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Flashcards in GI and General Deck (47):
1

A 2-year-old boy is referred to the Emergency department with a painful, swollen, irreducible lump in his right groin. The boy was born six weeks prematurely and spent two weeks on the special care baby unit.
His mother has noticed the lump, which usually comes out on crying or straining, over the previous six months, but has always been reducible until today.

Herniotomy
Inguinal hernias are more common in preterm infants (10%). There is a male to female ratio of 10:1 in children. Commonly the hernia reduces on induction of anaesthesia.

Treatment consists of simple herniotomy (excision of the hernia sac) and should be undertaken as soon as possible after diagnosis, as the chances of incarceration are very high. If the hernia can be reduced the operation can be delayed and performed on an elective list the next day.

2

A 72-year-old woman is referred to the Emergency department with a one day history of abdominal distension and vomiting. On examination there is an irreducible lump in the left groin which is arising below and lateral to the pubic tubercle. A plain abdominal x ray shows multiple loops of small bowel.

McEvedy repair
Femoral hernias account for 20% of hernias in women, with 40% of femoral hernias presenting initially with strangulation.

A transverse (unilateral Pfannenstiel) incision is made and the rectus muscle is retracted medially. The hernia sac is reduced by traction, the sac is then opened and the contents inspected. The hernia defect is repaired with sutures or prosthetic mesh.

The Lockwood (low approach) should only be performed in elective repairs.

3

A 41-year-old man is referred to the outpatients' department urgently with a painful recurrent left inguinal hernia. The hernia was repaired at the age of 27. However, the hernia recurred 12 years later and was repaired with the incorporation of a synthetic mesh. On examination although tender the hernia is reducible.

Laparoscopic transabdominal preperitoneal prosthetic repair
The hernial defect may be approached laparoscopically by three approaches:

Intraperitoneal
Transabdominal preperitoneal
Totally extraperitoneal.
The three techniques incorporate a synthetic mesh or plug over the defect.

The laparoscopic approach has the advantage in recurrent hernias of avoiding scar tissue in the groin, avoiding the missed hernia and a lower recurrence rate.

4

A 42-year-old woman presents with unexplained hypertension at a well woman clinic. Analysis of urine collected over 24 hours reveals metanephrines (MTA) and vanillyl-mandellic acid (VMA). A CT of abdomen reveals a lesion in the right adrenal gland. The patient is prepared for a laparoscopic adrenalectomy.

Phenoxybenzamine
This patient has a phaeochromocytoma. Raised MTAs and VMAs are the major breakdown products of catecholamines. This is the most useful screening test for phaeochromocytomas. To prevent excessive release of catecholamines during the procedure the patient requires alpha-blockade with phenoxybenzamine and beta-blockade. Alpha-blockade must be established before the introduction of beta-blockade.

5

A 72-year-old man has undergone a left femero-popliteal bypass graft for critical ischaemia. The conduit is a reverse long saphenous vein graft. At the end of the procedure, there is some concern that the graft is not functioning properly.

Papaverine
The use of papaverine before or after a vein harvest has been shown to be beneficial. It acts by causing smooth muscle relaxation, which prevents vigorous prolonged contracture of the vein preventing endothelium sloughing.

6

An 18-year-old man is brought to the emergency department following a stab wound to his back. A CT of abdomen is performed which reveals some peripancreatic fluid. The patient is systemically well and the surgeon decides to treat him conservatively.

Octreotide
Octreotide is an analogue of the hypothalamic release-inhibiting hormone somatostatin. In the case described, it is prudent to rest the pancreas by keeping the patient nil by mouth. The administration of octreotide further reduces pancreatic exocrine secretions.

7

A 27-year-old lady presents with progressive dysphagia for solids and liquids. She also gives a history of delayed regurgitation of food. x Ray reveals a dilated oesophagus and absent gastric air bubble.

Achalasia Cardia
Achalasia cardia (cardiospasm) is a neuromuscular failure of relaxation at the lower end of the oesophagus due to loss of ganglia from Auerbach's plexus.

It affects more females than males (3:2), and is common during the third decade of life. There is progressive dysphagia to solids and liquids, chest pain and regurgitation of old food from the dilated oesophageal sac.

Radiologically, achalasia is diagnosed by finding a dilated oesophagus with a tapering lower oesophageal segment, likened to a bird's beak, which fails to relax. There is no gastric air bubble because the dilated oesophagus never completely empties and therefore swallowed air cannot pass into the stomach.

8

A 45-year-old lady presents with dysphagia and iron-deficiency anaemia. On examination, she has a smooth tongue and koilonychia.

Plummer-Vinson syndrome (Pharyngeal web)

Plummer-Vinson syndrome (Paterson-Brown-Kelly syndrome or pharyngeal web) is usually seen in middle-aged or elderly women.

Patients present with

Dysphagia
Iron-deficiency syndrome
Koilonychias
Angular cheilitis
Glossitis, and sometimes
Splenomegaly.
This is a pre-malignant condition and is associated with carcinoma of the crico-pharyngeal region.

9

A 78-year-old man presents with dysphagia and weight loss. On examination, there is swelling in the anterior triangle of the neck which contains free fluid.

Pharyngeal pouch
Pharyngeal pouch occurs more often in the elderly where they often have a long and symptom-free natural development. The patient presents with dysphagia and regurgitation of undigested food (which has collected in the pouch), and consequent weight loss.

Pulmonary overspill is a problem and on occasions hoarseness and chest infection may be the only presenting symptoms. A mass low down in the anterior triangle of the neck may be felt and deep palpation over this may produce a squelching sound, caused by free fluid in the pouch.

10

A 32-year-old married lady presents with increasing abdominal pain for 24 hours. She is nauseated but not vomiting, has not opened her bowels for 24 hours, has some PV bleeding but in the presence of a chronically irregular menstrual cycle. On examination she has a pulse of 115 bpm, BP 100/60 mmHg, looks pale and is maximally tender in the left iliac fossa.

Ectopic pregnancy
This lady is of child bearing age and one must assume there is a chance she is pregnant. Her symptoms are non-specific, but the high pulse and pale complexion raise the possibility of blood loss, which would not be explained by the small amount of PV bleeding. In addition to fluid resuscitation and oxygen therapy one would perform a urinary pregnancy test in the Emergency department, send blood for full blood count, cross match, clotting and U&E. If investigations were positive for pregnancy, a discussion should be had with the gynaecologists.

11

A 28-year-old married lady returns from honeymoon in Gambia with a two day history of nausea, loin pain and painful micturition. On examination she is flushed, mildly tender in the right loin with maximal tenderness in the suprapubic region.

Urinary tract infection
This lady is maximally tender over the renal tract with a flushed complexion indicative of pyrexia. Increased sexual activity on holiday is often associated with bladder infection ("honeymoon cystitis"). Dipping the urine in the Emergency department will confirm the diagnosis; the urine should be sent for culture and the patient can be sent home with a course of antibiotics.

12

A previously well 38-year-old lady presents with 48 hours of bloody diarrhoea associated with general malaise and nausea. No one else in the family is ill. She is maximally tender in the left paracolic gutter. PR examination reveals loose, blood stained stool; protoscopy/sigmoidoscopy fail due to inability to get a view.

Infective diarrhoea
Infective diarrhoea. Loose bloody stools can be associated with inflammatory bowel disease, diverticulitis or infective diarrhoea; the former two diagnoses usually have a longer course with associated weight loose and bowel disturbance. Although food hygiene in Britain is usually of high standard transmission of infective organisms does occur. Management in this case will involve assessment of FBC, U&E, CRP/ESR, blood culture if pyrexial and transfusion if anaemic. A baseline abdominal film should be taken as well as an erect CXR. One should get stool samples sent urgently and obtain a mucosal biopsy as soon as possible. In the absence of pyrexia or other signs of systemic disease, antibiotics should be avoided with treatment being based on fluid replacement. With all the results one will be able to distinguish infective from inflammatory causes.

13

A 21-year-old man presents with 48 hours of bloody diarrhoea associated with general malaise and nausea. No one else in the family is ill. He has had two previous episodes this year and has lost weight. He is maximally tender in the left paracolic gutter. PR reveals loose, blood stained stool; protoscopy/sigmoidoscopy get a poor view, but the mucosa looks inflamed.

Inflammatory bowel disease
Inflammatory bowel disease. Loose bloody stools can be associated with inflammatory bowel disease, diverticulitis or infective diarrhoea; in this case the gentleman has a recent history of altered bowel habit and weight loss leading one to believe there is a chronic process. Additionally the mucosa at protoscopy is inflamed. Treatment will be the same as above except that steroids and antibiotics should be used. Regular clinical and radiological review must be made and if deterioration occurs laparotomy should be performed.

14

A 58-year-old male presents with pain in the right groin. He had a right inguinal hernia repair 20 years ago with no complications.
On examination there is a cough impulse in his right groin.

Hernia recurrence: many hernia repairs, before the use of mesh, were performed using a "darn" method which often did not repair the deficiency in the transversalis fascia and as such were associated with high rates of recurrence.
Pain and a cough impulse leads one to conclude that this is the situation here. If there was any doubt, the diagnosis can be confirmed with an ultrasound scan or a herniogram.

15

A 58-year-old male presents with right groin pain 12 weeks after a right inguinal hernia repair using mesh.
On examination the wound is well healed, there is no collection but the medial end of the wound is exquisitely tender.

Pubic periostitis
Pubic periostitis: when placing a mesh, it is tempting to take a large bite of the pubic attachment of the inguinal ligament to "anchor" the mesh. Unfortunately if you do this it will often cause a chronic inflammatory reaction/periostitis which can be disabling in the younger patient.
Treatment is initially with NSAIDs and rest; if this does not work after four weeks a depot steroid (triamcinolone) and local anaesthetic should be used. If this fails and the patient is finding activity difficult, one may have to remove the mesh.

16

A 62-year-old male alcoholic presents with a two month history of weight loss, pale stools, and of abdominal pain radiating through to his back.

Carcinoma of the pancreas
The 62-year-old chronic alcoholic has features suggestive of carcinoma of the head of the pancreas with backache, weight loss and most importantly the pale stools.

The latter suggests obstruction and hence Ca pancreas rather than a chronic pancreatitis. Other risk factors include chronic pancreatitis which would predispose to the development of pancreatic carcinoma.

17

A 35-year-old male presents with one month history of epigastric abdominal pain. His weight has been steady but he describes being aware of hunger pains particularly at night which are relieved by food.

Duodenal ulcer

The second case has nocturnal hunger pains that would suggest a duodenal ulcer. Risk factors include increasing age, smoking and NSAIDs use.

18

A 72-year-old male with a low rectal cancer, has undergone an elective abdomino-perineal resection. The man is a lifelong smoker. He has mild angina and suffered a myocardial infarction at the age of 58. He also suffers from mild COPD, which is well controlled with inhaled bronchodilators. The patient had a short period of hypotension intra-operatively but was successfully extubated at the end of the procedure.

High dependency unit
This patient has been successfully extubated and therefore does not require ventilation. However, in view of the period of hypotension on a background of ischaemic heart disease he requires close monitoring as he is at high risk of having a further myocardial infarction.

Indications for admission to ICU are 'mechanical support of a vital function', for example, ventilation, haemofiltration. Indications for admission to HDU are close monitoring requiring the continuous attention of specially trained nurses, frequent medical interventions or 'heavy' nursing.

19

A 67-year-old female with tablet controlled type II diabetes who lives alone, has presented with persistent rectal bleeding. The rectal bleeding has been extensively investigated and has been put down to large third degree haemorrhoids, which were treated with injection scelotherapy in the clinic. Despite treatment, her haemorrhoids have continued to bleed and she has therefore been listed for an open haemorrhoidectomy. She undergoes the procedure under spinal anaesthetic.

General surgical ward
This woman needs to be admitted to the general surgical ward, as she is not suitable for admission as a day case.

20

A 23-year-old female has presented with recurrent biliary colic. She is fit and well, with no medical problems and weights 60 kg. She is booked for an elective day case laparoscopic cholecysectomy. The surgery is uneventful and a drain is not placed.

Day case ward
This woman is an ideal patient for a day case laparoscopic cholecystectomy, which is now available in most hospitals in the United Kingdom.

21

A 49-year-old woman presents with progressive deformity of the fingers and knee pain bilaterally.

Rheumatoid arthritis
Rheumatoid arthritis is a chronic polyarthritis characterised by exacerbations and remissions and generally affects adults between the ages of 25 and 55 years. The condition usually starts insidiously with the subsequent course being progressive or episodic.

The characteristic deformities, which develop in the hand, include ulnar deviation of the fingers and radial and volar displacement of the wrists. The 'Z' deformity of the thumb, the swan neck and boutonnière deformities of the fingers are mostly the result of tendon damage or displacement.

22

A 52-year-old woman has presented with a swollen right wrist, she complains of numbness of the thumb, index and middle fingers.

Carpal Tunnel
This syndrome results from compression of the median nerve as it passes through the carpal tunnel. The condition most frequently affects women between the ages of 40 and 60 years. A large number of conditions are associated (including rheumatoid arthritis, myxoedema, acromegaly) although these conditions do not predispose to carpal tunnel syndrome.

23

A 42-year-old diabetic man has noted a swelling in the palm of his left hand gradually getting bigger.

Dupuytren's contracture
This condition results in a contracture of the longitudinal bands of the palmar fascia due to progressive fibrosis. Initially nodules may develop with progressive contracture extending to the metacarpophalangeal joints. The condition is ill understood, but associations with epilepsy (or anti-convulsants therapy) and diabetes mellitus seem certain.

24

A 29-year-old woman had a lump at the base of the distal phalanx of the right index finger excised by the GP. The lump has rapidly recurred.

Ganglion
The differential is a mucous cyst (the cyst is a blow out of an arthritic joint) or a ganglion. Recurrence following surgery can be as high as 20%.

25

A 67-year-old lady with known atrial fibrillation presents to the Emergency department with severe abdominal pain associated with PR bleeding. Investigations:
Hb of 17 g/dL (11.5-16.5)
WCC of 19 ×109/L (4-11)
AXR shows a gasless abdomen.

Intestinal ischaemia
This lady has intestinal ischaemia, caused by atrial fibrillation. Other causes of intestinal ischaemia include:

Vasculitis
Trauma
Radiotherapy
Strangulation of hernias.

26

A 65-year-old lady presents to the Emergency department with fresh PR bleeding associated with colicky, left-sided abdominal pain relieved by defecation.

Diverticular disease
This patient has diverticular disease. Most diverticula occur in the sigmoid colon, with 95% of complications at this site.

27

A 25-year-old lady presents to her GP with a two day history of severe anal pain on defecation associated with fresh blood on the outside of the stool. She has a longstanding history of constipation.

Anal Fissure
This patient has an anal fissure, which is a midline longitudinal split in the squamous lining of the lower anus. Ninety percent are posterior.

28

A 70-year-old man presents to his GP complaining of bright red blood on the outside of his stool over the last six months. He also complains of an incomplete sensation after evacuation of faeces.

Colorectal adenocarcinoma
Presentation depends on the site, with left-sided tumours presenting with PR bleeding, altered bowel habit and tenesmus.

Right-sided tumours present with anaemia, weight loss and abdominal pain.

29

A 25-year-old man presents to his GP with a two day history of bloody diarrhoea associated with the passage of mucus PR. His GP notices mucosal ulceration around his lips.

Crohn's disease
This patient is more likely to have Crohn's disease than ulcerative colitis. Oral ulceration is more common in Crohn's disease and may be the first sign of the disease. Other complications of inflammatory bowel disease include:

Colon cancer
Fistulae and fissures
Abscess formation
Stricture formation
Toxic dilatation of the colon with the risk of perforation.

30

In which malignancy is CA125 a helpful serum tumour marker?

Serous carcinoma of the ovary
CA125 is a useful tumour marker in carcinoma of the ovaries, mainly epithelial ovarian cancers

31

In which malignancy is carcinoembryonic antigen (CEA) a commonly used tumour marker?

Colonic carcinoma
The carcinoembryonic antigen (CEA) is a protein that is normally found only during fetal development, but may be found in adults who develop certain types of tumours such as those of the gastrointestinal (GI) system. These include tumours of the colon, rectum, stomach and the oesophagus. The normal range is less than 2.5 ng/ml in an adult non-smoker and less than 5.0 ng/ml in a smoker. CEA levels may be used to diagnose a GI tumour but more importantly used in determining the treatment progress. The levels of CEA will fall following complete excision of the tumour but a rise after sometime may suggest tumour recurrence.

32

In which malignancy are β-human chorionic gonodotrophin (beta HCG) and α-feto protein (AFP) useful tumour markers?

Testicular tumour
β-Human chorionic gonodotrophin, α-feto protein and lactate dehydrogenase are the tumour markers for the diagnosis of testicular carcinoma, particularly germ cell tumours of the testis. The level of α-feto protein, however, may not be raised in seminoma of the testis. Elevated levels of one or more of these tumour markers after appropriate treatment may indicate the presence of residual disease or recurrence and thus the need for further therapy. α-Feto protein is also a useful tumour marker in hepatocellular carcinoma.

33

A 56-year-old man who is an alcoholic presents to the emergency department with a four week history of pain in his right hypochondrium, vomiting and loss of appetite. He also gives a history of vomiting blood a few times. On examination, he is jaundiced, has clubbing of fingers and spider naevi. The liver is palpable 5 cm below the right costal margin.

Alcoholic cirrhosis
This patient has signs and symptoms suggestive of alcoholic cirrhosis. Patients may present with haematemesis due to bleeding from oesophageal varices or with ascites.

Some of the other recognised clinical features of alcoholic cirrhosis include:

palmar erythema
finger clubbing
xanthomata
spider naevi (along the distribution of the superior vena cava)
hepatomegaly
jaundice, and
gynaecomastia and testicular atrophy (due to increased oestrogen levels).
In addition, there may be features of portal hypertension.

However, many patients in the early stages of alcoholic cirrhosis do not demonstrate any of the above signs and symptoms.

34

A 29-year-old woman presents to her general practitioner with a six week history of pain in her right hypochondrium, difficulty swallowing, tremors, difficulty in speech and loss of appetite. Abdominal examination reveals hepatomegaly and mild ascites. Serum caeruloplasmin level in her blood results is decreased.

Wilson’s disease
Wilson's disease is an autosomal recessive disorder which leads to the deposition of copper in various internal organs including the liver, brain and spinal cord. It is four times more common in females than in males.

The patient may present with cirrhosis, hepatitis or fulminant hepatic failure. The neurological symptoms include dysphagia, dysarthria, tremors, confusion, delirium and dementia. Kayser-Fleischer rings (formed by deposits of copper in the corneal membrane) in the eyes is a characteristic sign.

The serum caeruloplasmin level and copper level in blood is decreased. Urine copper levels are high.

35

A 42-year-old woman presents to her general practitioner with a four week history of pain in her right upper quadrant, pruritus and loss of appetite. On examination, she has finger clubbing, xanthelasmata, jaundice, hepato-splenomegaly and increased skin pigmentation.

Primary biliary cirrhosis
Primary biliary cirrhosis is a chronic, progressive non-suppurative form of cholestatic disease of the liver. The aetiology is unknown, although it thought to be autoimmune in nature. The disease leads to destruction of the small-to-medium bile ducts, which leads to progressive cholestasis and often end-stage liver disease.

Nearly 75-90% of patients affected by the disorder are women.

The patient may present with:

pruritus
fatigue
jaundice
hepato-splenomegaly, and
melanotic skin pigmentation.
Other recognised features include clubbing, xanthelasmata and arthralgia.

36

A 24-year-old intravenous drug abuser presents to the surgical outpatient clinic with a two week history of a gradually enlarging swelling in his left groin. On examination, he is afebrile and his pulse rate is 74/min. The swelling is non-tender but has expansile pulsation. There are no enlarged lymph nodes in the region.

Femoral artery aneurysm
This patient has probably got a pseudo-aneurysm or false aneurysm of the femoral artery. This is seen in intravenous drug abusers who repeatedly inject into the femoral artery which leads to damage to the tunica media and intima, thus resulting in a false aneurysm.

False aneurysm must be distinguished from a local haematoma with transmitted pulsations from the femoral artery (femoral aneurysm has expansile pulsations). A colour duplex scan is a very useful initial investigation.

37

A 72-year-woman presents to the Emergency department with a 72 hour history of pain and swelling in her right groin, colicky abdominal pain and vomiting. She has not opened her bowels for five days. On examination, her temperature is 37.6º C and her pulse rate is 106/min. The swelling over her groin is tender and non-reducible. She has also got tinkling bowel sounds.

Strangulated femoral hernia
The contents of the femoral triangle (from lateral to medial) are the femoral nerve, femoral artery, femoral vein, and the femoral canal. The femoral canal thus lies medial to the femoral vein and lateral to the lacunar ligament (also known as the Gimbernat ligament).

The femoral hernia follows the tract below the inguinal ligament through the femoral canal. The femoral hernia frequently become incarcerated or strangulated since they protrude through such a small confined space.

Patients present with abdominal and/or groin pain, swelling in the groin and signs and symptoms of intestinal obstruction such as vomiting and constipation. If the hernia is not reduced as soon as possible, there is a risk of bowel necrosis, perforation, peritonitis and sepsis.

38

A 27-year-woman who is an intravenous drug abuser presents to the Emergency department with a three day history of pain and swelling in her right groin. On examination, her temperature is 38.4º C and her pulse rate is 94/min. The swelling is very tender and fluctuant. Few enlarged inguinal lymph nodes are palpable.

Groin abscess
Soft tissue infections are a common complication of intravenous drug use since there is increased bacterial colonisation (and/or contamination) on the skin surface. The infection is caused either due accidental injection of drugs into the fatty layer under the skin, leakage of drugs out of the veins during injection or tissue death due to toxic materials in drugs.

The signs and symptoms are classical of any soft tissue infection or abscess formation. The surrounding lymph nodes may be enlarged. However, patients may present with enlarged lymph nodes (due to blocked lymphatic vessels) in the absence of local infection.

39

A 43-year-old woman presents to the Emergency department with an eight hour history of severe pain over the right upper quadrant of her abdomen and vomiting. On examination, her pulse rate is 88/min and her temperature is 37.6º C. Abdominal examination reveals tenderness over the right hypochondrium but a soft abdomen. She says that she gets colicky pain over this region following fatty meals but only this time she is she so unwell.

Acute cholecystitis is usually caused due to impaction of stone in the cystic duct or the common bile duct. The pain is usually continuous in nature (in contrast to the colicky pain in biliary colic) and is localised over the right upper quadrant or epigastric region. The pain often radiates to the right lower scapula. If the inflamed gall bladder irritates the undersurface of the diaphragm, the patient may complain of right shoulder tip pain. The patient may also have vomiting, fever and a palpable gall bladder.

40

A 35-year-old man of Pakistani origin presents to his general practitioner with a five day history of sharp pains over the right upper quadrant of his abdomen, fever, chills and rigors. On examination, he is jaundiced and appears dehydrated. His temperature is 38.2º C. He had been to Pakistan recently and he says that he was suffering from dysentery for a few days during his stay there.

Amoebic liver abscess
Amoebic liver abscess is caused by Entamoeba histolytica, the same organism which causes amoebiasis. It is more common in tropical countries and may occur in people visiting these places. The organism is carried from the intestine to the liver through the blood.The patient presents with stabbing pain over the right hypochondrium, high fever associated with chills and rigors, jaundice, diarrhoea, weight loss and general malaise. In most instances the patients would have had an attack of intestinal amoebiasis (diarrhoea and dysentery) preceding the development of the liver abscess.

41

A 66-year-old sheep farmer presents to his general practitioner with a three week history of dull aching pain over the right upper quadrant of his abdomen and loss of appetite. On examination, he is jaundiced and a mass can be felt over his right hypochondrium. His routine bloods reveal a very high eosinophil count. Plain abdominal x ray shows a calcified mass over the right hypochondrium.

Hydatid cyst of the liver
Hydatid disease is a form of zoonotic disease which involves humans as the accidental intermediate host. It is very common in Asia, South America, Australia and Africa. In the Western countries, it is common in sheep-farming areas or in sheep farmers. The liver is the commonest site of infection. The patient may present with dull abdominal pain and mass over the right hypochondrium, dyspepsia and vomiting. This may be associated with fever, jaundice and loss of weight. The eosinophil count may be very high. Plain abdominal x ray may reveal a calcification in the liver which is due to the calcified outer coating of the cyst.

42

A 65-year-old woman is seen in the clinic with a small mass in the left groin. On examination there is a reducible left groin mass lying below and lateral to the pubic tubercle.

Femoral
Femoral hernias are more common in women than men and occur below and lateral to the pubic tubercle. They occur as a result of a weakness of the femoral ring. They often contain only omentum but may contain bowel leading to intestinal obstruction. All femoral hernias should be repaired.

43

A 45-year-old lady presents with a two week history of dull retrosternal chest pain. Clinical examination is unremarkable as is the ECG. A CXR demonstrates an air fluid level behind the heart.

Hiatal
Hiatal hernias may be either sliding or paraoesophageal. In the former, the whole of the stomach moves proximally whereas in the latter, a portion of the stomach, rolls up alongside the oesophagus. The symptoms of retrostenal chest pain in sliding hernias may be treated by proton pump inhibitors but if the pain is poorly controlled and persistent there may be a role for surgery. For paraoesophageal hernias, early repair should be considered as there are risks of strangulation of the stomach.

44

A 4-month-old baby boy is brought by his mother who is concerned that his scrotum is swollen and he is constantly crying. He was born at 32 weeks gestation. On examination there is no discolouration of the scrotum and the swelling is non-tender and fully reducible.

Indirect inguinal
The description indicates an indirect inguinal hernia. Boys are more commonly affected, especially if premature. In children the defect is a patent processus vaginalis. These hernias pass through the deep ring along the inguinal canal and out through the superficial ring and may pass into the scrotum. They are the commonest of abdominal hernias. All patients with inguinal hernias should be offered a repair. In children this is a herniotomy whilst in adults a herniorrhaphy is performed.

45

A 68-year-old man attends the clinic with a swelling closely related to his right iliac fossa terminal ileostomy. He had previously undergone an emergency total colectomy for toxic megacolon. On examination there is a soft reducible swelling with a positive cough impulse.

Parastomal
Parastomal hernias are probably under recorded and occur as a segment of bowel emerges alongside the stoma. For ileostomies, this often causes severe pain whilst for colostomies, the symptoms are more commonly related to poorly fitting appliances. The diagnosis can be confirmed with CT and the stomal hernia repaired.

46

A 44-year-old woman is seen in the clinic with a history of chronic right-sided abdominal pain. She has been extensively investigated but no cause found. On examination a small reducible swelling is detected lateral to the rectus muscle at the level of the anterior superior iliac spines.

Spigelian
This history is of a spigelian hernia, a less common form of hernia that is often not recognised leading to delayed presentation and treatment. It has a classic anatomic location as described. Hernias should be repaired if identified.

47

A 36-year-old female intravenous drug abuser is seen in the emergency department with jaundice, a fever and vague right upper quadrant pain.
Prior to accepting the patient, a liver function test is requested and this shows the following:
Bilirubin 170 µmol/l (1-22)
Aspartate aminotransferase 1500 IU/l (1-31)
Alkaline phosphatase 220 IU/l (45-105)
What is the most likely diagnosis?

Hep B

Given the history this is patient must be suspected of having an infective hepatitis either B or C.

The acute presentation is in two phases: a pre-icteric (normal bilirubin and alkaline phosphatase with markedly elevated transaminases), followed by an icteric phase (markedly elevated bilirubin and transaminases and a slightly elevated alkaline phosphatase).

Viral titres should be requested. Acute cholecystitis alone is not usually associated with deranged LFTs, although a mild obstructive picture can be seen in severe inflammation.

The other options are all examples of extrahepatic or obstructive jaundice and they would be expected to exhibit an elevation of the alkaline phosphatase, but a transaminitis would not be expected.