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.
