Flashcards in GI and General Deck (47)
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.
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.
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.
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.
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:
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.
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.
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.
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.
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.
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 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.
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 (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.
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
Glossitis, and sometimes
This is a pre-malignant condition and is associated with carcinoma of the crico-pharyngeal region.
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 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.
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.
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.
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.
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. 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.
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.
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.
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: 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.
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.
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.
The second case has nocturnal hunger pains that would suggest a duodenal ulcer. Risk factors include increasing age, smoking and NSAIDs use.
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.
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.
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.
A 49-year-old woman presents with progressive deformity of the fingers and knee pain bilaterally.
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.
A 52-year-old woman has presented with a swollen right wrist, she complains of numbness of the thumb, index and middle fingers.
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.
A 42-year-old diabetic man has noted a swelling in the palm of his left hand gradually getting bigger.
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.
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.
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%.
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.
This lady has intestinal ischaemia, caused by atrial fibrillation. Other causes of intestinal ischaemia include:
Strangulation of hernias.
A 65-year-old lady presents to the Emergency department with fresh PR bleeding associated with colicky, left-sided abdominal pain relieved by defecation.
This patient has diverticular disease. Most diverticula occur in the sigmoid colon, with 95% of complications at this site.
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.
This patient has an anal fissure, which is a midline longitudinal split in the squamous lining of the lower anus. Ninety percent are posterior.
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.
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.
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.
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:
Fistulae and fissures
Toxic dilatation of the colon with the risk of perforation.