Clinical Topic 4: Abdominal Pain

Question 1

What are the contents of the Inguinal Canal?

Answer 1

• Spermatic cord (males)
• Round ligament of uterus (females)
• Ilioinguinal nerve
• Genitofemoral nerve

Question 2

What structure is at most risk of damage during an Inguinal hernia repair?

Answer 2

Ilioinguinal nerve

Question 3

What are some risk factors of hernia formation?

Answer 3

Previous history of hernia, older age, male sex, chronic cough, chronic constipation, smoking

Question 4

What is the relation of the Ilioinguinal nerve to the spermatic cord in males?

Answer 4

The ilioinguinal nerve is anterior to the spermatic cord

Question 5

What are the medial, lateral and inferior borders of the Hasselbach triangle?

Answer 5

Medial: Rectus abdominus
Inferior: Inguinal ligament
Lateral: Inferior epigastric vessels

Question 6

What are the five sets of tissue, anterior to posterior, separating the bowel from herniation?

Answer 6

1. External Oblique Aponeurosis
2. External Oblique
3. Internal Oblique
4. Transversus Abdominus
5. Transversalis Fascia

Question 7

What are the anterior and posterior borders of the Inguinal Canal?

Answer 7

Anteriorly: External Oblique Aponeurosis

Posteriorly: the Transversalis Fascia

Question 8

What is the floor of the Inguinal Canal?

Answer 8

Inguinal Ligament

Question 9

What is the roof of the Inguinal Canal?

Answer 9

Internal Oblique, Transversalis Fascia, Transversus Abdominus

Question 10

What is the cause of an Indirect Inguinal Hernia? What is the fate of the peritoneal sac?

Answer 10

Failure of the processus vaginalis to regress. The peritoneal sac enters the inguinal canal through the deep inguinal ring and out the superficial inguinal ring

Question 11

What is the cause of a Direct Inguinal Hernia? What is the fate of the peritoneal sac?

Answer 11

Weakening of the abdominal musculature. The peritoneal sac enters the inguinal canal through the Hasselbach’s triangle / posterior wall and out the superficial inguinal ring

Question 12

Where is the Indirect inguinal hernia with reference to the inferior epigastric artery?

Answer 12

Lateral to the inferior epigastric artery

Question 13

Where is the Direct inguinal hernia with reference to the inferior epigastric artery?

Answer 13

Medial to the inferior epigastric artery

Question 14

What are the medial, lateral and superior borders of the Femoral Triangle?

Answer 14

Superiorly: Inguinal Ligament
Medially: Adductus Longus
Laterally: Sartorius

Question 15

Are Indirect and Direct Inguinal Hernias acquired or congenital? Which are more common?

Answer 15

Indirect - Congenital (are more common)

Direct - Acquired (are least common)

Question 16

What is an Epigastric Hernia?

Answer 16

Herniation of bowel through the Linea Alba, above the umbilicus

Question 17

What are the references for the Femoral Nerve and Femoral Artery?

Answer 17

Femoral Nerve: Midpoint of Inguinal ligament

Femoral Artery: Mid-Inguinal point

Question 18

What are complications of a Hernia?

Answer 18

Incarceration (trapping of hernia in wall)

Strangulation (ischaemia of bowel tissue)

Question 19

The appendix is embryologically derived from what? What is the arterial supply and drainage?

Answer 19

The midgut. Is supplied by the appendicular artery, a branch of the superior mesenteric artery. Drained by the appendicular vein

Question 20

What is the lymphatic drainage of the Appendix?

Answer 20

Ileocolic lymph nodes

Question 21

The sympathetic fibres to the Appendix run from which region of the spinal cord?

Answer 21

T10

Question 22

What is the most common position of the Appendix?

Answer 22

Retrocaecal position (11 o’clock)

Question 23

What is McBurney’s Point defined as?

Answer 23

1/3 lateral from the ASIS to the umbillicus

Question 24

Where is the approximate base of the appendix?

Answer 24

2cm from the Ileocaecal valve

Question 25

Rupture of the appendix causing peritonitis leads to what specific set of pain symptoms?

Answer 25

Rebound tenderness (pain on removing pressure) and abdominal guarding

Question 26

What are 4 causes of Appendicitis?

Answer 26

- Obstructed Faecolith - Undigested material - Parasitic infection - Lymphoid hyperplasia

Question 27

What are 3 complications of Appendicitis?

Answer 27

- Rupture of appendix - Periappendiceal abscess - Subphrenic abscess

Question 28

What are the two bacterial strains associated with a case of perforated Appendicitis?

Answer 28

Bacteroides fragilis | Echerischia coli

Question 29

What is the Rovsing's sign? What does it suggest?

Answer 29

Palpation of the LLQ increases pain in RLQ. Sign of appendicitis

Question 30

What is the Psoas sign? What does it suggest?

Answer 30

Extension of right hip causes pain in RLQ. Sign of appendicitis in the retrocaecal position

Question 31

What are the three main types of Volvulus? Which is most common

Answer 31

Sigmoid volvulus (most common) Caecal volvulus Mindgut volvulus

Question 32

What is Hirschprung's disease?

Answer 32

Where nerves to the intestine are missing in parts, causing constipation as the main symptom

Question 33

Sigmoid volvulus is commonly seen in what sorts of patients?

Answer 33

- Can affect pregnant women - Can affect middle-aged / elderly with constipation - Can affect patients with Hirschprung's disease

Question 34

Caecal volvulus is caused by what? What patients present with it?

Answer 34

Presents in young adults, and occurs due to poor mesentery development where there are fever attachment points

Question 35

Midgut volvulus is caused by what? What patients present with it?

Answer 35

Presents in babies and young children, where they have a poorly developed intestine causing malrotation at 12 weeks in utero

Question 36

How might a Volvulus present on a Barium Enema?

Answer 36

"Bird's beak appearance"

Question 37

How are Sigmoid and Caecal volvulus treated?

Answer 37

Sigmoid volvulus - Sigmoidoscopy | Caecal volvulus - Colonscopy