The Acute Abdomen

Question 1

A 55-year-old man, with a 2-year history of dyspepsia, is brought to the
emergency department following a sudden onset of severe epigastric pain. The pain is made worse on movement and the patient has also experienced one episode of haematemesis. On examination, the patient is cold, sweating profusely and taking shallow breaths. The abdomen is rigid and bowel sounds are absent. A plain film chest radiograph reveals free air under the diaphragm. The most likely diagnosis is:
A. Perforated appendicitis
B. Acute cholecystitis
C. Acute pancreatitis
D. Myocardial infarction
E. Perforated peptic ulcer

Answer 1

E. Perforated peptic ulcer

Free air under the diaphragm on a chest radiograph is a classic sign of a perforation of a hollow viscus. In this case the history of dyspepsia, coupled with sudden onset of acute epigastric pain, fits in better with a diagnosis of a perforated peptic ulcer (E) rather than a perforated appendix (A).

Acute cholecystitis (B) typically presents with RUQ or epigastric pain, patients are usually pyrexial and nausea/vomiting may be present.

Acute pancreatitis (C) also presents with severe epigastric or upper abdominal pain which may radiate to the back.

Around 10% of perforated peptic ulcer cases do not have visable free air under the diapragm on chest radiograph, making differentiation from pancreatitis difficult.

Patients suffering from a myocardial infarction (D) can also present with symptoms similar to an acute abdomen, so this should always be considered.

Question 2

A 26-year-old woman arrives at the emergency department with unbearable
intense right iliac fossa pain. Earlier that day, she was experiencing ‘on and off’
moderate pain in the umbilical area which gradually moved over to the right iliac
fossa. Associated symptoms include anorexia, nausea and vomiting. On
examination, the patient is pyrexial and there is rebound tenderness and guarding
over the right iliac fossa. A b-human chorionic gonadotrophin test is negative.
What should you do next?
A. Send the patient to the emergency operating theatre for an
appendicectomy
B. Alert the obstetrics and gynaecology team, suspecting that she may
have a ruptured ectopic pregnancy
C. Manage the patient medically in the emergency department
D. Order an ultrasound scan of the abdomen
E. Send the patient for a plain film radiograph of the abdomen

Answer 2

A. Send the patient to the emergency operating theatre for an
appendicectomy

As we learnt in O&G all women attending hospital are pregnant until proven otherwise, this scenario tells us there is a negative beta hCG so we can safely exclude (B).

The patient is experiencing what can only be described as textbook symptoms of acute appendicitis, with the poorly localised pain that then localises to the right iliac fossa with associated anorexia, nausea and vomiting, combined with a perotinitic abdomen.

This patient needs an emergency appendectomy (A), any delays in management (C) increase the chances of complications such as perforation leading to generalised peritonitis/sepsis. Plain film radiography has limited use for the management of appendicitis (E). Ultrasound scanning (D) can be diagnostic when used by an expert, but given the severity of this patient’s symptoms it would be an unwise delay.

Laparoscopy is both diagnostic and therapeutic, so the patient should be sent to theatre without unecessary delay (A).

Question 3

A 12-year-old boy is admitted to the emergency department with sudden onset of
severe right testicular and lower abdominal pain during athletic training. He has
had one episode of vomiting and constantly feels nauseous. On examination, the
patient is sweating and in unbearable pain. There is marked tenderness and
swelling of the right testicle which is observed to be lying horizontally. What is the
most appropriate next step in this patient’s management?
A. Order a Doppler ultrasound of the testicular arteries
B. Send the patient immediately for emergency surgical exploration of the
scrotum
C. Perform urine dipstick
D. Manage the patient with analgesia and observe
E. Obtain a second opinion from your senior colleague, who will only be
able to see the patient in an hour

Answer 3

B. Send the patient immediately for emergency surgical exploration of the
scrotum

This is a clear case of testicular torsion, where the testis become twisted on it’s blood supply and become ischaemic. It is most common in the ages of 12-27, with sudden onset severe painfollowing mild trauma or straining/sports. Those with congenital horizontally lying testicals are more susceptible.

The pain is felt in the abdomen because the testesretain thier embyological nerve supply from T10.

Testicular torsion is a surgical emergency , and should lead to immediate surgical exploration (B) when suspected. Definitive management should never be delayed as the testis can infarct in 4 hours.

Although a doppler (A) would be useful it should never delay surgical exploration.

Question 4

You see a 55-year-old woman in the emergency department, who was admitted
with central colicky abdominal pain and multiple episodes of vomiting. She last
opened her bowels 4 hours ago. On examination she appears dehydrated and is in pain. The abdomen is generally tender and slightly distended. Bowel sounds are increased. You suspect bowel obstruction and decide to order some investigations. What is the most valuable initial investigation that will support your suspected diagnosis?
A. Upper gastrointestinal endoscopy
B. Colonoscopy
C. Computed tomography scan of the abdomen
D. Plain film radiograph of the abdomen
E. Barium follow-through

Answer 4

D. Plain film radiograph of the abdomen

There are four cardinal signs of small bowel obstruction:

• Vomiting (occurs early in SBO)
• Colicky pain (in SBO it is felt periumbilical)
• Absolute constipation
• Abdominal distension

Absolute constipation may not always be a feature if the site of obstruction is high up and is usually a late sign of SBO.

The abdo plain film radiograph (D) is extremely useful and should be the first line imaging investigation in confirming a bowel obstruction.

Barium follow-through (E), colonoscopy (B), and CT (C) are all helpful and can be performend after the initial plain film.

Uper GI endoscopy (A) is not helpful in the diagnosis of SBO.

Question 5

A 48-year-old woman is admitted with severe epigastric pain and vomiting. The
pain is continuous in nature and is made worse on movement. On examination you notice the patient is lying still, taking shallow breaths and sweating. There is
marked tenderness in the epigastric and right upper quadrant of the abdomen.
Murphy’s sign is positive and the patient is slightly pyrexial. You suspect acute
cholecystitis. What is the next best step in managing this patient?

A. Keep nil by mouth, administer parenteral analgesia and systemic
antibiotics
B. Send patient for emergency laparoscopic cholecystectomy
C. Request a plain film abdominal radiograph
D. Administer analgesia and seek the opinion of a superior colleague
E. Request an ultrasound of the abdomen

Answer 5

A. Keep nil by mouth, administer parenteral analgesia and systemic
antibiotics

It can be easy to confuse the presentation of billiary colic with acute cholecystitis (as in this case). In biliary colic patients tend to be seen writhing in pain, whereas in cholecystitis they classically lie perfectly still and breathe shallow (due to local peritonitis).

In acute cholecystitis there is impaction of a bile stone at the outlet of the gallbladder, or in the cystic duct leading to external occlusion of the outflow (Mirizzi’s syndrome). This leads to the accumulation of bile, which can lead to a chemical inflammatory process within the gallbladder. A seecondary bacterial infection can further complicate the presentation, and this becomes acute bacterial cholecystitis.

The most important step in the managementis to provide pain relief and systemic antibiotics (such as IV cefuroxime and metronidazole). IV fluids are always a consideration in a patient that has been vomiting but the best option here is answer (A).

Cholecystitis will usually settle over 24-48hrs with the aforementioned conservite approach, the patients are then offered an elective cholecystectomy after 6-8 weeks. If there isn’t improvement after 72hrs then cholecystectomy (B) is preferred.

Question 6

A 45-year-old Asian man is brought in with an acute onset of epigastric pain,
nausea and severe vomiting. The pain is worse on movement and is only relieved
slightly by leaning forward. The patient is an alcoholic and has been admitted to
the emergency department on several occasions for alcohol intoxication. On
examination the patient is tachycardic, pyrexial and dehydrated. The abdomen is
diffusely tender and soft, and bowel sounds are normal. The patient’s serum
amylase is raised by six times the upper limit of normal. The most likely diagnosis
is:
A. Perforated peptic ulcer
B. Small bowel obstruction
C. Acute cholecystitis
D. Acute pancreatitis
E. None of the above

Answer 6

D. Acute pancreatitis

The classic description of epigastric pain that is relieved on leaning forward points to the diagnosis of acute pancreatitis (A). This is the case because the head and neck of pancreas are retroperitoneal and so leaning forward lifts the pancreas off of the inflammed peritoneum.

Patinets will usually have a fever and tachycardia in acute pancreatitits as it is a systemic inflammatory process, the abdomen is usually soft although it can become more in keeping with peritonism in the later stages.

Although all of the options here can cause a raised serum amylase, the figure of six times the normal limit is strongly suggestive of acute pancreatitis.

Question 7

A 75-year-old man, who suffers from chronic atrial fibrillation, is admitted to the
emergency department with a sudden onset of severe central colicky abdominal
pain and vomiting. The patient has been bleeding from the rectum. The blood is
dark in colour and has an altered consistency. On examination the patient is pale,
has cold peripheries and is tachycardic. The abdomen is diffusely tender and bowel sounds are decreased. What is the likely diagnosis?
A. Diverticulitis
B. Small bowel obstruction
C. Acute mesenteric ischaemia
D. Perforated peptic ulcer

E. None of the above

Answer 7

C. Acute mesenteric ischaemia

Acute mesenteric ischaemia (ischaemic colitis).presents with the triad of colicky abdominal pain, rectal bleeding, and signs of shock. It almost always occurs in the small boweldue to an embolos of thrombosis of the mesenteric vessels.

Arterial embolic causes (such as AF, mural thrombosis post MI, detachment of atheromatous plaques and cardiogenic shock) are more common than venous thrombotic causes (venous stasis due to portal hypertension, or portal thrombosis, sepsis, coagulapathies).

In cases of mesenteric ischaemia an abdo film may show a ‘gasless abdomen’, the patient will usually be sent for emergency laparotomy, which will revel necrotic bowel. In this question we can see that the PR blood is of altered consistency and dark colour which is classic of necrotic breakdown of the bowel,

Of the other options here Diverticulitis (A) would likely have left iliac fossa localising signs with signs of peritonitis, often with a background of chronic constipation. The likely presentations of the SBO (B) and a perforated ulcer (D) are covered in earlier questions.

Question 8

A 50-year-old woman presents with an acute episode of epigastric pain, vomiting
and fever. The registrar, who has already clerked and examined the patient, tells
you that ‘Murphy’s sign is positive’. Despite not having seen the patient, from the
information conveyed to you, what is the most likely top differential diagnosis that
is running through your mind.
A. Acute appendicitis
B. Acute cholecystitis
C. Peritonitis
D. Biliary colic
E. Cholangitis

Answer 8

B. Acute cholecystitis

Murphy’s sign is a good clinical diagnostic test for cholecystitis, it is reported to have a sensitivity of 97.2% with a 48.3% specificity. The
positive predictive value of this test has been recorded at 70 per cent and
negative predicted value at 93.3 per cent.

Essentially a negative Murphy’s all but excludes cholecystitis and a positive result is strongly suggestive.

Question 9

A 65-year-old man is admitted to the emergency department following an acute
episode of abdominal pain and collapse. The pain is intermittent and radiates to
the back and iliac fossae. On examination, the patient appears confused, is
sweating and has tachycardia. On inspection, the abdomen appears normal but on palpation, you discover a pulsatile, expansile swelling in the midline of the
abdomen. You suspect a ruptured abdominal aortic aneurysm. What is the most important next step?

A. Establish intravenous access and begin fluid resuscitation with a colloid
B. Send for a computed tomography scan of the abdomen
C. Obtain blood to determine haemoglobin and amylase levels
D. Request an abdominal plain film radiograph
E. Perform electrocardiography

Answer 9

A. Establish intravenous access and begin fluid resuscitation with a colloid

This patient has a ruptured AAA and is in hypovolaemic shock, the absolute first thing to do for any patient in, or at risk, or hypovolaemic shock is to establish IV access, preferably with two large bore cannulas in the anticubital fossae.

The next step is to resucitate with fluids, there is controversy over colloid or crystaloid but option (A) is still the best answer here.

With the management of a ruptured AAA the aim is to maintain a systolic BP of 10mmHg or less as any higher risks exacerbating the bleed. Emergency vascular surgery should be arranged concomminantly.

although all the other options form part of the management they do not take priority over the fluid resuscitation. These management options would also only likely be considered if the patient was stable.

Question 10

A patient has been sent to theatre for emergency surgery with suspected
appendicitis. He is given three doses of intravenous cefuroxime and metronidazole
in a timely fashion. When is the best time to administer the first dose of
antibiotics?
A. One hour after the first incision is made
B. One hour before surgery
C. One hour postoperatively
D. Just before the surgical incision is made
E. None of the above

Answer 10

B. One hour before surgery

Surgical site infections account for 15% of nosocomial infections and have a variety of negative sequele. It has been found in random trials that starting antibiotics one hour before surgery reduces the incidence of surgical site infection, the course of antibiotics should not exceed 24hrs for the majority of surgical procedures.

Question 11

An elderly man with chronic constipation experiences acute-onset left iliac fossa
pain and tenderness. On examination, the patient has fever and is slightly
tachycardic. There is marked tenderness and guarding in the left iliac fossa. Full
blood count results reveal raised white cells. What is the most likely diagnosis
here?
A. Diverticular disease
B. Diverticulitis
C. Diverticulosis
D. Perforated diverticulitis
E. None of the above

Answer 11

B. Diverticulitis

A colonic diverticula is not a true diverticula as it only involves the mucosa and serosa in an outpouching betwen the tenia coli, usually ast the site of perforating blood vessels (this is the weakest point).

If a patient has diverticula and have no symptoms then they are said to have diverticulosis (C).

If that patient gets symptoms, such as left sided or central colicky abdominal pain, or bloating with constipation, then they are said to have diverticular disease (A)

If that disease process then involves an active inflammatory process due to infection or fecal impaction it is termed Divertiulitis (B). It classically presents with lower central abdominal pain which moves to the left iliac fossa, known colloqially as ‘left-sided appendicitis’. It is accompanied by fever, vomiting, local tenderness and gaurding (local peritonitis).

When an inflamed diverticulum perforates, a perforated diverticulits (D), signs of general peritonitis develop, characterised by general abdominal rigidity and gaurding. Patients may also be shocked and there may be air under the disphragm on an erect CXR.

Question 12

You are asked by your senior colleague to devise the treatment plan for the patient
in Question 11 (diverticulitits). What is the most appropriate treatment plan?
A. Keep nil by mouth and send for emergency laparotomy
B. Give analgesia and antibiotics
C. Keep nil by mouth, administer antibiotics and analgesia
D. Keep nil by mouth, administer intravenous fluids, antibiotics and
analgesia
E. Keep nil by mouth, administer intravenous fluids and analgesia

Answer 12

D. Keep nil by mouth, administer intravenous fluids, antibiotics and
analgesia

Management of diverticulitis is conservative in the first instance, the goal is to rest the bowel by making the patient nil by mouth and giving IV fluids. The patient is also given cefuroxime and metronidazole (or trust specific reccomendation) to treat the uderlying infection. Finally analgesia is essential as diverticulitis is very painful. This makes option (D) the choice here as none of the other option cover all these aspects of the management.

Question 13

You are asked to see a 48-year-old woman who has been admitted to the
emergency department with sudden onset of right upper quadrant pain. Your
registrar liaises with you, after having seen this patient, and tells you that the
patient has ‘Charcot’s triad’. From the information conveyed to you, what is the
most likely diagnosis that you should be thinking of?
A. Biliary colic
B. Acute cholecystitis
C. Cholangitis
D. Gallstone ileus
E. Pancreatitis

Answer 13

C. Cholangitis

Charcot’s tiad refers to right upper quadrant pain, jaundice and fever/rigors as seen in ascending cholangitis (C) (although Charcot also described a less commonly used triad relating to MS). If Charcot’s triad is accompanied by hypotension and altered mental state that is termed Reynold’s pentad and is suggestive of septic cholangitis.

A patient with suspected ascending cholangitis requires prompt treatment with IV fluids and antibiotics and then should be offered an elective cholecystectomy around 6 weeks later.

Question 14

A 78-year-old African Caribbean man presents to the emergency department with
severe pain arising from his hernia in the left groin. The patient is also
experiencing central colicky abdominal pain. On examination, the abdomen is
generally tender, distended and bowel sounds are raised. Examination of the
hernial orifices reveals a left-sided, irreducible, tense and extremely tender
inguinal hernia. The overlying skin of the hernia is warm and erythematous. What
is the most appropriate course of action in managing this patient?
A. Alert theatre and send patient for emergency surgery
B. Request a computed tomography scan of the abdomen
C. Request an ultrasound
D. Attempt to reduce the hernia
E. None of the above

Answer 14

A. Alert theatre and send patient for emergency surgery

Hernias can be classified as reducible or irreducible, of the irreducible hernias they can be classified as incarcerated or strangulated. As the terms would suggest an incarcerated hernia is one that cannot go anywhere but is otherwise healthy, versus a strangulated hernia which is suffering obstruction/ischaemia.

In the case of this patient has a strangulated hernia as evidenced by the signs of bowel obstruction and the tender and erythemotous hernia site. It is vital that this patient has prompt surgical intervention (A) as the pressure on the neck of the hernia will lead to ischaemia and necrosis of the contents, any delays could be fatal and so answer (A) is the only valid choice here.

It is important to note that in this case there is small bowel in the hernial sac (hence the symptoms of SBO), if there was only omentum present there would still be the tense erythematous hernia but there would not be the other symptoms.

Question 15

A 57-year-old man presents with acute colicky pain in the suprapubic area. He has been constipated over the last 2 days and has been feeling bloated. He feels
nauseous but he has not vomited. On examination of the abdomen you notice
marked abdominal distension, and increased bowel sounds. What is the most likely diagnosis?
A. Small bowel obstruction
B. Irritable bowel syndrome
C. Diverticular disease
D. Large bowel obstruction
E. Appendicitis

Answer 15

D. Large bowel obstruction

pain inlarge bowel obstruction is usually colicky in nature and felt in the suprapubic area. Vomiting is usually a late sign in large bowel obstruction, coversely is is normally an early sign in SBO. Conversely absolute constipation is usually a later sign in Large bowel obstruction, and early in SBO. This all makes sense considering which end of the ailementary tract the obstruction is nearer. Finally distention is more marked in large bowel obstruction.

options (E), (C) are discused in other questions

IBS (B) is a chronic functional disorder which doesn’t fit with this presentation of two days duration in a 57 year old man.

Question 16

What is the least number of factors that must be present from the modified
Glasgow criteria for acute pancreatitis to be classified as severe within 48 hours of
admission?
A. 2
B. 4
C. 3
D. 5
E. 1

Answer 16

C. 3

The modified Glasgow criteria (sensitivity 68% and specificity 84%) are commonly used in the UK as a prognostic tool. It is composed of these measurements;

• paO2 <8kPa
• age >55 years
• white cell count >15 ¥ 109/L
• calcium <2 mmol/L
138 Section 6: The acute abdomen
• urea >16 mmol/L
• LDH >600 IU/L
• AST >200 IU/L
• albumin <32 g/L
• blood glucose >10 mmol/L.

Positives in any 3 criteria within 48hrs of onset indicates that the pancreatitis is severe.

Question 17

A 28-year-old man with a 10-year history of ulcerative colitis presents to the
emergency department with an acute severe episode of abdominal pain, nausea
and vomiting and blood-stained, watery diarrhoea. On examination you notice
that the patient has fever, is tachycardic and the abdomen is markedly distended.
An abdominal plain film radiograph shows that the transverse colon is dilated at
approximately 6.5 cm. What is the most likely diagnosis?
A. Large bowel obstruction
B. Toxic megacolon
C. Perforated diverticulitis
D. Crohn’s colitis
E. None of the above

Answer 17

B. Toxic megacolon

Toxic megacolon is an acute complication of ulcerative colitis, severe inflammation of the colon due tto the disease process leads to severe dilation of the colon (usually the transverse).

Clinically the patients are suffering from toxaemia (pyrexia, tachycardia, and hypotension), anaemia, acute loss of water and electrolytes and progressive abdominal distention. Along with the clinical features toxic megacolon can be diagnosed from a plain film x-ray (as in this case), usually a transverse colon greater than 6cm is diagnostic of toxic megacolon. Although toxic megacolon can be a complication of Crohn’s, the patient in this scenario has a history of ulcerative colitis.

Treatment for toxic megacolon involves fluid resuscitation, correcting the electrolyte disturbances and administering high dose steroids. The size of the colon is monitored with repeated abdominal plain radiographs, if the colon does not respond to medical therapy it indicates the need for surgical treatment to avoid perforation.

Question 18

From the list of options below which one is the most unlikely cause of mechanical
intestinal obstruction?
A. Faecal impaction
B. Caecal volvulus
C. Paralytic ileus
D. Congenital intestinal atresia
E. Crohn’s colitis

Answer 18

C. Paralytic ileus

intestinal obstruction can be divided into mechanical and paralytic causes (known as paralytic ileus). Paralytic ileus is a result of the intestines being in complete atony. It is seen clinically as abdominal distesion, absolute constipation, vomiting and absent bowel sounds (no motility). As there is n abscence of gut movement the characteristic coliky central pain of a mechanical obstruction is absent.

Paralytic ileus can be caused by peritonitis, ileus following abdominal surgery, trauma, acute pancreatitis, potassium deficiency, uraemia, and drugs such as anticholinergic and antidiarrhoeals.

Causes of mechanical obstruction can be divided into;

Luminal factors - impaction, foreign body, intususception, large polyps

Intramural factors - congenital intestinal atresia, Crohn’s colitis, tumours, strictures

Extramural factors - volvulus, adhesions, strangulated hernia, extrinsic compression (mass effect).

Question 19

A 44-year-old woman presents to the emergency department with acute onset of
right upper quadrant pain and fever. On examination, the patient is lying still and
has a tachycardia. The abdomen is tender in the right upper quadrant with
guarding in that area. Murphy’s sign is positive. What is the most useful
investigation for this patient?
A. Ultrasound
B. Colonoscopy
C. Barium follow-through
D. Upper gastrointestinal endoscopy
E. Serum amylase

Answer 19

A. Ultrasound

RUQ pain with a positive Murphy’s sign suggests acute cholecystitis. An uper Gi endoscopy (D), colonoscopy (B) or a Barium follow through (C) will not add anything to the management of acute cholecystitis.

Serum amylase would (E) be useful to rule out pancreatitis, but we are strongly suspecting cholecystitis.

An ultrasound (A) would be very useful as it can confirm the prescence of gallstomes and visualise the gallbladder itself.

Question 20

A 75-year-old man is admitted to the emergency department with acute-onset
suprapubic pain and inability to pass urine for 2 days. On examination, the patient
is in discomfort, neurologically intact, and the abdomen is particularly tender in
the suprapubic region. A digital rectal examination reveals a smooth, enlarged
prostate. What is the most likely diagnosis?
A. Bladder outflow obstruction due to prostate cancer
B. Bladder outflow obstruction due to benign prostatic hypertrophy
C. Bladder outflow obstruction due to a urethral stricture
D. Bladder outflow obstruction due to a spinal cord lesion
E. None of the above

Answer 20

B. Bladder outflow obstruction due to benign prostatic hypertrophy

In this case we have findings on DRE that are strongly suggestive of benign prostatic hypertrophy (B), if the enlargement was irregular and rough then that would be more indicative of malignancy (A).

Given the prescence of the large prostate this makes the other options (C-E) less likely, especially given the fact that the patient is neurologically intact with no history of urethral pathology.

Question 21

From the list of options below, select the most appropriate course of action to take
in managing the patient in Question 20 (benign prostatic hypertrophy).
A. Ask the urology registrar to see the patient
B. Obtain blood for urea and electrolytes sampling
C. Request an abdominal plain film radiograph
D. Urinary catheterization
E. Request an intravenous urogram

Answer 21

D. Urinary catheterization

By urinary catheterising (D) the patient it will rapidly relieve his discomfort and reduce the risk of acute renal failure. Urethral catheterization is the first method, and suprapubic is attempted if that fails.

Abdominal plain film radiography (C) would add very little to the management.

Obtaining U&Es (B) would be important to assess kidney function but should not happen prior to catheterization.

Question 22

A 55-year-old woman presents to the emergency department with severe epigastric and left upper quadrant pain. Since admission, the patient has vomited. On examination you notice the patient is retching (which is non-productive),
tachycardic and is hypotensive. There is marked tenderness in the upper abdomen and bowel sounds are slightly raised. There is failure to pass a nasogastric tube. A chest radiograph reveals a dilated stomach and large fluid level behind the heart. Which is the most likely diagnosis?
A. Small bowel obstruction
B. Perforated peptic ulcer
C. Gastro-oesophageal obstruction secondary to a gastric volvulus
D. Gastro-oesophageal obstruction secondary to an adenocarcinoma of the
stomach
E. Sigmoid volvulus

Answer 22

C. Gastro-oesophageal obstruction secondary to a gastric volvulus

The presentation of vomiting (with later non-productive retching), pain, and inability to pass an NG tube are classic signs of a gastro-oesophageal obstruction.

Combined with the fluid level and gastric dilitation strongly suggests this is due to a volvulus (C), given that this is occuring in the stomach a sigmoid volvulus (E) is unlikely.

The gastric volvulus could be due to congenital causes (paraoesophageal hernia, congenital bands, bowel malformations, pyloric stenosis) and acquired (previous surgery to the upper GI tract or adhesions). Gastric volvulus requires an emergency laparotomy to avoid the risk of perforation.

Question 23

You see an 11-year-old boy in the emergency department who is admitted with an
acute onset of abdominal pain, nausea and vomiting. There is diffuse pain around
the central abdomen and right iliac fossa and is continuous in nature. On
examination, the patient is febrile and there is marked tenderness and rebound in
the right iliac fossa. The patient’s mother tells you that he has recently had a sore
throat. You suspect mesenteric adenitis and request an ultrasound scan which is
inconclusive. What is the best next step to take in managing this patient?
A. Start the patient on analgesia and intravenous antibiotics
B. Send for a computed tomography scan of the abdomen
C. Observe patient for the next 2 hours and reassess
D. Send for emergency explorative laparotomy
E. None of the above

Answer 23

D. Send for emergency explorative laparotomy

Mesenteric adenitis is a process of inflammation of the mesenteric lymph nodes and is a key differential diagnosis in the presentation of acute appendicitis.

It is commonly a childhod illness, though occasionally seen in adults. It is often preceeded by a viral respiratory tract infection. The enlargement of these nodes causes right iliac fossa pain (can be a diffuse pain) and tendernes as well as causing a fever. The patient can also experience nausea, vomiting, anorexia and diarrhoea.

There can be a differnce in the white cell count, with a lymphocytosis rather than a raise neutrophil count as seen in acute appendicitis.

Given the prescence of symptoms suggestive of acute appendicitis, coupled with an inconclusive ultrasound, the next step here is to proceed to an explorative laparotomy. If this is mesenteric adenitis then it will settle after around 24hrs, analgesia and observation is warented. However, the explorative laparotomy (D) is needed to be certain this isn’t the much more dangerous situation of acute appendicitis.

Question 24

A 13-month-old girl is diagnosed with intussusception. She was admitted to the
emergency department 2 hours ago with vomiting, passing red mucus-like stools
and persistent crying. You are asked by your consultant about the first line
treatment for this condition. What is the most likely first line treatment option?
A. Laparotomy and reduction
B. Barium enema per rectum and abdominal plain film radiography
C. Analgesia and observation for 24 hours
D. Intravenous fluids and antibiotics
E. Laparotomy and resection

Answer 24

B. Barium enema per rectum and abdominal plain film radiography

Intussusception is when a portion of the bowel invaginates into it’s own lumen, this can occur commonly as an ileo-ileal, ileocaecal and colocolic invagination. The condition is more common in children, after the age of 3 factors such as polyps, carcinoma, intestinal lymphoma, foreign bodies, or an inverted Meckel’s diverticulum predispose to intussusception.

The clasic presentation is intermittent abdominal colic (screaming and pallor in infants), vomiting and the passage of mucus and bloody stools known as ‘redcurrent jelly’. The child will appear pale, anxious and irritable, on palption there may be a sausage sshaped mass felt. Plain film radiography is often normal, although in the later stages there may be evidence of bowel obstruction.

Initial treatment is with the use of barium enemas (B) and plain abdo radiographs, the passage of the barium enema may be enough to reduce the intussusception. If there is no success with the barium enemas then surgical intervention is indicated, if the bowel has become ischaemic then resection is indicated. Chances of bowel ischaemia are reduced if the intussusception is reduced within 24hrs.

Question 25

A 49-year-old postmenopausal woman is admitted to the emergency department
following severe attacks of abdominal pain, nausea and vomiting. The pain is
colicky in nature and starts from the left flank of the abdomen and radiates to the
left groin. You are unable to take a history from the patient as she is writhing in
pain. On examination you notice that the patient is sweating profusely. The
abdomen is soft, non-tender and bowel sounds are normal. What is the most likely
diagnosis?
A. Diverticulitis
B. Ruptured ectopic pregnancy
C. Renal colic
D. Small bowel obstruction
E. Ruptured abdominal aortic aneurysm

Answer 25

C. Renal colic

The presentation here is a classic picture of renal colic, with the described ‘loin to groin’ pain, coupled with the patient writhing on the floor. This is caused by the impaction of a renal calculi in the ureter, the subsequent dilation of the ureter and spasm leads to the pain experienced. The commonest sites for the impaction are at the renal pelvis (pelvico-ureteric junction), at the bladder (vesico-ureteric junction), or at the

Question 26

From the list below select the investigation that will be of most diagnostic value
to the patient’s condition mentioned in Question 25 (renal colic).
A. Computed tomography scan of the abdomen
B. KUB (kidneys, ureters and bladder)
C. Intravenous urogram
D. Ultrasound
E. Abdominal plain film radiography

Answer 26

A. Computed tomography scan of the abdomen

Although a KUB (B) would be an essential investigation for renal colic it has been found to detect 80% of stones, compared to 99% detection in a CT-KUB (A), making the CT scan the most diagnostically valuable.

Ultrasound (D) has also been found to be useful but still has a lower diagnostic accuracy than CT.

A plain film (E) doesn’t visualise the whole renal system

And an IV urogram (C) is greater risk due to contrast, than the CT.

Question 27

During a ward round, you are asked by your senior registrar to name the most
common causative factor that is responsible for the development of acute
pancreatitis. Which option from the list below would you choose as your answer?
A. Ethanol
B. Steroids
C. Gallstones
D. Drugs
E. Trauma

Answer 27

C. Gallstones

The common causes of acute pancreatitis can be remembered with the acronym GET SMASHED, with the G (gallstones) being the most common followed by the E (ethanol).

Question 28

You are asked to give your opinion on an abdominal plain film radiograph of a
patient with bowel obstruction. The film shows distended loops of large bowel
which form a ‘U’ shape, giving the appearance of a big coffee bean. Select the most
likely reason for the large bowel obstruction.
A. Faecal impaction
B. Sigmoid volvulus
C. Obstructing carcinoma
D. Foreign body
E. None of the above

Answer 28

B. Sigmoid volvulus

Sigmoid volvulusd (B) is the most common form of volvulus, it is commonly seen in elderly patients with a long history of constipation.

Patients will likely present with absolute constipation and central colicky pain, the coffee bean sign is a classic radiological sign.

On radiology you can sometimes see an ‘apple core’ lesion on contrast films when there is an obstructing carcinoma (C)

In a foreign body (D) scenario you might expect to see the object.

If there was faecal impaction (A) this might be seen of an abdominal film.

Question 29

You see a 50-year-old woman, admitted with colicky central abdominal pain, and
passing blood-stained diarrhoea and mucus per rectum. She has a marked fever
and tachycardia. Abdominal plain film radiography appears normal. The white cell
count is raised and stool analysis reports reveal the presence of Clostridium difficile
cytotoxins. What is the most likely diagnosis?
A. Ulcerative colitis
B. Crohn’s colitis
C. Ischaemic colitis
D. Pseudomembranous colitis
E. None of the above

Answer 29

D. Pseudomembranous colitis

pseudomembranous colitis (D) is an infection caused by the gram-positive pathogen C.difficile. It presents similarly to other forms of colitis with watery diarrhoea (often bloody), passage of mucus per rectum, crampy abdo pain and fever.

The patogenesis involves the production of two toxins by C.difficile, toxin A is a proinflammatory enterotoxin that acts on the intestinal receptors acting to loosen the junctions between epithelial cells. Through these gaps toxin B can permeate and it acts to promote an inflammatory cascade. This results in fluid secretion, mucosal cell injury, oedema and inflammation.

The prescence of cytotoxin in the stool is highly suggestive of the diagnosis of C.difficile, colonoscopy +/- histology may also be performed. First line treatment is with metronidazole or vancomycin. If the patient goes on to develop toxic megacolon then emergency resection is indicated.

Question 30

A 75-year-old man, with a history of diverticular disease, is experiencing swinging
fevers and left-sided abdominal pain. You suspect the patient has a diverticular
abscess. Which one of the following investigations is the most appropriate to
confirm your suspicion?
A. Barium enema studies
B. Abdominal plain film radiography
C. Computed tomography scan of abdomen
D. Colonoscopy
E. Flexible sigmoidoscopy

Answer 30

C. Computed tomography scan of abdomen

Barium enema (A) was historically the investigation of choice for a diverticular abcess but has been supersceeded by CT scanning (C).

An abdo plain film (B) isn’t particularly helpful

The introduction of a scope (D)(E) carries a risk of perforation in an acute inflammatory situation and may not even be able to visualise the abcess.