1. 1. 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? A. Haematoma B. Intra abdominal adhesions C. Anastomotic leak D. Anastomotic stricture E. Obstructed incisional hernia Theme from September 2011 Exam In this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt surgical exploration is warranted. Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections. Acute incisional hernia Any surgical procedure involving entry into a cavity containing viscera may be complicated by post operative hernia The abdomen is the commonest site The deep layer of the wound has usually broken down, allowing internal viscera to protrude through Management is dictated by the patients clinical status and the timing of the hernia in relation to recent surgery Bowel obstruction or tenderness at the hernia site both mandate early surgical intervention to reduce the risk of bowel necrosis Mature incisional hernias with a wide neck and no symptoms may be either left or listed for elective repair Risk factors for the development of post operative incisional hernias include post operative wound infections, long term steroid use, obesity and chronic cough Theme: Abdominal stomas A. End ileostomy B. End colostomy C. Loop ileostomy D. Loop colostomy
2. 2. E. End jejunostomy F. Loop jejunostomy G. Caecostomy For each of the following scenarios, please select the most appropriate type of stoma to be constructed. Each option may be selected once, more than once or not at all. 2. A 56 year old man is undergoing a low anterior resection for carcinoma of the rectum. It is planned to restore intestinal continuity. You answered End colostomy The correct answer is 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. 3. A 23 year old man with uncontrolled ulcerative colitis is undergoing an emergency sub total colectomy. You answered Loop ileostomy The correct answer is End ileostomy Following a sub total colectomy the immediate surgical options include an end ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal anastomosis would be unsafe. 4. A 63 year old women presents with large bowel obstruction. On examination she has a carcinoma 10cm from the anal verge. You answered End colostomy The correct answer is Loop colostomy Large bowel obstruction resulting from carcinoma should be resected, stented or defunctioned. The first two options typically apply to tumours above the peritoneal reflection. Lower tumours should be defunctioned with a loop colostomy and then formal staging undertaken prior to definitive surgery. An emergency attempted rectal resection carries a high risk of involvement of the circumferential resection margin and is not recommended.
3. 3. Abdominal stomas Stomas may be sited during a range of abdominal procedures and involve bringing the lumen or visceral contents onto the skin. In most cases this applies to the bowel. However, other organs or their contents may be diverted in case of need. With bowel stomas the type method of construction and to a lesser extent the site will be determined by the contents of the bowel. In practice, small bowel stomas should be spouted so that their irritant contents are not in contact with the skin. Colonic stomas do not need to be spouted as their contents are less irritant. In the ideal situation the site of the stoma should be marked with the patient prior to surgery. Stoma siting is important as it will ultimately influence the ability of the patient to manage their stoma and also reduce the risk of leakage. Leakage of stoma contents and subsequent maceration of the surrounding skin can rapidly progress into a spiraling loss of control of stoma contents. Types of stomas Name of stoma Use Common sites Gastrostomy Gastric decompression or fixation Feeding Epigastrium Loop jejunostomy Seldom used as very high output May be used following emergency laparotomy with planned early closure Any location according to need Percutaneous jejunostomy Usually performed for feeding purposes and site in the proximal bowel Usually left upper quadrant Loop ileostomy Defunctioning of colon e.g. following rectal cancer surgery Does not decompress colon (if ileocaecal valve competent) Usually right iliac fossa End ilestomy Usually following complete excision of colon or where ileo- colic anastomosis is not planned May be used to defunction colon, but reversal is more difficult Usually right iliac fossa End colostomy Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable Either left or right iliac fossa
4. 4. Loop colostomy To defunction a distal segment of colon Since both lumens are present the distal lumen acts as a vent May be located in any region of the abdomen, depending upon colonic segment used Caecostomy Stoma of last resort where loop colostomy is not possible Right iliac fossa Mucous fistula To decompress a distal segment of bowel following colonic division or resection Where closure of a distal resection margin is not safe or achievable May be located in any region of the abdomen according to clinical need Theme: Acute abdominal pain A. Ruptured abdominal aortic aneurysm B. Perforated peptic ulcer C. Perforated appendicitis D. Mesenteric infarction E. Small bowel obstruction F. Large bowel obstruction G. Pelvic inflammatory disease H. Mesenteric adenitis I. Pancreatitis J. None of the above Please select the most likely cause of abdominal pain for the scenario given. Each option may be used once, more than once or not at all. 5. 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. Mesenteric infarction In mesenteric infarction there is sudden onset of pain together with vomiting and occasionally passage of bloody diarrhoea. The pain present is usually out of proportion to the physical signs. 6. 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
5. 5. adhesions are noted between the liver and abdominal wall. Her appendix is normal. You answered Small bowel obstruction The correct answer is Pelvic inflammatory disease This is Fitz Hugh Curtis syndrome in which pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions. 7. 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. Ruptured abdominal aortic aneurysm This will be a retroperitoneal rupture (anterior ones generally don't survive to hospital). The debate regarding CT varies, it is the authors opinion that a systolic BP of 60 years Continued bleeding despite endoscopic intervention Recurrent bleeding Known cardiovascular disease with poor response to hypotension Surgery Selective mesenteric embolisation if life threatening bleeding. This is most helpful if conducted during a period of relative haemodynamic instability. If all haemodynamic parameters are normal then the bleeding is most likely to have stopped and any angiography normal in appearance. In many units a CT angiogram will replace selective angiography but the same caveats will apply. If source of colonic bleeding unclear perform a laparotomy, on table colonic lavage and following this attempt a resection. A blind sub total colectomy is most unwise, for example bleeding from an small bowel arterio-venous malformation will not be treated by this manoeuvre. Summary of Acute Lower GI bleeding recommendations Consider admission if: * Over 60 years * Haemodynamically unstable/profuse PR bleeding * On aspirin or NSAID * Significant co morbidity Management All patients should have a history and examination, PR and proctoscopy Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding References http://www.sign.ac.uk/guidelines/fulltext/105/index.html heme: Surgical signs A. Rovsing's sign B. Boas' sign C. Psoas stretch sign D. Cullen's sign E. Grey-Turner's sign F. Murphy's sign G. None of the above Please select the most appropriate eponymous abdominal sign for the scenario given. Each option may be used once, more than once or not at all.
6. 11. 11. Severe acute peri-umbilical bruising in the setting of acute pancreatitis. Cullen's sign Cullens sign occurs when there has been intraabdominal haemorrage. It is seen in cases of severe haemorrhagic pancreatitis and is associated with a poor prognosis. It is also seen in other cases of intraabdominal haemorrhage (such as ruptured ectopic pregnancy). 12. In acute cholecystitis there is hyperaesthesia beneath the right scapula. Boas' sign Boas sign refers to this hyperaesthesia. It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level. 13. In appendicitis palpation of the left iliac fossa causes pain in the right iliac fossa. Rovsing's sign Rovsings sign elicits tenderness because the deep palpation induces shift of the appendix (which is inflamed) against the peritoneal surface. This has somatic innervation and will therefore localise the pain. It is less reliable in pelvic appendicitis and when the appendix is truly retrocaecal Abdominal signs A number of eponymous abdominal signs are noted. These include: Rovsings sign- appendicitis Boas sign -cholecystitis Murphys sign- cholecystitis Cullens sign- pancreatitis (other intraabdominal haemorrhage) Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage) In clinical practice haemorrhagic pancreatitis is thankfully rare. The signs are important and thus shown below: Cullen's sign
7. 12. Image sourced from Wikipedia Grey Turner's sign Image sourced from Wikipedia Theme: Surgical access A. Gridiron B. Lanz C. McEvedy D. Midline abdominal E. Rutherford Morrison F. Battle (abdominal) G. Lower midline Please select the most appropriate incision for the procedure required. Each option may be used once, more than once or not at all. 14. A 78 year old lady is admitted with a tender lump in her right groin. It is within the femoral triangle and there is concern that there may be small bowel obstruction developing.
8. 13. McEvedy This is one approach to an obstructed femoral hernia. It is possible to undertake a small bowel resection through this approach. Although recourse to laparotomy may be needed if access is difficult. 15. A 45 year old woman with end stage renal failure is due to undergo a cadaveric renal transplant. This will be her first transplant. Rutherford Morrison This is the incision of choice for the extraperitoneal approach to the iliac vessels which will be required for a renal transplant. 16. A slim 20 year old lady is suffering from appendicitis and requires an appendicectomy. Lanz Either a Lanz or Gridiron incision will give access for appendicectomy. However, in the case described a Lanz incision will give better cosmesis and can be extended should pelvic surgery be required eg for gynaecological disease. Abdominal incisions Theme in January 2012 exam Midline incision Commonest approach to the abdomen Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus) Bladder can be accessed via an extraperitoneal approach through the space of Retzius Paramedian incision Parallel to the midline (about 3-4cm) Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum Incision is closed in layers
9. 14. Battle Similar location to paramedian but rectus displaced medially (and thus denervated) Now seldom used Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open) Lanz Incision in right iliac fossa e.g. Appendicectomy Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz Gable Rooftop incision Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation. Image sourced from Wikipedia Theme: Hernias A. Littres hernia B. Richters hernia C. Bochdalek hernia D. Morgagni hernia E. Spigelian hernia F. Lumbar hernia G. Obturator hernia Please select the type of hernia that most closely matches the description given. Each option may be used once, more than once or not at all.
10. 15. 17. 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. Richters 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. 18. 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. Littres hernia Hernia containing Meckels diverticulum is termed a Littres hernia. 19. 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. Spigelian hernia This is the site for a spigelian hernia. Theme: Groin masses A. Femoral hernia B. Lymphadenitis C. Inguinal hernia D. Psoas abscess E. Saphenous varix F. Femoral artery aneurysm G. Metastatic lymphadenopathy H. Lymphangitis I. False femoral artery aneurysm What is the likely diagnosis for groin mass described? Each option may be used once, more than once, or not at all. 20. A 52 year old obese lady reports a painless grape sized mass in her groin area.
11. 16. She has no medical conditions apart from some varicose veins. There is a cough impulse and the mass disappears on lying down. Saphenous varix The history of varicose veins should indicate a more likely diagnosis of a varix. The varix can enlarge during coughing/sneezing. A blue discolouration may be noted. 21. A 32 year old male is noted to have a tender mass in the right groin area. There are also red streaks on the thigh, extending from a small abrasion. You answered Lymphangitis The correct answer is Lymphadenitis The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes. 22. A 23 year old male suffering from hepatitis C presents with right groin pain and swelling. On examination there is a large abscess in the groin. Adjacent to this is an expansile swelling. There is no cough impulse. False femoral artery aneurysm False aneurysms may occur following arterial trauma in IVDU. They may have associated blood borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not contain all layers of the arterial wall. Groin masses clinical Groin masses are common and include: Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm Saphena varix (more a swelling than a mass!) In the history features relating to systemic illness and tempo of onset will often give a
12. 17. clue as to the most likely underlying diagnosis. Groin lumps- some key questions Is there a cough impulse Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm) Are both testes intra scrotal Any lesions in the legs such as malignancy or infections (?lymph nodes) Examine the ano rectum as anal cancer may metastasise to the groin Is the lump soft, small and very superficial (?lipoma) Scrotal lumps - some key questions Is the lump entirely intra scrotal Does it transilluminate (?hydrocele) Is there a cough impulse (?hernia) In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound scan is often the most convenient next investigation. heme: Right iliac fossa pain A. Urinary tract infection B. Appendicitis C. Mittelschmerz D. Mesenteric adenitis E. Crohns disease F. Ulcerative colitis G. Meckels diverticulum Please select the most likely cause for right iliac fossa pain for the scenario given. Each option may be used once, more than once or not at all. 23. 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. Meckels diverticulum This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration.
13. 18. 24. 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. Mittelschmerz Typical story and timing for mid cycle pain. Mid cycle pain typically occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours. 25. 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. Crohns disease Weight loss and chronic symptoms coupled with change in bowel habit should raise suspicion for Crohns. The presence of intermittent right iliac fossa pain is far more typical of terminal ileal Crohns disease. Both UC and Crohns may be associated with a low grade pyrexia. The main concern here would be locally perforated Crohns disease with a small associated abscess. Right iliac fossa pain Differential diagnosis Appendicitis Pain radiating to right iliac fossa Anorexia Typically short history Diarrhoea and profuse vomiting rare Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis
14. 19. If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus 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? A. Incarcerated inguinal hernia B. Thrombophlebitis of a saphena varix C. Incarcerated femoral hernia
15. 20. D. Incarcerated obturator hernia E. Deep vein thrombosis Femoral hernia = High risk of strangulation (repair urgently) Femoral herniae account for 3 times normal go against this diagnosis. 41. A 79 year old lady develops sudden onset of abdominal pain and collapses, she has passed a large amount of diarrhoea. In casualty her pH is 7.35 and WCC is 18. You answered Acute on chronic mesenteric ischaemia The correct answer is Acute mesenteric embolus Although mesenteric infarct may raise the lactate the pH may be raised often secondary to vomiting. Mesenteric vessel disease Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused by arterial embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries. Types Acute mesenteric embolus (commonest 50%) Sudden onset abdominal pain followed by profuse diarrhoea. May be associated with vomiting. Rapid clinical deterioration. Serological tests: WCC, lactate, amylase may all be abnormal particularly in established disease. These can be normal in the early phases. Acute on chronic mesenteric ischaemia Usually longer prodromal history. Post prandial abdominal discomfort and weight loss are dominant features. Patients will usually present with an acute on chronic event, but otherwise will tend not to present until mesenteric flow is reduced by greater than 80%. When acute thrombosis occurs presentation may be as above. In the chronic setting the symptoms will often be those of ischaemic colitis (mucosa is the most sensitive area to this insult).
16. 38. Mesenteric vein thrombosis Usually a history over weeks. Overt abdominal signs and symptoms will not occur until venous thrombosis has reached a stage to compromise arterial inflow. Thrombophilia accounts for 60% of cases. Low flow mesenteric infarction This occurs in patients with multiple co morbidities in whom mesenteric perfusion is significantly compromised by overuse of inotropes or background cardiovascular compromise. The end result is that the bowel is not adequately perfused and infarcts occur from the mucosa outwards. Diagnosis Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease). Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the arterial phase with thin slices (8cm Fluid levels in the colon Ground glass appearance to film (usually due to large amounts of free fluid). Sentinel loop in patients with inflammation of other organs (e.g. pancreatitis). Features which should be expected/ or occur without pathology In Chialditis syndrome, a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression that free air is present. Following ERCP (and sphincterotomy) air may be identified in the biliary tree. Free intra abdominal air following laparoscopy / laparotomy, although usually dissipates after 48-72 hours. 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 A. Abdominal ultrasound scan B. Barium enema C. Rectal MRI Scan D. Endoanal ultrasound scan E. 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. An MRI scan will not provide the relevant information, unless the lesion is rectal and below the peritoneal reflection.
17. 42. Abdominal radiology Plain abdominal x-rays are often used as a first line investigation in patients with acute abdominal pain. A plain abdominal film may demonstrate free air, evidence of bowel obstruction and possibly other causes of pain (e.g. renal or gallbladder stones). Investigation of potential visceral perforation is usually best performed by obtaining an erect chest x-ray, as this is a more sensitive investigation for suspected visceral perforation. Features which are usually abnormal Large amounts of free air (colonic perforation), smaller volumes seen with more proximal perforations. A positive Riglers sign (gas on both sides of the bowel wall). Caecal diameter of >8cm Fluid levels in the colon Ground glass appearance to film (usually due to large amounts of free fluid). Sentinel loop in patients with inflammation of other organs (e.g. pancreatitis). Features which should be expected/ or occur without pathology In Chialditis syndrome, a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression that free air is present. Following ERCP (and sphincterotomy) air may be identified in the biliary tree. Free intra abdominal air following laparoscopy / laparotomy, although usually dissipates after 48-72 hours. Theme: Management of splenic trauma A. Splenectomy B. Angiography C. CT Scan D. Admit for bed rest and observation E. Ultrasound scan F. Splenic conservation G. MRI of the abdomen Please select the most appropriate intervention for the scenario given. Each option may be used once, more than once or not at all. 1. A 7 year old boy falls off a wall the distance is 7 feet. He lands on his left side and there is left flank bruising. There is no haematuria. He is otherwise stable and haemoglobin is within normal limits. Ultrasound scan
18. 43. This will demonstrate any overt splenic injury. A CT scan carries a significant dose of radiation. In the absence of haemodynamic instability or other major associated injuries the use of USS to exclude intraabdominal free fluid (blood) would seem safe when coupled with active observation. An USS will also show splenic haematomas. 2. A 42 year old motorcyclist is involved in a road traffic accident. A FAST scan in the emergency department shows free intrabdominal fluid and a laparotomy is performed. At operation there is evidence of small liver laceration that has stopped bleeding and a tear to the inferior pole of the spleen. Splenic conservation As minimum damage, attempt conservation. 3. An 18 year old man is involved in a road traffic accident. A CT scan shows disruption of the splenic hilum and a moderate sized perisplenic haematoma. Splenectomy Hilar injuries usually mandate splenectomy. The main risk with conservative management here is that he will rebleed and with hilar injuries this can be dramatic. Splenic trauma The spleen is one of the more commonly injured intra abdominal organs In most cases the spleen can be conserved. The management is dictated by the associated injuries, haemodynamic status and extent of direct splenic injury. Management of splenic trauma Conservative Small subcapsular haematoma Minimal intra abdominal blood No hilar disruption Laparotomy with conservation Increased amounts of intraabdominal blood Moderate haemodynamic compromise Tears or lacerations affecting 3 loose or watery stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days Acute Diarrhoea Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever Antibiotic therapy More common with broad spectrum antibiotics Clostridium difficile is also seen with antibiotic use Constipation causing overflow A history of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderly Chronic Diarrhoea Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur Crohn's disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction Colorectal cancer Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia
19. 48. Coeliac disease In children may present with failure to thrive, diarrhoea and abdominal distension In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist Other conditions associated with diarrhoea include: Thyrotoxicosis Laxative abuse Appendicitis with pelvic abscess or pelvic appendix Radiation enteritis Diagnosis Stool culture Abdominal and digital rectal examination Consider colonoscopy (radiological studies unhelpful) Thyroid function tests, serum calcium, anti endomysial antibodies, glucose 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 A. Inflammation of Payers patches B. Cystic fibrosis C. Meckels diverticulum D. Mesenteric cyst E. Mucosal polyps 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. Cystic fibrosis may lead to the formation of meconium ileus equivalent and plugs may occasionally serve as the lead points for an intussusception. Intussusception- Paediatric Intussusception typcially presents with colicky abdominal pain and vomiting. The telescoping of the bowel produces mucosal ischaemia and bleeding may occur resulting in the passage of "red current jelly" stools. Recognised causes include lumenal pathologies such as polyps, lymphadenopathy and diseases such as cystic fibrosis. Idiopathic intussceception of the ileocaecal valve and terminal ileum is the most common variant and typically affects young children and toddlers. The diagnosis is usually made by abdominal ultrasound investigation. The decision as
20. 49. to the optimal treatment is dictated by the patients physiological status and abdominal signs. In general children who are unstable with localising peritoneal signs should undergo laparotomy as should those in whom attempted radiological reduction has failed. In relatively well children without localising signs attempted hydrostatic reduction under fluroscopic guidance is the usual treatment. Which one of the following is least likely to cause malabsorption? A. Primary biliary cirrhosis B. Ileo-colic bypass C. Chronic pancreatitis D. Whipples disease E. 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. An ileo-colic bypass leaves a redundant loop of small bowel in continuity, where the contents will stagnate and bacterial overgrowth will occur. Therefore this is recognised cause of malabsorption. Malabsorption Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production or secretion) and biliary (deficiency of bile-salts needed for emulsification of fats) Intestinal causes of malabsorption coeliac disease Crohn's disease tropical sprue Whipple's disease Giardiasis brush border enzyme deficiencies (e.g. lactase insufficiency) Pancreatic causes of malabsorption chronic pancreatitis cystic fibrosis pancreatic cancer
21. 50. Biliary causes of malabsorption biliary obstruction primary biliary cirrhosis Other causes bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop) short bowel syndrome lymphoma Theme: Intra abdominal malignancies A. Metastatic adenocarcinoma of the pancreas B. Metastatic appendiceal carcinoid C. Metastatic colonic cancer D. Pseudomyxoma peritonei E. MALT lymphoma F. Retroperitoneal liposarcoma G. Retroperitoneal fibrosis For the disease given please give the most likely primary disease process. Each option may be used once, more than once or not at all. 10. A 32 year old man is admitted with a distended tense abdomen. He previously underwent a difficult appendicectomy 1 year previously and was discharged. At laparotomy the abdomen is filled with a gelatinous substance. You answered Metastatic appendiceal carcinoid The correct answer is Pseudomyxoma peritonei Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source. 11. A 62 year old man is admitted with dull lower back pain and abdominal discomfort. On examination he is hypertensive and a lower abdominal fullness is elicited on examination. An abdominal ultrasound demonstrates hydronephrosis and intravenous urography demonstrated medially displaced ureters. A CT scan shows a periaortic mass. You answered Metastatic colonic cancer
22. 51. The correct answer is Retroperitoneal fibrosis Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly understood. In a significant proportion the ureters are displaced medially. In most retroperitoneal malignancies they are displaced laterally. Hypertension is another common finding. A CT scan will often show a para-aortic mass 12. A 48 year old lady is admitted with abdominal distension. On examination she is cachectic and has ascites. Her CA19-9 returns highly elevated. Metastatic adenocarcinoma of the pancreas Although not specific CA 19-9 in the context of this history is highly suggestive of pancreatic cancer over the other scenarios. Pseudomyxoma peritoneii- Curative treatment is peritonectomy (Sugarbaker procedure) and heated intra peritoneal chemotherapy. Pseudomyxoma Peritonei Rare mucinous tumour Most commonly arising from the appendix (other abdominal viscera are also recognised as primary sites) Incidence of 1-2/1,000,000 per year The disease is characterised by the accumulation of large amounts of mucinous material in the abdominal cavity Treatment Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C. Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year survival rates of 75% have been quoted. Patients with disseminated intraperitoneal malignancy from another source fare far worse. In selected patients a second look laparotomy is advocated and some practice this routinely. Theme: Abdominal pain A. Acute mesenteric embolus B. Acute on chronic mesenteric ischaemia
23. 52. C. Mesenteric vein thrombosis D. Ruptured abdominal aortic aneurysm E. Pancreatitis F. Appendicitis G. Acute cholecystitis Please select the most likely underlying diagnosis from the list above. Each option may be used once, more than once or not at all. 13. A 72 year old man collapses with sudden onset abdominal pain. He has been suffering from back pain recently and has been taking ibuprofen. Ruptured abdominal aortic aneurysm Back pain is a common feature with expanding aneurysms and may be miss classified as being of musculoskeletal origin. 14. A 73 year old women collapses with sudden onset of abdominal pain and the passes a large amount of diarrhoea. On admission she is vomiting repeatedly. She has recently been discharged from hospital following a myocardial infarct but recovered well. You answered Mesenteric vein thrombosis The correct answer is Acute mesenteric embolus Sudden onset of abdominal pain and forceful bowel evacuation are features of acute mesenteric infarct. 15. A 66 year old man has been suffering from weight loss and develops severe abdominal pain. He is admitted to hospital and undergoes a laparotomy. At operation the entire small bowel is infarcted and only the left colon is viable. You answered Mesenteric vein thrombosis The correct answer is Acute on chronic mesenteric ischaemia This man is likely to have underlying chronic mesenteric vascular disease. Only 15% of emboli will occlude SMA orifice leading to entire small bowel infarct. The background history of weight loss also favours an acute on chronic event.
24. 53. Mesenteric vessel disease Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused by arterial embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries. Types Acute mesenteric embolus (commonest 50%) Sudden onset abdominal pain followed by profuse diarrhoea. May be associated with vomiting. Rapid clinical deterioration. Serological tests: WCC, lactate, amylase may all be abnormal particularly in established disease. These can be normal in the early phases. Acute on chronic mesenteric ischaemia Usually longer prodromal history. Post prandial abdominal discomfort and weight loss are dominant features. Patients will usually present with an acute on chronic event, but otherwise will tend not to present until mesenteric flow is reduced by greater than 80%. When acute thrombosis occurs presentation may be as above. In the chronic setting the symptoms will often be those of ischaemic colitis (mucosa is the most sensitive area to this insult). Mesenteric vein thrombosis Usually a history over weeks. Overt abdominal signs and symptoms will not occur until venous thrombosis has reached a stage to compromise arterial inflow. Thrombophilia accounts for 60% of cases. Low flow mesenteric infarction This occurs in patients with multiple co morbidities in whom mesenteric perfusion is significantly compromised by overuse of inotropes or background cardiovascular compromise. The end result is that the bowel is not adequately perfused and infarcts occur from the mucosa outwards. Diagnosis Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease). Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the arterial phase with thin slices (