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Flashcards in GI and General II Deck (43):
1

An 80-year-old man presented with large bowel obstruction. Following resuscitation, he underwent a laparotomy. A large carcinoma of the rectum was found, fixed to the lateral pelvic wall, with omental and peritoneal secondary deposits.

Transverse loop colostomy

Primary anastomosis can be performed at the time of emergency surgery if colonic lavage is carried out.

2

A 75-year-old male presented with 18 hours of acute abdominal pain. He was noted to have generalised peritonitis and free intra-peritoneal air on an erect chest x ray. At laparotomy, he was found to have widespread faecal peritonitis due to perforated sigmoid diverticular disease.

Hartmann's procedure

When there is widespread faecal peritonitis the majority of surgeons would avoid an anastomosis as the risk of continued peritoneal infection and anastomotic leak is very high. The operation time would also be longer.

3

A 45-year-old man presents with known severe ulcerative colitis that has not responded to maximal medical therapy. He has had five days of bloody diarrhoea. Examination shows mild abdominal distension with generalised guarding. A plain abdominal x ray shows a colonic diameter of 7 cm.

Subtotal colectomy with ileostomy

The definition of toxic megacolon is non-obstructive, total or segmental colonic dilatation of 6 cm or more, associated with systemic toxicity. In acute toxic dilatation of the colon due to ulcerative colitis the treatment is subtotal colectomy and ileostomy.

Excision of the rectum and anus (panproctocolectomy) would add considerable time to the procedure and remove the possibility of creating a pouch in the future.

4

A 58-year-old lady undergoes an anterior resection for colorectal cancer. After radiological and pathological staging her disease is staged as a Dukes' stage C.
What is the 5-year survival rate for this stage of disease?
(Please select 1 option)

35-40%

This lady is already one year post operative, so she is asking for her chance of five year survival. The overall five year survival for Dukes' stage C colorectal cancer is around 40%.

Five year survival for the other Dukes' stages are as follows:

Dukes' A D around 10-15%.

5

A 76-year-old man is admitted on the surgical intake complaining of colicky lower abdominal pain, absolute constipation and abdominal distension of two days duration.
On examination he has a grossly distended soft abdomen. Plain abdominal x ray demonstrates large bowel dilation throughout the colon. Routine bloods are requested and he is placed nil by mouth.
What is the most appropriate next management step for this gentleman?
(Please select 1 option)
Barium enema
Barium small bowel follow through
Colonoscopy
Laparotomy
Water soluble contrast enema

Water soluble contrast enema This is the correct answerThis is the correct answer
This gentleman's history, examination and x ray findings suggest large bowel obstruction. A water soluble contrast enema should be obtained to differentiate between a mechanical cause and pseudo-obstruction.

Barium examinations should be avoided as he may be likely to require urgent surgery.

As he has no signs of peritonitis immediate laparotomy is not indicated without further investigation.

6

You are called to see a 56-year-old patient in the emergency department who has been diagnosed with large bowel obstruction.
She reports longstanding constipation but the symptoms of abdominal pain and distension came on suddenly. There has been no bleeding or weight loss. Past medical history includes schizophrenia.
Which of the following is the most likely cause?
(Please select 1 option)
Adhesions
Crohn’s disease
Incarcerated hernia
Intussusception
Volvulus of sigmoid colon

Volvulus of sigmoid colon This is the correct answerThis is the correct answer
Volvulus, faeces and tumours are common causes of large bowel obstruction.

In this case the likely diagnosis given the long history of constipation and psychiatric illness and a short history of pain/distension in the absence of other gastrointestinal symptoms is sigmoid volvulus.

The other conditions listed tend to result in small bowel obstruction.

7

Rectus sheath haematoma

The history of a spontaneous mass within the rectus is typical of a haematoma. These haematomas are often seen in patients on anticoagulants and are seen following minor trauma such as coughing.

In this case the patient was more at risk to the antibiotic therapy upsetting INR control.

The haematomas should be managed conservatively with analgesia, volume replacement if necessary, and correction of any haemostatic abnormalities.

8

A 43-year-old woman presents to the emergency department with an eight hour history of severe right upper quadrant pain and vomiting. She says that the pain exacerbates on breathing and is radiating to her right scapula.
On examination, she is pale and mildly jaundiced. Her pulse rate is 104/min and temperature is 38.8°C. Abdominal examination reveals a tender mass over the right hypochondrium. She says that she used to get this type of pain following a fatty meal, although not this severe. Serum amylase is not elevated.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Cirrhosis of the liver
Gall stones

Acute cholecystitis is the acute inflammation of the gall bladder. Gallstones are the commonest cause for inflammation. They may obstruct the common bile duct which in turn prevents the flow of the bile. This leads to accumulation of bile and inflammation leading to an acutely inflamed gall bladder.

Build up of bile within the gall bladder also increases the pressure within the gall bladder, thus increasing the chance of perforation. Other risk factors for acute cholecystitis include

Alcohol abuse
Tumours of the gall bladder.
Acute cholecystitis is more common in females over 40 years of age who have a high BMI; the incidence increases with fertility.

The frequent signs and symptoms of acute cholecystitis include

Severe right hypochondrial pain which is exacerbated by breathing
Nausea and vomiting
Pyrexia.
A tender, inflamed gall bladder is frequently, but not always, palpable. Jaundice may or may not be present.

This condition has to be distinguished from biliary cholangitis, where the signs and symptoms of inflammation/infection are more severe; the gall bladder, however, is not palpable in isolated biliary cholangitis.

Pain associated with gall stones is typically seen after a fatty meal and the mere presence of gall stones do not present with signs of inflammation (for example, pyrexia).

The other differential diagnoses for acute cholecystitis include

Acute pancreatitis
Peptic ulcer
Appendicitis
Pleurisy.
Since the clinical diagnosis of acute cholecystitis may be difficult, an ultrasound scan or a cholescintigraphy may be necessary to clinch the diagnosis.

The immediate management of acute cholecystitis involves rest, intravenous antibiotics, and analgesia. Anti-emetics and naso-gastric tube (and nil by mouth) may be indicated in severe cases.

Once the acute symptoms have subsided cholecystectomy is the preferred line of management. However, if acute cholecystitis is complicated by perforations or gangrene, immediate removal of the gall bladder may become necessary.

9

A 43-year-old gentleman presents to the emergency department with severe stabbing type of pain over the epigastric region.
The pain started following episodes of repeated vomiting and it worsens on swallowing. He is a heavy drinker and has been consuming 10-15 units of alcohol every day for the past 20 years.
On examination, his blood pressure is 100/78 mmHg, and his pulse is 124/min and thready. Chest x ray reveals air in the mediastinum and in the subcutaneous tissues. There is no change in the anatomical contour of the diaphragm.
From the options below choose the most appropriate cause for this patient's signs and symptoms.
(Please select 1 option)
Acute cholecystitis
Boerhaave's syndrome
Diaphramatic rupture
Myocardial contusion
Traumatic haemothorax

Boerhaave's syndrome is the spontaneous rupture of a non-diseased oesophagus, usually caused after episodes of vigorous vomiting. It is seen in patients who consume excessive amounts of alcohol. The dramatically raised intra-oesophageal pressure caused by vigorous vomiting (and associated failure of relaxation of the cricopharyngeal sphincter) may lead to sudden spontaneous rupture of the oesophagus.

It is vital to recognise this condition since delay in diagnosis is associated with high morbidity and mortality. The signs and symptoms include

Sudden pain in the thorax and epigastrium following forceful protracted vomiting
Pain radiating to the neck
Progressive dyspnoea
Tachypnoea
Cyanosis
Shock.
The x ray shows an abnormal left cardiac border with free fluid within the left hemithorax (pleural effusion).
Physical examination usually is non specific; however, subcutaneous emphysema may be present, palpable in the neck or chest. This sign may take an hour to develop after injury.

The triad of vomiting, chest pain, and subcutaneous emphysema is also known as 'Mackler triad'; however, this should not always be relied on since only one or two of the above symptoms may be present in a majority of patients in the early stages.

Patients may appear acutely ill with tachycardia and tachypnoea. Fever, sepsis and gross hypotension may be seen in patients with delayed presentation.

Examination of chest may reveal decreased breath sounds on the side of perforation, usually the left. A crunching sound (known as Hamman's sign) may be heard with each heartbeat in up to 20% of cases.

10

A 53-year-old man who is a heavy alcohol drinker presents to the Emergency Department with a 12 hour history of sharp, central abdominal pain and vomiting. He prefers to sit up as the pain is aggravated on lying flat.
On examination, he is mildly jaundiced, his temperature is 38.2°C, his pulse rate is 132/min and his blood pressure is 118/82 mmHg. Abdominal examination reveals periumbilical discolouration and maximal tenderness over the epigastric region.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Acute pancreatitis
Acute viral hepatitis
Crohn's disease
Perforated duodenal ulcer
Pyelonephritis

The common causes for acute pancreatitis include

alcohol
gallstones
trauma
hyperlipidaemia
certain drugs, such as azathioprine.
Pancreatitis is thought to result from early activation of pancreatic enzymes, producing auto-digestion of the pancreas and surrounding tissues. Exposure of trypsinogen to lysosomal enzymes (e.g. cathepsin B) may be the cause for early trypsin activation. Digestive enzyme release is amplified as acinar cells lyse, leading to a vicious cycle of inflammation and necrosis.

Central abdominal pain that starts at a low intensity and gradually becomes very painful is a very common presentation. The pain may radiate to the back and may be relieved by sitting forward. This is usually associated by nausea and vomiting. On examination, the patient may be tachycardic, pyrexial, jaundiced and may or may not manifest signs and symptoms of shock. There may be discolouration in the peri-umbilical region (Cullen's sign). Blood test may reveal elevated inflammatory markers and a significantly raised serum amylase levels.

Management of acute pancreatitis includes

keeping the patient nil by mouth and insertion of nasogastric tube
intravenous fluids
analgesia
antibiotics
plasma expanders (if there is haemodynamic compromise).
Laparotomy may be indicated in selected patients in whom there is evidence of fulminant pancreatic necrosis. A CT scan may be needed prior to laparotomy.

Complications of acute pancreatitis include intra-abdominal infection, pseudocyst, renal failure and pancreatic necrosis.

11

A 53-year-old male is admitted via the Emergency department. His main presenting complaint is severe upper abdominal pain.
During the history taking he says he has lost his job within the last few months and his alcohol intake has been steadily increasing as a result. He is currently drinking over one bottle of vodka a day. His admission bloods show a serum amylase of 902 IU/L (50-150).
Which of the following blood tests is not part of the Glasgow criteria for assessing the severity of an attack of pancreatitis?
(Please select 1 option)
Albumin
Arterial blood gas
Calcium
CRP
LDH

CRP

The Glasgow criteria use nine variables to assess the severity of the pancreatitis. It can be easily remembered using the mnemonic PANCREAS:

P PO2 55 years -
N Neutrophils (WCC) >15 ×109/L (4-11)
C Calcium 16 mmol/L (2.5-7.5)
E Enzymes LDH >600 U/L (10-250)
A AST >125 U/L (1-31)
Albumin 10 mmol/L (3.0-6.0)
Three positive criteria indicate severe acute pancreatitis. The number of variables relates to the severity and mortality of the pancreatitis.

Although CRP is not part of the Glasgow scoring criteria, a raised level is an independent indicator of severity.

12

A 72-year-old female presents with vomiting, colicky abdominal pain and an absence of flatus. She has never had surgery to her abdomen.
On examination her abdomen is distended, non-tender and tympanic to percussion. Plain abdominal radiograph reveals distended loops of small bowel, no air is seen in the colon.
What is the most likely diagnosis?
(Please select 1 option)
Caecal carcinoma
Duodenal carcinoma
Gastric carcinoma
Pancreatic carcinoma
Rectal carcinoma

Caecal carcinoma

The commonest cause of bowel obstruction in an abdomen that has not previously been operated is colonic carcinoma. Colonic malignancy can present as an emergency or with chronic symptoms.

Tumours of the caecum and the ascending colon typically present with anaemia and no change in bowel habit, due to the liquid nature of the faeces. An obstructing caecal tumour usually causes obstruction of the ileocaecal valve resulting in a small bowel obstruction with a collapse of the distal colon.

Obstructing rectal tumours result in large bowel obstruction ± small bowel obstruction on the plain film.

Obstructing gastric tumours result in a gastric outlet obstruction producing a distended stomach.

Obstructing duodenal or pancreatic tumours result in high small bowel obstructions which usually do not result in the small bowel being visible on the plain film.

13

A 24-year-old male is found to have an inflamed non-perforated appendicitis at operation.
What is the most predictive symptom, sign or serological marker in appendicitis?
(Please select 1 option)
Low grade pyrexia
Nausea
Raised C reactive protein
Raised white cell count
Tenderness over the site of the appendix

Tenderness over the site of the appendix This is the correct answerThis is the correct answer
The diagnosis of appendicitis can be difficult even for the most experienced clinician.

Patients with appendicitis usually present with a typical pattern of symptoms and signs. Pain is usually one of the earliest symptoms. The pain is usually periumbilical initially (irritation of the visceral peritoneum due to early obstruction, dilatation and infection of the appendix) localising to the right iliac fossa (irritation of the parietal peritoneum due to spread of infection through the appendix) a few hours later.

After the initial pain, anorexia, nausea and occasionally vomiting may develop. Tenderness over the appendix is the hallmark of appendicitis. Tenderness is due to inflammation of the serosa of the appendix and overlying peritoneum.

Pyrexia tends to be a late sign and may be very elevated if the appendix is perforated.

Laboratory markers of infection are unreliable in appendicitis, as white cell count and C reactive protein only become raised when appendicitis is established.

14

A 55-year-old man presents having recently noticed a lump in his right groin which disappears when he is recumbent. It is accompanied by some discomfort.
He has a chronic cough due to smoking. He has had an appendicectomy previously.
What is the most likely diagnosis?
(Please select 1 option)
Epigastric hernia
Femoral hernia
Incisional hernia
Inguinal hernia
Spigelian hernia

Inguinal hernia is the most likely cause of a lump in the right groin in a patient of this age.

The hernia protrudes through the external inguinal ring. It may

Go unnoticed for quite some time
Cause an ache
Resolve on lying flat.
Femoral hernias are more common in females.

The anatomical site is inconsistent with an epigastric hernia; and an incisional hernia following appendicectomy would be very unusual.

This patient is at increased risk of hernias as he has a persistent cough due to his smoking.

15

A 40-year-old male presents with a history of intermittent, but slowly progressive dysphagia for both solids and liquids. He experiences pain on swallowing and has regurgitation of food swallowed several hours earlier. He has no heartburn but has anorexia and weight loss.
Ba swallow demonstrates proximal dilatation of the oesophagus and failure of relaxation of the lower oesophageal sphincter.
What should first line management consist of?
(Please select 1 option)
Amlodipine
Amyl nitrite
Intrasphincteric botulinum toxin
Oesophageal bouginage
Oesophageal myotomy

Oesophageal bouginage

The patient has achalasia of the cardia, which is a functional obstruction at the lower oesophageal sphincter caused by a failure of relaxation.

Balloon dilatation is first line management, but if this fails oesophageal cardiomyotomy (Heller's operation) is the preferred treatment.

Drug therapy, such as botulinum toxin injections, does not achieve medium to long-term relief.

16

A 35-year-old female presents with acute severe abdominal pain associated with tachycardia, hypotension and tachypnoea.
Which of the following is likely concerning the finding of a raised serum amylase in this patient?
(Please select 1 option)
Could indicate a perforated duodenal ulcer
Is diagnostic of acute pancreatitis
Makes diabetic ketoacidosis less likely
Makes ectopic pregnancy less likely
Makes mesenteric ischaemia less likely

Perf DU

A raised serum amylase may occur in all these conditions.

17

A 32-year-old female who is known to have Crohn's disease presents with increased frequency of micturition. She is demonstrated to have sterile pyuria.
Which is the most likely diagnosis?
(Please select 1 option)
Colo-vesical fistula
Recto-vesical fistula
Ileo-vesical fistula
ileo-ureteric fistula
Vesico-vaginal fistula

ileo-vesical fistula

In Crohn's disease the most common origin of a fistula to the urinary tract is the ileum:

ileum - 64%
colon - 22%
rectum - 8%.
The most common urinary tract connection is the bladder:

bladder - 90%
ureter - 5%
urethra - 2%
urachus - 3%.

18

A 69-year-old man presents to the Emergency department with sudden onset of epigastric/upper abdominal pain radiating to his back. He is sweating, nauseated and is feeling faint. On examination a pulsatile mass is identified.

Ruptured abdominal aortic aneurysm
In the case of the 69-year-old man, a diagnosis of leaking or ruptured abdominal aortic aneurysm should be considered in the elderly with sudden onset of upper abdominal/periumbilical pain radiating to the back and associated with signs of progressive shock. Acute pancreatitis is the other diagnosis to be considered but the pain is more epigastric and shock is not a predominant feature.

19

A 49-year-old alcoholic presents to the Emergency department with severe epigastric/retrosternal pain associated with haematemesis. His blood pressure is 90/60 mmHg and his pulse is 118/min. Chest x ray reveals mediastinal gas.

Boerhaave’s syndrome (ruptured oesophagus)

In the case of the 49-year-old, in alcoholics with repeated haematemesis (with or without features of shock), ruptured oesophagus should be considered to be a cause for acute epigastric/retrosternal pain. The tear is usually on the left posterior aspect of the oesophagus just above the cardia.

20


A 44-year-old barmaid complains of severe epigastric/RUQ pain two hours after eating chips and fried chicken. The pain radiates to her back and makes her nauseated. There are no other systemic symptoms.

Biliary colic


The 44-year-old has biliary colic. Biliary colic presents with pain in the RUQ/epigastric region usually (but not always) two to three hours after a fatty meal. The pain is sometimes associated with nausea and vomiting. There are no inflammatory signs such as raised temperature or increased white cell count which are present when the obstruction leads to acute cholecystitis.

21

These follow breakdown of muscle closure after previous surgery.

Incisional
The risk of incisional hernias is higher with open surgery as opposed to laparoscopic surgery.

22

These pass through the linea alba above the umbilicus.

Epigastric
Epigastric hernias pass through the linea alba.

23

These involve the bowel wall only.

Richters
The bowel lumen is not affected.

24

These occur at the lateral edge of the rectus sheath, below and lateral to the umbilicus.

Spigelian hernias occur at these sites.

25

These pass through a defect in the abdominal wall in an area known as Hesselbach's triangle.

Direct
As opposed to indirect hernias, which pass through the internal ring, and if large enough, out through the external ring.

26

Subphrenic abscess

A pleural effusion and a raised hemi-diaphragm typical of a subphrenic abscess.

An additional sign not always evident on a plain radiograph is an air fluid level beneath the diaphragm. This space is the most common for the development of an intra-abdominal abscess.

Abscesses may appear postoperatively or following visceral perforation. If there is doubt, an ultrasound will confirm the diagnosis and also allow for targeted drainage of collections that are usually polymicrobial (Gram negative organisms and anaerobes).

27

SBO

The history and examination findings are classical of small bowel obstruction. The x ray is also classical with a ladder appearance to the small bowel. The supine x ray is adequate in most cases but if non-diagnostic an erect abdominal x ray may show air fluid levels.

The common causes of obstruction are:

Adhesions
Hernias, and
Tumour.
In this case, given the history of perforated appendix, the absence of masses and the young age, the likely cause of obstruction is adhesions.

28

A 38-year-old alcoholic male has presented to hospital following a 72 hour drinking binge. He has been vomiting excessively. On examination he is pale and clammy, tachycardic and hypotensive. He is noted to have surgical emphysema tracking into his neck on the left side.

Boerhaave's syndrome
Boerhaave's syndrome, postemetic 'spontaneous' perforation occurs as a vertical tear in the lower left posterolateral aspect of the oesophagus. It usually results from vomiting against a closed cricopharyngeus resulting in a full thickness rupture into the pleural cavity.

29

A 1-day-old infant boy born at 35 weeks' gestation has developed a number of cyanotic episodes since birth. He has failed to feed. Attempts to pass a nasogastric tube have been unsuccessful.

Atresia
Atresia results from abnormal development of the foregut between 28 and 32 days after conception and affects 1:3500 births. The condition is usually associated with a tracheo-oesophageal fistula. It is associated with polyhydramnios as the fetus is unable to swallow amniotic fluid. There is also an association with VACTERL (Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial Limb anomalies) syndrome.

30

A 76-year-old man has presented with anorexia and weight loss. He is now only able to tolerate a liquid diet. Gastroscopy confirms a lesion in the distal third of the oesophagus.

Eighty percent of adenocarcinomas occur in the lower third of the oesophagus and 20% in the middle third. 35% of squamous cell carcinomas occur in the lower third, 50% in the middle third and 15% in the upper third.

Adenocarcinomas of the oesophagus now account for 50% of all newly diagnosed oesophageal malignancies. They arise from proximal gastric epithelium or from Barrett's oesophagus (a premalignant condition seen in longstanding gastro-oesophageal reflux). The tumour spreads longitudinally in the submucosal plane. Patients tend to present late with progressive dysphagia, weight loss and anaemia.

31

A 34-year-old women presents to the surgical outpatient clinic with a six week history of streaks of blood on her stools and blood in the toilet paper. She also has pain on defecation.

Anal fissures are common in young patients. They usually occur along the posterior wall of the anal canal and cause intense pain on defecation.

An anal fissure does not cause profuse PR bleed but the patient usually notices blood on the toilet paper. It is not associated with any systemic symptoms.

32

A 39-year-old electrician presents to the outpatient clinic with a four month history of painless PR bleed following defecation. He has no other symptoms.

Haemorrhoids
Haemorrhoids are the commonest cause of painless rectal bleeding in the young. They may be associated with a per rectal mass, depending on the grade of haemorrhoids.

33

A 69-year-old man presents to the Emergency department with a four week history of PR bleed. He has altered bowel habits, and there is blood mixed with the stools. He has no pain on defecation.

Colonic malignancy
Any PR bleed in the elderly associated with a change in bowel habits (with or without loss of weight and/or appetite) should be considered due to malignancy unless proven otherwise.

34

A 25-year-old company executive presents to the outpatient clinic with blood and mucus on defecation. She is opening her bowels 8-10 times a day and has recently noticed some ulcers in her mouth.

Crohn's disease
In young patients, PR bleeding (with or without mucus) associated with an increased frequency of bowel motions should alert the clinician to inflammatory bowel diseases such as Crohn's or ulcerative colitis.

Crohn's disease is associated with ulcers in the mouth, as it can affect any part of the alimentary tract, i.e. mouth to anus.

35

A 19-year-old women presents to the Emergency department with severe right iliac fossa pain. She is feeling light headed and tired. Her pulse is 124/min and her blood pressure is 100/60 mmHg.

Ruptured ectopic pregnancy
Pain in the right iliac fossa (RIF) is a common presenting complaint among surgical patients, particularly the young. The important differential diagnoses for both sexes are acute appendicitis, UTI, right renal calculi, Crohn's ileitis, and in women pelvic inflammatory disease and conditions affecting the right fallopian tube and ovary. Ruptured ectopic pregnancy should be suspected in any female patient of child bearing age (even if the patient denies pregnancy or is currently using contraceptives) manifesting signs of shock.

36

An 81-year-old gentleman presents to the Emergency department with a 12 hour history of generalised abdominal pain associated with nausea and vomiting. He has absent bowel sounds and he is in atrial fibrillation.

Mesenteric infarction
Mesenteric infarction should be suspected in elderly patients presenting with acute abdominal pain and in atrial fibrillation. This is a surgical emergency, and laparotomy and removal of the dead gut is vital to save the patient's life.

37

A 20-year old women presents to the Emergency department with a 24 hour history of lower abdominal pain. She is systemically well and does not have any specific signs or symptoms. Her last period was two weeks ago.This has been happening about the same time every month.

Mittelschmerz
Mittelschmerz (mid-cycle abdominal pain) is a common condition seen in young, menstruating women. The signs and symptoms are non-specific, if there are any. The pain usually lasts for 24-48 hours and settles without any treatment. The patient usually gives a history of similar pains during her monthly cycles.

38

A 40-year-old Caucasian lady presents to her GP with a painless swelling of her right leg. She had a lesion excised from the sole of her foot 10 years ago, but is unsure of the diagnosis. On examination, she is systemically well but has a mildly swollen right leg with pitting oedema. Inguinal and external iliac lymph nodes are palpable.

Malignancy
Enlarged lymph nodes are usually inflammatory or neoplastic in origin, and there is no evidence of an infective focus in this lady. The previous excision of a lesion in the foot is suggestive of malignancy, commonly a melanoma, and the late lymph node recurrence and secondary lymphoedema indicates a possible recurrence of the tumour.

39

A 15-year-old girl presents to her GP with a swollen left leg, with the swelling extending up to the knee. She is systemically well and is not on any medications.

Lymphoedma praecox
Lymphoedema praecox has a peak age of onset between 10-30 years. It is more commonly seen in females shortly after menarche. It is more likely to be unilateral (1:3) and usually extends up to the knee.

40

A 68-year-old gentleman of Asian origin presents with painless, swollen bilateral lower limbs and foot. On examination, the contour of the ankle is lost, and the skin over the dorsum of the foot is hard and cannot be pinched.

Elephantiasis
Elephantiasis is the commonest cause of lymphoedema worldwide. It is prevalent in Asia, Africa and South America and is transmitted by mosquitoes (Wuchereria bancrofti).
The parasite enters the blood stream and then into the lymphatics. On entering the lymph nodes, it causes fibrosis and obstruction, partly due to direct physical damage and partly due to immune response of the host. The other signs and symptoms include fever and lymphadenitis.
ESR may be raised. Diagnosis is made from the blood film which may show immature parasites (microfilariae), and from serology. Treatment with diethylcarbamazine kills the parasite but the lymphatic changes are irreversible.

41

A 32 year old man is admitted with a distended tense abdomen. He previously underwent a difficult appendicectomy 1 year previously and was discharged. At laparotomy the abdomen is filled with a gelatinous substance.

Pseudomyxoma peritonei

Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source.

Pseudomyxoma Peritonei


Rare mucinous tumour
Most commonly arising from the appendix (other abdominal viscera are also recognised as primary sites)
Incidence of 1-2/1,000,000 per year
The disease is characterised by the accumulation of large amounts of mucinous material in the abdominal cavity

Treatment
Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C.

Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year survival rates of 75% have been quoted. Patients with disseminated intraperitoneal malignancy from another source fare far worse.
In selected patients a second look laparotomy is advocated and some practice this routinely.

42

A 62 year old man is admitted with dull lower back pain and abdominal discomfort. On examination he is hypertensive and a lower abdominal fullness is elicited on examination. An abdominal ultrasound demonstrates hydronephrosis and intravenous urography demonstrated medially displaced ureters. A CT scan shows a periaortic mass.

Pseudomyxoma peritoneii- Curative treatment is peritonectomy (Sugarbaker procedure) and heated intra peritoneal chemotherapy.


The correct answer is Retroperitoneal fibrosis

Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly understood. In a significant proportion the ureters are displaced medially. In most retroperitoneal malignancies they are displaced laterally. Hypertension is another common finding. A CT scan will often show a para-aortic mass

43

A 48 year old lady is admitted with abdominal distension. On examination she is cachectic and has ascites. Her CA19-9 returns highly elevated.

Metastatic adenocarcinoma of the pancreas

Although not specific CA 19-9 in the context of this history is highly suggestive of pancreatic cancer over the other scenarios.