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appendix mass vs abscess

Appendix massThe natural history of untreated acute appendicitis is that it will resolve, become gangrenous and perforate, or it will become surrounded by a mass of omentum and small bowel that walls off the inflammatory process and prevents inflammatory spread to the abdominal cavity yet delays resolution of the condition. Such patients usually present with a longer history (a week or more) of right lower quadrant abdominal pain. On examination the patient has a persistent low-grade fever, mild tachycardia and there is a tender indistinct mass in the right iliac fossa. The condition is usually best managed conservatively, as the risk of perforation has passed and removal of the appendix can be difficult. This differs from appendix abscess, when a perforated appendix becomes walled off by omentum. Unlike an appendix mass, the patient with an appendix abscess becomes systemically unwell with intermittent swinging pyrexia, rigors and profuse sweating. Drainage, either under radiological control or surgically, is the best initial treatment


Rectus sheath haematoma

Rectus sheath haematomaThis occurs following rupture of the inferior epigastric artery, typically after coughing or straining. The site of the haematoma is usually at the level of the arcuate line and produces a mass in the relevant iliac fossa. The lump is related to the muscles of the anterior abdominal wall, contraction of which makes the lump indistinct. Bruising may not always be apparent. The condition occurs in three distinct groups of individuals: elderly women, pregnant women and athletic, muscular men. Exploration of the anterior abdominal wall, evacuation of haematoma and ligation of the bleeding vessel may be required, however, small haematomas can be treated conservatively.


Utero-vaginal prolapse

Utero-vaginal prolapseUtero-vaginal prolapse is related to pelvic floor trauma sustained during childbirth and oestrogen deficiency following the menopause. Typically, symptoms associated with genital prolapse include a dragging sensation in the pelvis or awareness of ‘something coming down’. Resultant pelvic floor dysfunction impacts on urinary, sexual and rectal evacuatory function, resulting in voiding difficulties/urinary incontinence, impaired coitus and evacuation difficulties, respectively. The multi-system disruption of pelvic organ function suggests the diagnosis, which is confirmed on clinical examination. Such patients are prone to bladder and rectal prolapse as a result of weakening of the pelvic floor musculature. Treatment may include non-surgical measures (pelvic floor physiotherapy, oestrogen replacement therapy and intravaginal devices), although surgery to eliminate the prolapse and restore pelvic floor function offers definitive treatment.


Benign ovarian tumour

Benign ovarian tumourBenign ovarian tumours are common in this age group. Most tumours of the ovary are simply large versions of the cysts that form during the normal ovarian cycle, and so are small, asymptomatic and resolve spontaneously. These are termed ‘functional’ cysts. Benign germ cell tumours (eg dermoid cyst) are also common in women less than 30 years of age. Other histological types include benign epithelial and sex cord stromal tumours. Symptoms tend not to occur until the tumour is larger than 3–5 cm, although complications such as rupture, haemorrhage, or infection may result in acute pelvic pain. Occasionally, large tumours may give rise to urinary or gastrointestinal symptoms because of pressure effects. Menstrual disturbance is uncommon, unless the tumour secretes oestrogens (sex cord tumours). Cyst formation may complicate endometriosis (endometrioma), but here the clinical picture is usually of dysmenorrhoea, dyspareunia and sub-fertility.


Painful bladder syndrome

Painful bladder syndromePatients with painful bladder syndrome complain of bladder pain and irritative bladder symptoms (frequency, urgency, nocturia and dysuria). The bladder pain is worse when the bladder is distended, and often improved following micturition. Urine cultures are repeatedly negative, leading the unwary to exclude a urinary cause of pain in such patients. Causes include radiation, chemical and interstitial cystitis. Urine should be cultured for atypical organisms (Mycoplasma and Ureaplasma). Cystometry and cystoscopy are useful diagnostic tests and often reveal a low capacity, non-compliant (‘stiff’) bladder. Cystoscopy may reveal subepithelial haemorrhages in patients with interstitial cystitis and allows biopsies to be taken for histological confirmation of this condition.


caecal ca

Carcinoma of the caecumIn contrast with left-sided tumours, caecal carcinoma has an insidious onset with generalised features of malignant disease, such as anaemia, anorexia, weight loss and lethargy. Late features include a palpable mass in the right iliac fossa and obstruction to the ileocaecal valve resulting in small bowel obstruction. Obstruction of the appendiceal orifice can give rise to symptoms and signs of acute appendicitis, a fact that should be remembered when faced with a patient over the age of 40 with appendicitis.


pancreas ca

Carcinoma of the head of the pancreasThe history and findings are of obstructive jaundice with a palpable gallbladder. Courvoisier’s law states ‘when the gallbladder is palpable and the patient is jaundiced, the obstruction of the bile duct causing the jaundice is unlikely to be a stone because previous inflammation will have made the gallbladder thick and non-distensible’. While there are a few exceptions to this rule, the history of substantial weight loss, and of pain radiating to the left side of the back strongly indicate the likelihood of pancreatic carcinoma – which is the commonest cause of malignant biliary obstruction


mesenteric cyst

Mesenteric cystThese cysts are found most commonly in the mesentery of the ileum arising from congenitally misplaced lymphatic tissue (chylolymphatic cyst) or from remnants of reduplicated bowel (enterogenous cyst). They typically present in the second decade of life as a painless swelling or with recurrent episodes of abdominal pain. Acute abdominal pain may arise following rupture or bleeding into a cyst. On examination the characteristic finding is that of a fluctuant, resonant, spherical swelling, close to the umbilicus. The cyst is freely mobile in a plane at right angles to the root of the mesentery and may ‘slip’ during the course of the examination.


Congenital spherocytosis

Congenital spherocytosisApproximately 75% of cases are autosomal dominant disorders characterised by defects in the red cell membrane that render erythrocytes spheroidal, less deformable and vulnerable to splenic sequestration. Anaemia, moderate splenomegaly and jaundice are characteristic. After 10 years of age, 40–50% of patients develop gallstones secondary to hyperbilirubinaemia. Splenectomy is indicated in the majority of patients, as red cell survival reverts to normal even though the abnormality persists.



B – Chronic myeloid leukaemiaThis primarily affects adults in the 4th and 5th decades of life, accounting for 15–20% of all cases of leukaemia. It is a clonal disorder of pluripotent stem cells that predominantly differentiate along the granulocytic pathway. Initial symptoms are non-specific; however, a dragging sensation in the abdomen caused by extreme splenomegaly is characteristic. Symptomatic hypersplenism may occur during the chronic phase of the disorder and may require splenectomy.


Overwhelming post-splenectomy sepsis

Overwhelming post-splenectomy sepsisAfter splenectomy the ability of the spleen to destroy encapsulated organisms is lost and infection can lead to the distinct clinical syndrome of overwhelming post-splenectomy infection (OPSI). In children splenectomised for trauma the incidence is about 1–2%, while for adults it is about 0.5%. Long-term penicillins are of proven value in children, as the maximal incidence of OPSI occurs within 2 years of surgery. Prophylaxis with polyvalent vaccines is also recommended (usually to pneumococcus, meningococcus and Haemophilus influenzae).


gallstone ileus

Gallstone ileusGallstones are responsible for less than 1% of all cases of small bowel obstruction. About 90% of stones entering the intestine will impact in the terminal ileum, although other reported sites include the duodenum, jejunum, colon and rectum. A stone formed in the gall bladder enters the small bowel via a biliary-enteric fistula, usually between the gallbladder and duodenum. Patients tend to be elderly and often do not report a history of cholecystitis. On X-ray the presence of a pneumobilia is pathognomic, provided there is no recent history of biliary-intestinal bypass or sphincterotomy



The case gives the classical history of a patient with a sigmoid volvulus who is typically elderly and institutionalised, suffering with chronic constipation and regular laxative use. There is usually a history of similar episodes in the past, which resolve following ‘untwisting of the sigmoid mesentery’. Typical X-ray findings are of a large oval gas shadow on the left hand side, which is looped onto itself, the so-called ‘bent inner tube’ or ‘coffee bean’ sign. Treatment is by decompression by means of a flatus tube inserted via a sigmoidoscope, done of course at arm’s length! Should this fail then operative ‘untwisting’ with or without resection may be required.


large bowel obstruction

There are four common causes of large bowel obstruction in Western society: carcinoma, diverticular disease, volvulus (principally sigmoid) and pseudo-obstruction.



Pseudo-obstructionIn a large hospital, barely a week goes by without being referred such a patient either by the medical, neurosurgical, or orthopaedic teams. Colonic pseudo-obstruction probably represents about a quarter of all large bowel obstruction. It is a reactive dilatation and ileus, presumed (although notproven) to be secondary to disturbed autonomic (cholinergic) innervation. Classic conditions that may precipitate it are sepsis, especially chest infections, cerebrovascular accident/neurosurgery, fractured NOF, and spinal/retroperitoneal surgery (these probably directly disrupt nerves – indeed, the condition was first described in this respect with retroperitoneal tumours (Ogilvie’s syndrome).


ischaemic stricture

Ischaemic strictureIschaemia of the left hemicolon is a recognised complication of abdominal aortic aneurysm repair and occurs as a result of an insufficient collateral blood supply from the marginal artery following ligation of the inferior mesenteric artery. Presentation may be acute, with the passage of bloody diarrhoea, or insidious as in the case described. The region of the splenic flexure is commonly affected and chronic ischaemia may result in the formation of a stricture, indistinguishable from a carcinoma on barium enema examination. Mesenteric arteriography confirms the diagnosis.


Diffuse oesophageal spasm

Diffuse oesophageal spasmThis is a clinical syndrome characterised by symptoms of retrosternal chest pain and/or intermittent dysphagia. The chest pain can be severe and is frequently mistaken as cardiac in origin. Initially described by Osgood in 1889, the first manometric descriptions were not until 1958. Before manometry, the diagnosis relied on the symptom complex and the radiological findings of a normal oesophageal lumen, failure of peristaltic propagation, and simultaneous oesophageal contractions, sometimes resulting in a beaded appearance. A variety of radiological appearances and terminologies have been used such as ‘pseudodiverticulosis’, ‘segmental spasms’, and ‘corkscrew oesophagus’, although in most cases the diagnosis would be missed by barium swallow/gastroscopy as the oesophagus usually appears normal.


Bulbar palsy

This is a palsy of the tongue, muscles of mastication, muscles of deglutition, and facial muscles as a result of loss of function of brainstem motor nuclei. The signs are those of a lower motor neurone lesion. Bulbar palsy is one of the principal clinical patterns distinguished in motor neurone disease (MND) (25% of cases); other causes include Guillain–Barré syndrome, polio and brainstem tumours. MND never affects the extraocular movements, distinguishing it from myasthenia gravis. In contrast to bulbar palsy, pseudobulbar palsy is an upper motor neurone lesion usually caused by stroke.


actively bleeding duodenal ulcer with visible vessels at its base.

OGD and adrenaline injectionIn such a situation it is recommended that haemostasis is attempted with injection of 1 : 10, 000 adrenaline. Although evidence-based practice has shown heat probe, bipolar diathermy and injection sclerotherapy all to be effective, adrenaline injection is often used in combination with these modalities, and available trials show that adrenaline alone is equally effective. Repeated injection of fibrin glue or the application of micro-clips should be limited to specialist centres where operators are undertaking such procedures on a regular basis, and hence have special expertise. Only if this fails or if there are other endoscopic or clinical indications should the patient undergo surgery (under-running of ulcer).


pancreatic ca

Pancreatic carcinomaThe patient has presented with progressive symptoms suggestive of underlying pancreatic carcinoma. The finding of a palpable gallbladder may imply gallbladder pathology (eg gallstones). However, if Courvoisier’s law (‘if in the presence of jaundice the gallbladder is palpable, the cause is unlikely to be related to stones’) is applied, the correct diagnosis is reached. The principle is that if the obstruction of the common bile duct is a stone, the gallbladder is usually fibrotic and therefore does not distend. Cholangiocarcinoma and multiple liver metastases can present similarly but the former is much less common than pancreatic cancer (this is therefore the more likely diagnosis) and the latter is associated with a palpable liver not gallbladder. Other characteristic symptoms of pancreatic cancer include severe abdominal and back pain. Investigations include ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography and cytology.



Primary biliary cirrhosisThe presentation described is fairly typical for this disorder, 90% of cases are female and the peak age is 45–50 years. This autoimmune disorder is suspected from the typical pattern of the liver function tests, is confirmed by the finding of anti-mitochondrial antibodies/smooth muscle antibodies, and is proven by characteristic histology from liver biopsy. Associated disorders include thyroid disease and CREST (calcinosis, Raynaud phenomenon, oesophageal motility disorders, sclerodactyly, telangiectasia) syndrome. Treatment is symptomatic, eg nutritional support for malabsorption. Liver transplantation may be required.


acute pancreatitis

Acute pancreatitisThe patient’s symptoms and signs are consistent with the diagnosis of acute pancreatitis. Of importance is the fact that a normal serum amylase concentration is not sufficiently sensitive to rule out the diagnosis. As in the case illustrated, late presentation makes this more likely; serum amylase typically peaks in the first 12–48 h and may return to normal after 72 h. In such cases the urinary amylase and serum lipase concentrations may be of value. Hypocalcaemia may occur in this potentially life-threatening disorder. The absence of previous episodes of pain, diabetes and symptoms suggestive of malabsorption make chronic pancreatitis unlikely. The diagnosis is confirmed on ultrasound and computed tomography scan findings.



VipomaThese tumours are of APUD cells of the gastroenteropancreatic endocrine system. Patients tend to be middle-aged, with more women affected than men. Episodes of profuse watery diarrhoea are typical and continue even in the presence of fasting. Hypokalaemia occurs following excessive gastrointestinal secretion and symptoms of such may be the presenting feature. Vasoactive intestinal peptide (VIP) normally inhibits acid secretion; therefore, patients are hypochlorhydric or achlorhydric. Other abnormalities include hypercalcaemia and hyperglycaemia. Plasma VIP levels are elevated. Initial treatment is directed toward correcting volume and electrolyte abnormalities. Octreotide controls diarrhoea in 80% of cases. Both computed tomography and magnetic resonance imaging are of value in diagnosis and staging. Surgical exploration with tumour resection leads to cure in 50% of patients


ß-cell tumour of the pancreas

ß-cell tumour of the pancreasß-Cell tumour, or insulinoma, is the commonest form of islet cell tumour. Symptoms are related to hypoglycaemia and occur with increasing frequency and severity. Attacks may be more frequent in the early hours of the morning, with vague abdominal pain relieved by carbohydrates, hence the confusion with peptic ulcer disease. Episodes may similarly occur following exercise. The diagnosis is suggested by Whipple’s triad, ie: • attacks occurring in the fasting state• during the height of the attack there is hypoglycaemia below 2.5 mmol/litre• symptoms relieved by glucose.Confirmation is by the identification of fasting hypoglycaemia associated with elevated levels of human insulin. Pancreatic angiography may aid in preoperative localisation with treatment by surgical excision of the tumour.


Gallstone ileus

Gallstone ileusThis patient has symptoms typical of small bowel obstruction. Small bowel obstruction from impaction of a gallstone in the distal ileum is rare but most commonly occurs in women over 70 years old. It accounts for 20% of older patients with small bowel obstruction who do not have a history of a hernia or previous abdominal surgery. Plain abdominal films may show a classic triad of small bowel obstruction, a gallstone in the gut and gas in the biliary tree (although the Editor has yet to observe this in practice). Treatment is surgical with proximal enterotomy, removal of the stone, a search for further stones but not cholecystectomy (which is dangerous and unnecessary). A bonus mark could be given for this question for also choosing Mirizzi’s syndrome because most patients also have a fistula



AngiodysplasiaThese are a type of arteriovenous malformation and are one of the common causes of significant lower gastrointestinal bleeding in the elderly population. As in this case, it is notoriously difficult to pinpoint the actual offending vessel. Where direct vision fails, mesenteric angiography or radionucleotide scans can sometimes be of diagnostic use but often also yield negative results if the vessel is not actively bleeding at the time of investigation. Should angiography demonstrate the source of bleeding, therapeutic embolisation can be performed. In cases of continued bleeding with negative investigations, treatment may involve total colectomy as a life-saving measure.


outlet obstruction

Outlet obstructionThis patient has ‘functional constipation’, because investigations have excluded an organic cause. Constipation may refer to the infrequent and/or difficult passage of stools. A predominance of symptoms of difficult evacuation, which is often referred to as obstructed defaecation (eg excessive straining, a sensation of incomplete evacuation, digitation etc) is suggestive of outlet obstruction, rather than slow transit constipation, although physiological confirmation is required as symptoms do not accurately predict underlying pathophysiology. The history of perineal massage and a ‘bulge’ in the vagina (posterior wall) is suggestive of the presence of a rectocoele, which may lead to outlet obstruction, as a result of redistribution of evacuatory forces during defaecation.


idiopathic megabowel

Persistent dilatation of the bowel is known as megabowel. This may occur secondary to an absence of ganglion cells in the myenteric plexus (Hirschsprung disease), where failure of relaxation of the affected segment leads to gross proximal dilatation. Alternatively, no obvious cause may be identifiable, when it is termed idiopathic megabowel. This condition is characterised by severe infrequency of defaecation, with several weeks between bowel movements. There is usually associated passive leakage of stool as a result of ‘overflow’ around impacted stool in the rectum. The diagnosis is confirmed on barium enema, which reveals dilatation of the rectum, and sometimes colon. Management involves behavioural, medical and, rarely, surgical treatment.


collagenous colitis

Collagenous colitisThis is an uncommon form of colitis and is part of the disease spectrum termed microscopic colitis (the other main subdivision is lymphocytic). It is most common among middle-aged women and there is an association with autoimmune disorders such as coeliac disease, thyroid disorders, diabetes and rheumatoid arthritis. Patients typically present with symptoms and signs of colitis, as in the case described. Stool and blood investigations tend to be normal. Endoscopic examination of the bowel similarly appears normal to the naked eye and the disorder is generally diagnosed on histolological examination of biopsies taken at endoscopy – hence the name, microscopic colitis. No cure is yet available. Treatment is directed at reducing inflammation and the symptoms of diarrhoea by means of drugs such as sulphasalazine and mesalazine. Short courses of steroids may be required for severe cases.


colorectal cancer risk

D – ColonoscopyWhen assessing a patient’s risk of developing colorectal cancer (CRC), the family history is of paramount importance. A family history of CRC in a first-degree relative is a significant finding and the age at which the diagnosis was made is similarly of importance when quantifying a patient’s overall relative risk. So an individual with a first-degree relative diagnosed with CRC earlier than age 55 years has a relative risk that is two- to fivefold above that of individuals without a family history of CRC. In this case, the patient is categorised as at moderate risk of developing CRC during her lifetime and as such this warrants screening by colonoscopy. Moderate risk is defined as having:
one first-degree relative affected by CRC before the age of 45 years
two (one aged less than 55 years) or three relatives at any age affected by CRC or endometrial carcinoma who are first-degree relatives of each other and one a first-degree relative of the patient
two affected first-degree relatives (one aged less than 55 years).