Abdominal condition 1

Question 1

pathophysiology of Abdominal Aortic Aneurism

Answer 1

irreversible dilation of the vessel by at least 50% of normally expected diameter (2cm)

caused by degrading of the elastic layer of the artery

Question 2

what is the normal diameter of the abdominal aorta

Answer 2

2 cm ( but inc with age)

Question 3

presentation of unruptured AAA

Answer 3

mostly have no symptoms, incidental findings in AXR or CTKUB.

can also present with pain in the back+/-abdo+/-loin

pulsatile expansive swelling/limb ischaemia

Question 4

presentation of ruptured AAA

Answer 4

hypoTN

atypical abdominal symptoms

sudden onset and severe pain in the back

syncope

shock

collapse

PEA cardiac arrest

Question 5

where is the most common place in the abdominal aorta for the aneurysm to occur

Answer 5

infra-renal portion of the abdominal aorta

Question 6

examination finding of AAA

Answer 6

triad of abdo/back pain + pulsating abdo mass + hypotension

bimanual palpitation of the supra umbilical region

pulsatile and expansile pulse

abdo bruit

Cullen’s and grey turners’ Sign if ruptured

Question 7

investigation fot AAA

Answer 7

abdo USS - to confirm the diagnosis of AAA

bloods –> FBC, U&Es, clottings, crossmatch, group & save, clotting, CRP

ECG

USS, CT, MR angiography if non-urgent

Question 8

Management of ruptured AAA

Answer 8

Acute ruptured AAA
• acute resus  A-E, target systolic BP 50-70, NBM for urgent surgical repair (endovascular aneurysm repair EVAR preferred) + ABx for surgery

Symptomatic but not ruptured AAA
• if symptomatic regardless of diameter  urgent surgical repair (EVAC preferred) + low-dose aspirin & control HTN (both to lower cardiovascular risk) + Abx for surgery

Incidental finding – small asymptomatic AAA (4 – 5.5cm)
• surveillance + aggressive cardiovascular risk management (low dose aspirin + control HTN + statin + beta-blocker if MI risk high)

Incidental finding – large asymptomatic AAA (>5.5cm in men, > 5cm in women)
• elective surgical repair (EVAR/open) + low-dose aspirin + control HTN +/- beta blocker + abx for surgery

Question 9

Aetiology of appendicitis

Answer 9

infection and obstruction caused by lymphoid tissue hyperplasia, faecolith or filarial worms leading to oedema, ischaemic necrosis and perforation

Question 10

presentation of appendicitis

Answer 10

abdo pain - starts generalised, then becomes to localised to the RIF

lack of appetite and sometimes vomiting and diarrhoea

Question 11

findings on examination for appendictis

Answer 11

abdo pain and guarding in the RIF

could be a tender mass due to an appendix abscess

Rovsing’s sign - inc pain in the RIF when LIF is pressed

Psoas sign - pain on extending the hip if retrocaecal appendix

Cope sign - pain on flexion and internal rotation of the righ hip if appendix is close to the obturator internus

general signs - tachycardia, fever, furred tonged, lying still, coughing hurts, shallow breathe (due to pain)

Question 12

investigation for appendicitis

Answer 12

usually clinical diagnosis but can also do USS/CT (CT more accurate)

bloods - neutrophil leucocytes, elevated CRP/ESR

US - may show inflamed appendix (not always visible)

CT - highly accurate but not always worth the radiation dose

Question 13

management of appendicitis

Answer 13

appendectomy - eith open or laproscopic

ABX - metronidazol and cefuroxime

Question 14

differentials of appendicitis

Answer 14

ectopic pregnancy 
UTI 
PID 
diverticulitis 
mesentric adenitis 
cystitis

Question 15

what is another name for biliary tract infection

Answer 15

cholecystitis

Question 16

RF of cholecystitis & gall stones

Answer 16

5 fs

Fat 
Forty 
Female 
Fiar 
Fertile

Question 17

what are 2 main types of gallstone

Answer 17

cholesterol gallstones = 80% of all gallstones ( from in the bile due to either lack of bile salt or hypercholesterolaemia)

pigment stones - consist of bilirubin polymers, seen in pt with chronic haemolysis (sickle cell)

Question 18

what is the biggest cause of acute cholecystitis

Answer 18

gallstone

Question 19

presentation of acute cholecystitis?

Answer 19

often asymptomatic

continuous epigastric/RUQ pain –> can radiate to R shoulder

vomiting, fever, local peritonism

Question 20

clinical signs of acute cholecystitis

Answer 20

exam often normal

Murphy’s sign - pain on inhalation due to peritonisum

fever Gallbladder mass

Question 21

investigation for cholecystitis

Answer 21

clinical diagnosis

USS for confirmation of diagnosis –> thicken wall, shrunken GB, fluid.

amylase

Inc in ALP and bilirubin, WBC (possible)

CXR and ECG to rule out atypical MI

Question 22

management of acute cholecystitis

Answer 22

initial treatment  supportive  NBM, IV fluids, analgesia (opiate), IV Abx (ceftriaxone + metronidazole + Tazocin/meropenem/imipenem

Definitive treatment
- Cholecystectomy  delayed for a few days to allow symptoms to settle

if worsening pain, fever, empyema or gangrene of GB urgent USS abdo/CT to identify pathogens then urgent lab cholecystectomy

Question 23

what are the different types of bowel obstruction

Answer 23

mechanical and functional

small and large bowel

Question 24

what does biliary colic mean

Answer 24

Biliary colic = RUQ pain, radiate to the back +/- jaundice

Question 25

what can cause mechanical bowel obstruction

Answer 25

``` adhesion constipation tumours hernias sigmoid/caecal volvulus diverticular stricture ``` ``` rare foreign body gallstone illeus CD strictures intussusception TB ```

Question 26

which section of the bowel is bowel volvus most commonly seen?

Answer 26

sigmoid

Question 27

what can cause functional bowel obstruction

Answer 27

due to paralysis of the muscle controlling the GIT post-op ileus (most commonly occur post- abdo surgery) electrolyte disturbance - hypokalemia, hyponatraemia, ureamia drugs - tricyclics

Question 28

clinical features of bowel obstruction

Answer 28

colicky abdo pain vomiting (faceical = sigmoid obstruction, bilious = small intestine) distension absolute constipation absence (late) or tinkling bowel sound general signs - fever, shock, hernia, dehydration

Question 29

investigation for bowel obstruction

Answer 29

bloods  FBC, U&Es, GC+S, clotting, VBG  assess for pH and electrolyte from vomiting and bowel strangulation AXR + erect CXR CT (with/without contrast) – to confirm the diagnosis, cause, and guides surgical intervention Abdo USS – critically ill patients, suspected SBO and contraindicated for contrast CT

Question 30

management for bowel obstruction

Answer 30

* NBM * drip and suck  IV fluids + NG (Ryles) tube to drain stomach content * IV analgesia and antiemetics * surgery if haemodynamically unstable, features of sepsis, signs of ischemia and necrosis, partial obstruction > 3 days * incomplete SBO  can be treated initially conservatively & correction of electrolyte imbalance * LBO/strangulation  requires surgery, emergency if strangulation, stenting can be use * sigmoid volvulus  ‘un-kinked’ with flexible sigmoidoscopy

Question 31

what is drip and suck

Answer 31

it is nasogastric depression of the gastric content as part of the management of the small bowel obstruction

Question 32

causes of diverticulitis

Answer 32

lack of dietary fibre is thought to be a cause of inc intra-luminal pressure, causing the mucosa to herniate through the muscle of the gut the hardened faeces cause stagnation of faces in the neck of the diverticulum allowing bacteria to grow and cause infection

Question 33

which part of the GIT is diverticulitis found

Answer 33

sigmoid colon

Question 34

definition of the diverticulitis

Answer 34

inflammation to the diverticulum - can be acquired or congenital

Question 35

what can diverticulitis lead to?

Answer 35

peri-colic abscess frank peritonitis

Question 36

presentation of diverticulitis

Answer 36

abdo pain - lower left-sided colic (sigmoid), constant, dull fever, tachycardia, tenderness, rigidity change in bowel habits pain often relied on defecation nausea and flatulence mass in LLQ, bowel sound reduced abrupt painless bleeding -> if diverticulum bleeding

Question 37

investigation for diverticulitis

Answer 37

bloods - FBC, U&Es, CPR and WCC erect CXR (perforation, free gas and fluid collections), AXR and USS

Question 38

management for diverticulitis

Answer 38

diverticulosis no treatment, but high fibre diet diverticulitis 24 hours admission if CRP elevated + ABx  ciprofloxacin + Metronidazole if severe disease o bowel rest o IV fluids o IV Abx  ciprofloxacin + metronidazole o surgical resection if severely sepsis and obstruction

Question 39

definition of ectopic pregnancy

Answer 39

fertilised ovum implants outside the uterine cavity

Question 40

where is the most likely place for an ectopic pregnancy to occur

Answer 40

in the fallopian tube - ampulla/narrow inextensible isthmus

Question 41

which type of ectopic pregnancy is most likely to rupture

Answer 41

in the inextensible isthmus

Question 42

RF for ectopic pregnancy

Answer 42

anything that slows the ovum to pass - PID or previous surgery prosgesterone only pill smoking IVF IUD

Question 43

what is the biggest RF for ectopic pregnancy

Answer 43

previous ligation of the tube --> 9x more likely to have ectopic pregnancy

Question 44

presentation of ectopic pregnancy

Answer 44

sudden, severe, lower abdo pain shoulder tip pain (irritation to the diaphragm) vaginal bleeding bloating collapse/fainting D+V amenorrhoea 6-8 wks peritonism

Question 45

investigation for an ectopic pregnancy

Answer 45

vaginal and speculum exam serum hCG TVUSS - gold standard, might be able to see Bagel sign bloods - FBC, G&S ( if surgery needed) Serum progesterone and hCG (lower than expected due to failed pregnancy) to help identify failing pregnancy

Question 46

management of ectopic pregnancy

Answer 46

if stable - expectant and medical management according to criteria (hCG<5000 Iu/L) if unstable - surgical management

Question 47

what are the selection criteria for expectant and medical management of ectopic pregnancy

Answer 47

asymptomatic or mild symptoms hCG< 5000 ru ectopic pregnancy < 3cm on scan with no foetal activity no haemoperitoneum on TVS

Question 48

what is expectant as an management for ectopic pregnancy

Answer 48

watch and wait medically - check up every week

Question 49

what is the medical management of ectopic pregnancy

Answer 49

methotrexate as a single dose (teratogenic) suggest future use of reliable contraceptive

Question 50

definition of miscarriage

Answer 50

foetal death < 24 wks

Question 51

causes of miscarriage

Answer 51

• foetal abnor • sporadic chromosomal abnor (most common) • structural malformation  major neural tueb defects eg 1/3 of Downs miscarry • uterine malformation eg bicornuate uterus • acute pyrexial illness • chronic maternal disease eg chronic renal failure • maternal age thrombophilia

Question 52

presentation of miscarriage

Answer 52

vaginal bleeding pain (lower chance of baby surviving) vaginal discaharge --> conception materials

Question 53

investigations for miscarriage

Answer 53

``` • hx and examination • blood group and rhesus factors • pregnancy test • TV USS serum HCG – inc if viable, dec if complete miscarriage ```

Question 54

management of miscarriage

Answer 54

if heavy bleeding --> use ergometrine 500 mcg IM (used to cause uterine to contract so hard to stop bleeding) expectant management medical management - misoprostol ( prostaglandin to cause the cervix to ripen (thinning) and cause the uterine to contract surgical management - EVAC

Question 55

what is ovarian cyst

Answer 55

A fluid-filled sac present in the ovarian tissue

Question 56

how common is ovarian cysts

Answer 56

extremely common particularly in women of reproductive age

Question 57

what size of ovarian cysts would you expected to not cause any problem

Answer 57

< 5cm

Question 58

what are the different types of ovarian cysts

Answer 58

physiological infectious benign neoplastic malignant neoplastic metastatic

Question 59

which cancer most commonly cause metastatic ovarian cyst

Answer 59

ovarian, endometrial, colonic and gastric cancer

Question 60

symptoms of ovarian cysts

Answer 60

often asymptomatic and incidental findings ``` chronic pain (dull ache) dysparaurea cyclical pain (with different periods) ``` can present as acute pain - due to bleeding within the cyst --> ovarian torsion irregular vaginal bleeding hormonal effects abdo swelling/mass - ascites suggest malignancy

Question 61

examination finding of ovarian cysts

Answer 61

can be normal is cyst small or women obese if acute presentation - signs of shock abdo exam - mass from pelvis, tenderness, peritonism or ascites vaginal exam - vaginal discharge or bleeding cervical excitation adnexal mass /tenderness

Question 62

investigation of ovarian cysts

Answer 62

FBC tumour markers - Ca-125, AFP, Ca-19.9, LDh, hCG and CEA transvaginal USS MRI abdo

Question 63

management of acute presentation of ovarian cysts

Answer 63

if unstable --> laparotomy

Question 64

management of ovarian cysts in pre menopausal women

Answer 64

preserve fertility and exclude malignancy conservative if stable & < 5cm TVS repeats in 6 wks if no sign of malignancy and symptoms resolve then no surigcal intervention but if still symopatic --> laparoscopic ovarian cystectomy

Question 65

management of ovarian cysts in post menopausal women

Answer 65

calculate risk of malignancy low risk cyst <5cm --> TVS every 4 months and Ca-125 moderate risk cysts --> bilateral oophorectomy high risk --> referral to cancer centre for staging and laparotomy

Question 66

what is pelvic inflammatory disease

Answer 66

infection spread from the cervix ascendingly to the ovary, uterus, fallopian tubes etc can also descend from other organs eg appendix but not common

Question 67

most common cause of PID

Answer 67

``` STI uterine instrumentation (hysterectomy, insertion of IUD, TOP - terminal of pregnancy) ```

Question 68

which STI most likely to cause PID

Answer 68

Chlamydia | Gonorrhoea

Question 69

symptoms of PID

Answer 69

lower abdo pain (can be both bilateral and unilateral) can be constant/intermittent deep dyspareunia vaginal discharge intermenstrual/poscoital bleeding dysmenorrhoea fever

Question 70

examination finding of PID

Answer 70

vaginal discharge maybe present cervical motion tenderness uterine tendernes adnexal tenderness

Question 71

investigation for PID

Answer 71

vulvovaginal/endocervical swabs - for chlamydia and gonorrhoea + MC&S FBC ( WCC elevated) CRP TVS ( if tubo-ovarian abscess)

Question 72

management of PID

Answer 72

treat at home with a review after 72 hour if stable if not hospital admission ceftriaxone or azithromycin for start + doxycycline for 2 weeks + metronidazole fo 2 wks

Question 73

what are the aetiologies of abdominal aortic aneurysms?

Answer 73

sometimes idiopathic aethersclerosis trauma infection - mycotic aneurysm (endocarditis), tertiary syphilis connective tissue disorder - Marfan's & Ehlers-Danlos inflammatory - Takayasu's aortitis

Question 74

presentation of acute cholangitis

Answer 74

Charcot's triad - fever, RUQ pain, jaundice if not pick up in time, it can progress to Raynoid's Pentard - Charcot's triad + hypotension and confusion

Question 75

management of acute cholangitis

Answer 75

initial IV ABx + urgent bile duct drainage (done via endoscopic retrograde approach) if severe ill  stent to reduce time for removing the stone definitive lap cholecystectomy to remove the stone

Question 76

management of unstable/ruptured ectopic pregnancy

Answer 76

surgical - lap salpingostomy/salpingectomy if hCG does not return to undetectable post-surgery --> single dose methotraxate