooftop Kochers Paramedian Battle Thoracoabdominal
A rooftop incision is typically used to access the pancreas for resectional surgery.
A 35 year old woman who is a heavy smoker has long standing stool frequency and crampy abdominal pain. A colonoscopy is performed (which is macroscopically normal) and pan colonic biopsies are taken. Histological analysis of the biopsies demonstrates a thickened sub apical collagen layer together with an increase in lymphocytes in the lamina propria. What is the most likely diagnosis?
Microscopic colitis Crohns disease Ulcerative colitis Pseudomembranous colitis Irritable bowel syndrome
Microscopic colitis is a common condition characterised by normal endoscopic appearances, microscopic features of colonic inflammation and thickening of the sub epithelial collagen layer.
A 45 year old man has recurrent colicky abdominal pain. As part of a series of investigations he undergoes a CT scan and this demonstrates a hernia lateral to the rectus muscle at the level of the arcuate line. What type of hernia is this?
Littres Richters Spigelian Morgagni Incisional
This is the site for a spigelian hernia.
A 40 year old man presents with a long standing inguinal hernia. On examination he has a small, direct inguinal hernia. He inquires as to the risk of strangulation over the next twelve months should he decide not to undergo surgery. Which of the following most closely matches the likely risk of strangulation over the next 12 months?
50% 40% 25% 15% <5%
The annual probability of strangulation is up to 3% and is more common in indirect hernias. Elective repair poses few risks. However, emergency repair is associated with increased mortality, particularly in the elderly.
An 18 year-old female presents to the Emergency Department with sudden onset sharp, tearing pelvic pain associated with a small amount of vaginal bleeding. She also complains of shoulder tip pain. On examination, she is hypotensive, tachycardic and has marked cervical excitation. What is the most likely explanation?
Degenerating fibroid Adnexial torsion Ruptured ectopic pregnancy Ruptured appendicitis Endometriosis
The history of tearing pain and haemodynamic compromise in a women of child bearing years should prompt a diagnosis of ectopic pregnancy.
A 60 year old women has fully recovered from an attack of pancreatitis. Over the following 12 months she develops episodic epigastric discomfort. Un upper GI endoscopy shows gastric varices only. An abdominal CT scan demonstrates a splenic vein thrombosis. What is the treatment of choice?
Splenectomy Insertion of transjugular porto-systemic shunt Surgical bypass of the splenic vein Gastrectomy Stapling of the gastro-oesophgeal junction
Splenectomy
Which of the following is commonest cause of acute abdominal pain in acute unselected surgical ‘take’?
Non specific abdominal pain Biliary colic Acute appendicitis Ureteric colic Pancreatitis
Non specific abdominal pain is a commonly recorded diagnosis for patients presenting with acute abdominal pain.
In which of the conditions listed below is Cullens sign most likely to be seen?
Ruptured ectopic pregnancy Appendicitis Intestinal malrotation Perforated peptic ulcer Incarcerared femoral hernia
Ruptured ectopic pregnancy
Cullens sign is seen with significant intra peritoneal haemorrhage.
A 72 year old obese man undergoes an emergency repair of a ruptured abdominal aortic aneurysm. The wound is closed with an onlay prolene mesh to augment the closure. Post operatively he is taken to the intensive care unit. Over the following twenty four hours his nasogastric aspirates increase, his urine output falls and he has a metabolic acidosis. What is the most likely underlying cause?
Colonic ischaemia Abdominal compartment syndrome Peritonitis Reactionary haemorrhage Aorto-duodenal fistula
Obese patients with ileus following major abdominal surgery are at increased risk of intra abdominal compartment syndrome.
What is the commonest site in the abdomen for fluid to collect following a perforated appendix?
Pelvis Hepatorenal pouch Between small bowel loops Right iliac fossa Lesser sac
Following perforated appendicitis fluid is most likely to accumulate in the pelvis. Fluid may accumulate in the hepatorenal pouch although this is less common. Gravity favors the pelvis as the site of most collections. The incidence of these is higher with laparoscopic rather than open surgery.
A 56 year old man undergoes a difficult splenectomy and is left with a pancreatic fistula. There are ongoing problems with very high fistula output. Which of the following agents may be administered to reduce the fistula output?
Metoclopramide Erthyromycin Octreotide Loperamide Omeprazole
Octreotide is a useful agent in reducing the output from pancreatic fistulae. Prokinetic agents will increase fistula output and should be avoided.
A 52 year old obese lady reports a painless mass in the groin area. A mass is noted on coughing. It is below and lateral to the pubic tubercle. What is the most likely cause?
Direct inguinal hernia Indirect inguinal hernia Femoral hernia Obturator hernia Lipoma
A mass below and lateral to the pubic tubercle is indicative of a femoral hernia.
