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Flashcards in GI and General III Deck (41):
1

Normal Ranges
Haemoglobin 12 - 16.5 g/dl
MCV 85 - 95 fL
Calcium 2.2 - 2.6 mmol/L
Alkaline phosphatase 50 - 110 U/L

A 65-year-old male presents with a four month history of weight loss, pale stools and diarrhoea. Investigations reveal a haemoglobin of 11.5 g/dl, MCV of 90 fl, serum calcium of 2 mmol/l and an alkaline phosphatase of 400 iu/l.

Pancreatic carcinoma

The history of pale stool and malabsorption of fat-soluble vitamins (low vitamin D and hence low calcium) together with elevated alkaline phosphatase suggests biliary obstruction and hence pancreatic carcinoma.

Folate and B12 absorption are unaffected and so mean corpuscular volume (MCV) is normal though a normochromic normocytic anaemia is often a feature.

The grossly elevated alkaline phosphatase would be excessive for purely a vitamin D deficiency and is far more in keeping with biliary obstruction.

2

Normal Ranges
Haemoglobin 12 - 16.5 g/dl
MCV 85 - 95 fL
Calcium 2.2 - 2.6 mmol/L
Alkaline phosphatase 50 - 110 U/L

A 69-year-old male presents with a three month history of weight loss and loose motions. His haemoglobin concentration of 10.1 g/dl, MCV of 80 fl and a calcium of 2.5 mmol/l with an alkaline phosphatase of 510 iu/l.

Colonic carcinoma
Change in bowel habit in an elderly patient with a microcytic anaemia and elevated alkaline phosphatase yet normal calcium suggests colonic carcinoma with hepatic metastases as the likely diagnosis.

3

Normal Ranges
Haemoglobin 12 - 16.5 g/dl
MCV 85 - 95 fL
Calcium 2.2 - 2.6 mmol/L
Alkaline phosphatase 50 - 110 U/L

A 22-year-old male presents with weight loss and loose motions of approximately six months duration. Investigations show a haemoglobin concentration of 11.5 g/dl, a MCV of 105 fl, a calcium of 2.1 mmol/l and an alkaline phosphatase of 150 iu/l.

Coeliac disease

The young male with change in bowel habit, elevated MCV associated with folate/B12 malabsorption and hypocalcaemia with mildly elevated alkaline phosphatase (more in keeping with a vitamin D deficiency/osteomalacia) suggests a diagnosis of coeliac disease. All patients with iron deficiency anaemia should be screened for coeliac disease (see BSG guidelines 2011).

4

A 35-year-old male is found on colonoscopy to have an ulcer. There is also found a fistula in ano and skin tags.

Crohn's disease
The triad of:

Fistula in ano
Anal skin tags
Ulceration on colonoscopy
is usually associated with Crohn's disease. Other differentials are tuberculosis, ulcerative colitis, watering can perineum from gonorrhoea.

Crohn's disease is also associated with extra-gastrointestinal (GI) features such as:

Clubbing
Arthropathy
Sacro-iliitis
Uveitis.

5

A man complains of intense pain on defecation. On PR a very tender dark purple swelling is found near the anal verge.

Anal haematoma
This gentleman has characteristic features of an anal haematoma (also called thrombotic pile or a seven day pile).

Piles are particularly common and can present with marked pain - strangulation and thrombosis.

Usually, the thrombosed piles appear much darker in colour - dark purple/black.

6

A 48-year-old woman is referred as an emergency with severe right upper quadrant (RUQ) pain. On examination she pyrexial,38.8, and has a tender, palpable right subcostal mass with local peritonism.

Empyema
An empyema is effectively a complication of a complication. It arises when a stone lodges in the cystic duct orifice, behind which mucous continues to be produced, forming a mucocele. The stagnant mucous then becomes secondarily infected leading to an abscess.

It requires urgent cholecystectomy or cholecystostomy in the unfit.

7

A 43-year-old obese, multiparous lady is seen in the emergency department reporting a first episode of RUQ pain and nausea. By the time her blood results come back, the pain has settled completely. She is apyrexial and there is only minimal tenderness.

Biliary colic
Biliary colic is probably caused by a stone transiently impacting in Hartmann's pouch, preventing emptying of the gallbladder. the pain typically lasts 15-20 minutes and follows ingestion of a fatty meal. The pain is recurrent and associated with nausea but there are no systemic signs.

8

A 54-year-old woman is admitted with a severe epigastric pain and vomiting. She has a longstanding history of RUQ pain and a USS arranged by her GP had shown gallstones but she had not been referred. On examination she has a blood pressure of 100/65 mm Hg and a pulse rate of 110/min. There is marked epigastric tenderness.

Acute pancreatitis
Gallstones are the commonest cause of acute pancreatitis in the United Kingdom followed closely by alcohol. The pain is often more central than for other manifestations of gallstone disease. It is relieved by sitting forward as this allows the stomach and small bowel to fall away from the pancreas in the retroperitoneum.

9

A 47-year-old woman who is on the waiting list for a cholecystectomy, having experienced recurrent episodes of biliary colic, is admitted with severe RUQ pain associated with a pyrexia of 38°C and localised tenderness at the tip of the ninth right rib.

Acute cholecystitis
Acute cholecystitis is characterised by biliary pain, together with signs of inflammation including local tenderness over the tip of the ninth rib consistent with local peritonism and an elevated temperature, WBC/CRP.

10

In cancer of the oesophagus in the UK which of the following is true?
(Please select 1 option)
Chest pain is a late symptom
Squamous cell carcinoma is the most common histology
Is associated with Crohn's disease
The commonest site is the lower third of the oesophagus
When occurring at the gastro-oesophageal level is equally likely to be an adenocarcinoma as a squamous carcinoma

The commonest site is the lower third at ~45-55% (increasing in incidence), followed by the middle at ~25-30%, then the upper with ~15%. (Some tumours will overlap these artificial divisions).

Adenocarcinoma accounts for 65% of oesophageal cancers in the UK but squamous cell still remains the most common form worldwide. Adenocarcinoma is the most common form at the gastro-oesophageal level.

Chest pain is the presenting symptom in 20% (invasion/achalasia) and it is associated with Barrett's and coeliac disease.

11

Regarding hypomagnesaemia, which of the following statements is correct?
(Please select 1 option)
Causes a broad QRS complex on the ECG
Causes hypercalcaemia
Causes tetany
Is often due to prolonged use of potassium sparing diuretics
Is seen in chronic obstructive pulmonary disease

Tetany

The ECG changes are almost the same as those of hypokalaemia:

Flattening of T waves
ST segment depression
Prominent U waves
Prolonged PR interval
Prolonged QT interval
There is a risk of atrial and ventricular ectopics and ventricular arrhythmias. There is an increased risk of digoxin toxicity.

In chronic hypomagnesaemia there is impaired synthesis and release of parathyroid hormone (PTH), and target organ response to PTH is impaired. This produces secondary hypocalcaemia.

Hypomagnesaemia may result (like hypokalaemia) from the use of potassium 'wasting' diuretics (loop diuretics and thiazides, for example, furosemide).

12

Which of the following is not associated with the development of colonic carcinoma?
(Please select 1 option)
Familial colonic polyposis
Gardner syndrome
Ménétrier's disease
Peutz-Jegher's syndrome
Ulcerative colitis

Menetriers disease

In familial adenomatous polyposis (FAP) the risk of colonic malignancy is 100% by the age of 40. Between 24-93% of those affected also have duodenal polyps. These are most common in the second part of the duodenum and 2-12% develop periampullary carcinoma.

Gardner syndrome (described in 1951) is a phenotypic variant of FAP. There are extracolonic clinical features that include desmoid tumours, epidermoid cysts and osteomas.

Ménétrier's disease is giant hyperplasia of the gastric folds. There is an increased risk of gastric carcinoma.

Peutz-Jegher's syndrome comprises gastrointestinal polyps (hamartomas) associated with pigmented lesions of the face, lips buccal mucosa, palms and soles of the feet. There is a 2-3% risk of malignancy. This is more common in duodenal polyps (which are more numerous) than in colonic polyps.

The risk of malignant change in ulcerative colitis is 15% at 20 years, and 45% at 35 years.

13

Which of the following is a method of sterilisation?
(Please select 1 option)
Alpha irradiation
Cellulose filtration
Dry heat at 134°C for 3 minutes
Moist heat at 121°C for 15 minutes
Steam at 80°C and sub-atmospheric pressure

Cellulose filtration
Moist heat (e.g. autoclave) is a method of sterilisation and the process kills all organisms and spores. It should be applied at 122°C at 1 atm for 30 minutes, 126°C at 1.5 atm for 10 minutes, or 134°C at 2 atm for 3 minutes to sterilise non-heat sensitive surgical instruments.

Steam is used to increase the temperature, so dry heat needs to be at a higher temperature for a longer time, e.g. 160°C for 1 hour, to have a similar effect to moist heat. Dry heat is used to sterilise glassware and powders.

Steam at low pressure and 80°C will only disinfect instruments, and it does not destroy spores. The addition of formaldehyde will cause sterilisation, and is used to sterilise heat sensitive equipment such as cannulae.

Cellulose filtration is used to sterilise heat sensitive fluids, but it may not remove viral particles.

14

Which of the following paediatric conditions is not associated with a palpable abdominal mass?
(Please select 1 option)
Congenital adrenal hyperplasia
Hirschsprung's disease
Meckel's diverticulum
Nephroblastoma (Wilms' tumour)
Neuroblastoma

CAH
Congenital adrenal hyperplasia may present with vomiting, weight loss and dehydration, with girls having virilised genitalia.

Hirschsprung's presents with

Lower bowel obstruction
Constipation
Abdominal distension
Left-sided faecal mass.
On rectal examination, the rectum is empty and there is a squirt of foul-smelling faeces and gas.

Meckel's usually presents with rectal bleeding, or intussusception which may be palpable.

Nephroblastoma is also known as Wilms' tumour, and any child with an abdominal lump should be suspected as having a Wilms' tumour. Patients look less ill than neuroblastoma patients. Often the patient is asymptomatic; they may have abdominal pain and vomiting, and some are hypertensive due to renal artery involvement.

Neuroblastoma is a firm tumour derived from nervous tissue. Seventy per cent arise in the abdomen, with over 50% of these in the adrenal glands. It may present as an asymptomatic mass, although it may bleed spontaneously causing pallor and hypotension.

15

An irregular liver edge is found in which of the following?
(Please select 1 option)
Amoebic liver abscess
Budd-Chiari syndrome
Congestive cardiac failure
Early alcoholic cirrhosis where the patient has stopped drinking
Sarcoid

Amoebic liver abscess

Irregular hepatomegaly may be found in

Late alcoholic hepatitis with underlying cirrhosis
Malignancy
Carcinoid
Tertiary syphilis
Actinomycosis.
Amoebic abscess would also cause irregular liver edge.

Smooth hepatomegaly is usually found in congestive cardiac failure, sarcoid affecting the liver.

Hepatomegaly tends not to be a feature of Budd-Chiari - portal vein thrombosis.

16

Which of the following is correct regarding solitary rectal ulcer syndrome?
(Please select 1 option)
The epithelial cells demonstrate cytological atypia
The highest incidence is seen between the ages of 55 and 75 years
The surrounding mucosa is usually normal
The ulcers are usually located on the posterior rectal wall
There is a weak association with rectal prolapse

The epithelial cells demonstrate cytological atypia

Many of the epithelial cells demonstrate cytological atypia with:

Hyperchromasia
Eosinophilic nucleoli
Pleomorphism, and
Mitoses.
These cytological features may suggest high-grade dysplasia or adenocarcinoma, but the cells typically show evenly distributed chromatin and evidence of maturation toward the luminal surface in contrast to cells from neoplastic tissue.

Important additional differential diagnostic considerations include:

Inflammatory pseudopolyps of ulcerative and Crohn's colitis
Ischaemia
Benign pseudopolyps
Drugs (non-steroidal anti-inflammatory drugs or NSAIDs, corticosteroids, and oral contraceptives)
Infection, and
Stercoral ulceration associated with faecal stasis.
Solitary rectal ulcer syndrome is most common between the ages of 25 and 35 years, but has been described in elderly patients.

The surrounding non-ulcerated mucosa usually has characteristic histological findings.

The ulcers are usually located 6-12 cm above the anus.

Rectal prolapse can be shown in the majority of patients. The aetiology is thought to involve chronic trauma due to repeated mucosal prolapse associated with puborectalis muscle dysfunction.

Persistent contraction of the puborectalis muscle during attempted defecation maintains an acute anorectal angle, which keeps the anal canal closed and results in increased intra-rectal pressure.

This leads to severe straining during defecation in an attempt to overcome the functional obstruction. Consequently, the mucosa of the anterior rectal wall is forced against or into the anal canal, and the stress of repeated mucosal prolapse induces focal ischaemia and ultimately ulceration.

Patients will often report attempts to remove hard stool digitally from the rectum; self-induced trauma may thus also contribute to ulceration.

17

Which one of the following statements concerning breast cancer is correct?
(Please select 1 option)
A GP with 2,500 patients will see on average two new cases per year
Alpha-fetoprotein is typically raised above normal
Surgery has been shown to improve survival rates more than radiotherapy
The five year survival of all patients with breast cancer is less than 50%
The incidence has been shown to be higher in women who have had previous bilateral oophorectomy for non-malignant disease

A GP with 2,500 patients will see on average two new cases per year

The incidence of breast cancer is approximately 1 per 2000 and a GP will see on average 10 new diagnoses of any cancer per year.

Alpha-fetoprotein is raised in cancer of the

Liver
Testis
Ovary
Pancreas
Lung
Stomach
Colon.
Current figures suggest an 80% five year survival of all patients with breast cancer.

18

Which of the following is correct of Hodgkin's disease?
(Please select 1 option)
Is associated with hirsutism
Is best treated with radiotherapy when there is marrow involvement
Is characterised by the Reed-Sternberg cell
Is more common in females than males
Most frequently involves the hilar lymph nodes

Is characterised by the Reed-Sternberg cell

The incidence of males to females is roughly 1.9:1.

Histologically it is characterised by the Reed-Sternberg cell, a giant multinucleated cell.

It most frequently involves the cervical lymph nodes, is associated with typical symptoms - night sweats, weight loss and pruritus.

Marrow involvement which is prognostically poor is most appropriately treated with chemotherapy.

More on Hodgkin's disease...

19

Splenectomy is helpful in the management of which of the following?
(Please select 1 option)
Acquired haemolytic anaemia
Coeliac disease
McArdle's disease
Pernicious anaemia

Acq haemolytic anaemia

Indications for splenectomy include haemolytic anaemias and particularly idiopathic thrombocytopenic purpura (ITP).

Coeliac disease is usually associated with hyposplenism as is sickle cell disease.

McArdle's disease, a glycogen storage disease that results in mild lactic acidosis with exercise, is not treated with splenectomy.

20

The c-myc proto-oncogene is not associated with carcinoma of which of the following?
(Please select 1 option)
Breast
Cervix
Colon
Kidney
Stomach

Kidney

C-myc, a proto-oncogene, is involved in the regulation of cell proliferation and DNA synthesis.

It has been implicated in the development of carcinoma of the

Breast
Colon
Cervix
Lung and
Stomach.

21

Which one of the following does not have a role in incisional hernia formation?
(Please select 1 option)
Corticosteroid use
Female sex
Laparoscopic surgery
Site of incision
Suture technique

Female

There is no sex difference. The risk factors are divided into

Preoperative:

Obesity
More than 60 years
Poor nutrition
Renal failure
Ascites
Malignancy
Diabetes mellitus.
Perioperatively:

Suture failure
Drain site
Laparoscopic surgery (can result in port site hernias).
Postoperatively:

Cough
Haematoma
Infection
Seroma.

22

Which one of the following wounds should be closed primarily?
(Please select 1 option)
A skin laceration 12 hours old
Gunshot wound to the abdomen
Hartmann's procedure performed for faecal peritonitis
Open cholecystectomy performed for mucocele of the gallbladder
Shocked patient

Open cholecystectomy

A skin laceration 12 - 24 hours old should be left open and packed, the wound should be inspected at seven days and if clean should be closed.

With severe soiling there is a very high chance of a superficial wound dehiscence, therefore the rectus should be sutured and the skin left opened, the wound should be inspected daily and if clean closed at seven days.

A shocked patient is unable to perfuse tissue therefore there is a high chance of skin edge necrosis, therefore the wound should be treated as above.

A high velocity injury causes cavitation within the abdomen drawing in debris. The wounds should be treated as above.

Cholecystectomy for a mucocele is usually a clean operation and is therefore safe to close.

23

Which of the following is true of a transverse anastomosis stapling device (TIA)?
(Please select 1 option)
Are haemostatic
Divides the bowel between the staples
Has two limbs which come apart
Have an angled head
Produces two layers of overlapping staples

Produces two layers of overlapping staples This is the correct answerThis is the correct answer
Transverse anastomosis stapling devices come with a cartridge, which inserts into the head.

These devices produce two rows of staples but do not divide the bowel. The bowel is divided with a scalpel immediately after the device has been fired and before it is released.

The staples are not haemostatic and therefore the cut bowel wall should be inspected for signs of bleeding.

These devices are used commonly to divide the rectum deep in the pelvis, therefore a rotating head (roticulator) is an advantage.

24

Which of the following is correct of surgical staples?
(Please select 1 option)
Are generally more expensive than skin sutures
Are painless
Are usually made from titanium
Should result in wound edge inversion
When used on the skin always result in skin hatching

Generally more expensive

Staples are usually made from stainless steel and thus have high tensile strength and minimal tissue reaction.

If removed promptly skin hatching does not result.

If applied properly they should cause wound edge eversion.

They are more expensive than non-absorbable sutures.

They are uncomfortable and require a special instrument to remove them.

25

Which of the following is correct regarding gastric adenocarcinoma?
(Please select 1 option)
Has a five year survival of 60%
Is more common in patients with blood group A
Is not associated with H. pylori infection
Occurs in the body and fundus in the majority of patients
Trosier's sign is the presence of an involved right supraclavicular lymph node

Blood group A

It is associated with blood group A.

H. pylori is a risk factor for gastric adenocarcinoma.

The tumour is located in the pylorus and antrum in 50-60% of patients, the cardia in 25% of patients and the remainder are in the body and fundus.

Trosier's sign is the presence of an enlarged left supraclavicular node (Virchow's node).

The majority of gastric cancers are detected at an advanced stage in the United Kingdom and the five year survival is 5-10%.

26

Which one of the following carcinogens is paired with the correct associated carcinoma?
(Please select 1 option)
Benzopyrene and nasopharyngeal carcinoma
B-Naphthylamine and bladder cancer
Diethyl-stilboestrol and endometrial cancer
Epstein-Barr virus and lung cancer
Hepatitis B and angiosarcoma of the liver

B-Naphthylamine and bladder cancer

B-naphthylamine is activated in the liver to the active carcinogen and conjugated with glucuronide. This is then excreted into the urine where glucuronidase unconjugates the molecule thus exposing the urothelium to its carcinogenic effect.

Diethyl-stilboestrol is associated with adenocarcinoma of the vagina.

Hepatitis B is associated with hepatocellular carcinoma.

Benzopyrene is one of the potent carcinogens found in cigarette smoke.

Epstein-Barr virus is also associated with Burkitt's lymphoma.

27

The trachea, which of the following is true?
(Please select 1 option)
Divides at the level of the second thoracic vertebra
Has the aortic arch on its right
Is closely related to the right recurrent laryngeal nerve
Is crossed posteriorly by the left brachiocephalic vein
Is supplied by the internal mammary artery

Is closely related to the right recurrent laryngeal nerve

The trachea descends through the neck and enters the thorax in the midline, immediately behind the upper border of the manubrium.

It runs vertically through the superior mediastinum and the level of the fourth thoracic vertebra (level of the aortic arch) divides into left and right main bronchi.

The thoracic part of the trachea is crossed anteriorly by the brachiocephalic trunk and the left brachiocephalic vein.

The trachea is related on the left to the arch of the aorta and left common carotid and subclavian arteries, on the right to the superior vena cava, the termination of the azygos vein, the right vagus nerve and the mediastinal pleura.

It is related posteriorly to the oesophagus and the left recurrent laryngeal nerve. The right recurrent laryngeal nerve does not enter the thorax but passes around the right subclavian artery in the root of the neck. However, in the neck the nerve is closely related to the trachea.

The vascular supply of the trachea is from the inferior thyroid arteries and veins.

28

Which of the following is true of gangrene?
(Please select 1 option)
In the affected part, sensation and venous return is usually preserved
Is a form of apoptosis
Is always diagnosed by the brown, greenish black or black appearance
It is advisable to convert dry gangrene into a moist type
With arterial insufficiency is usually dry

With arterial insufficiency is usually dry This is the correct answerThis is the correct answer
Gangrene is not a form of apoptosis (which is programmed cell death) and it implies death with putrefaction of macroscopic portions of the tissue.

A gangrenous part lacks arterial pulsation, venous return, sensation, warmth and function.

The colour of the part changes through a variety of shades according to circumstances (pallor, dusky red, mottled, purple) until finally taking on the characteristic dark brown, greenish black or black appearance, which is due to the disintegration of haemoglobin and the formation of iron sulphide.

Dry gangrene occurs when the tissues are desiccated by gradual slowing of the bloodstream; it is typically the result of atherosclerosis.

Moist gangrene occurs when venous as well as arterial obstruction is present, when the artery is suddenly occluded, as by a ligature or embolus, and in diabetes. In moist gangrene, infection and putrefaction are more severe, the affected part becomes swollen and discoloured, and the epidermis may be raised in blebs.

The final line of demarcation in moist gangrene becomes more proximal than in dry gangrene and hence dry gangrene should be kept as dry and aseptic as possible. In addition, every effort should be made to convert a moist into a dry type.

29

Which of the following is true regarding carcinoma of the stomach?
(Please select 1 option)
Adenomatous polys may predispose to malignant change
Duodenal involvement occurs in 75-80% of all gastric carcinomas
Incidence is higher in the UK than in Japan
Resection requires preservation of the greater omentum
Symptoms in early gastric cancer do not improve with acid-reducing treatment

Adenomatous polys may predispose to malignant change

The most common neoplasm of the stomach is an adenocarcinoma.

Japan has the highest age-adjusted incidence and death rate followed by Chile, Austria and Finland.

It is highest in social classes III-V, more common in blood group A (in the UK; Group B in Japan), and associated with increased ingestion of nitrates, smoked fish, spicy food and Helicobacter pylori infection.

The incidence of malignant transformation from adenomatous polyps is 18-75%.

The first symptoms of gastric cancer are those of

Dyspepsia
Epigastric pain
Vomiting
Dysphagia and
Bleeding.
These symptoms are sometimes impossible to distinguish from benign peptic ulceration and symptoms in early gastric cancer may, in fact, settle down with acid-reducing treatment (the temptation to treat patients medically for prolonged periods of time without confirmation of the diagnosis should therefore be resisted).

Gastric cancer may spread luminally into the duodenum and oesophagus. It is not true that the pylorus is the invariable limit of distal spread since duodenal involvement occurs in 25-30% of all gastric cancers.

Along with partial/total gastrectomy, the greater omentum is removed in all cases along with the left gastric, celiac and common hepatic nodes.

30

Following splenectomy, which of the following is correct?
(Please select 1 option)
Howell-Jolly bodies are seen
Lymphocytosis appears immediately
Red cell count falls
Target cells disappear
The platelet count falls

HJ bodies

After splenectomy the spleen is not able to remove immature or abnormal red blood cells from the circulation.

The red cell count does not change but cells with inclusions (for example, Howell-Jolly bodies) appear.

Target cells, reticulocytes and siderocytes appear within the first few days post splenectomy.

Granulocytosis appears immediately and is replaced over the next few weeks with lymphocytosis and monocytosis.

The platelet count is usually increased and thrombocytosis in excess of 1000 x 109/L may occur.

31

Which one of the following is not associated with an increased bleeding tendency?
(Please select 1 option)
Cirrhosis
Factor VIII deficiency
Factor IX deficiency
Lupus anticoagulant
von Willebrand factor deficiency

Lupus anticoagulant

von Willebrand disease/haemophila B and F VIII deficiency (haemophilia A) are associated with increased bleeding tendency. Christmas disease, a rare haemophilia is associated with a bleeding tendency.


Lupus anticoagulant is associated with increased prothrombotic tendency, recurrent abortions etc.

Although cirrhosis is associated with an increased bleeding tendency and can occur as a late feature of haemochromatosis it is not a typical feature of the treated condition.

32

An abdominal x ray is an inappropriate investigation in a patient suspected of having which of the following?
(Please select 1 option)
Acute pancreatitis
Biliary colic
Cholangitis
Perforation
Renal colic

Biliary colic

Cholangitis carries a poor prognosis if left untreated.

Air in the biliary tree in a patient who has not previously undergone sphincterotomy at ERCP would raise the suspicion of cholangitis.

Approximately 85% of renal stones are radio-opaque.

Approximately 15% of gallstones are radio-opaque and demonstrated on abdominal x ray.

Calcification of the pancreas is associated with chronic pancreatitis.

Abdominal x ray would be the initial investigation performed in suspected obstruction or perforation.

33

Which of the following is true of cardiac disorders in surgical patients?
(Please select 1 option)
60% of patients will re-infarct if operated on within three months of a myocardial infarction
Creatine phosphokinase (CPK) is a myocardial specific isoenzyme
Heart failure is classified by the NYHA classification system
Peri-operative myocardial infarction has a mortality of approximately 10%
Risk of peri-operative heart failure is approximately 70% if there is a pre-operative cardiovascular history

Heart failure is classified by the NYHA classification system

Creatine kinase is an MB isoenzyme that peaks at 24 - 48 hours following myocardial infarction but currently troponins are used as the specific markers of myocardial injury.

Of those that have already had a myocardial infarct 30% will reinfarct if operated within three months.

The mortality for peri-operative myocardial infarction is approximately 40%. Therefore elective surgery is undertaken after six months and urgent surgery at four to six weeks with invasive monitoring and a preoperative stress test.

The greatest risk is to those undergoing thoracic, abdominal or vascular surgery (5-15% aortic surgery).

Myocardial infarction, and more commonly, fluid overload may precipitate heart failure in the surgical patient.

The risk of peri-operative heart failure is approximately 17% if there is a pre-operative cardiovascular history.

Heart failure maybe classified into four groups according to the NYHA classification system, to allow prediction of operative mortality:

1 = no functional limitation
2= dyspnoea on exercise
3 = dyspnoea with normal activity
4 = dyspnoea at rest
Mortality: class 1 = 4%, 2 = 11%, 3 = 27%, 4 = 67%.

34

Which of the following is true of deep venous thrombosis in post-operative surgical patients?
(Please select 1 option)
A thrombus in the popliteal vein is more likely to cause pulmonary embolism than a femoral vein thrombus
It usually develops 48-72 hours post surgery
The diagnosis should be considered in patients having fluctuating pyrexia few days post-surgery
The incidence is increased in patients having pelvic surgery
The risk is not associated with prolonged hospital stay

The incidence is increased in patients having pelvic surgery

The signs and symptoms of a deep venous thrombosis (DVT) are usually seen 7-10 days post-operatively.

Some risk factors include

Increasing age
Pregnancy
Oral contraceptive pill
Orthopaedic or pelvic surgery
Malignancy
Past history of DVT and
Thrombophilia.
Immobility and prolonged hospitalisation increase their incidence.

The clinical features of DVT include

Redness
Swelling
Pain
Calf tenderness
Dilated superficial veins (sometimes) and
Low grade pyrexia (but not fluctuating pyrexia).
Urinary tract infection, atelectasis and pneumonia should be considered in post-operative surgical patients having fluctuating pyrexia.

A thrombus in the femoral vein is more likely to propagate distally and cause a pulmonary embolism (iliac vein thrombi are even more dangerous) than a thrombus in the popliteal vein.

A significant proportion of calf thrombi are asymptomatic although they may predispose to venous ulceration in the long term.

35

Which of the following is correct regarding pelvic abscesses?
(Please select 1 option)
Are an uncommon cause of intraperitoneal abscess
Are associated with a pyothorax
Can only be identified on CT if there is a full bladder
Commonly present with pneumaturia
May spontaneously drain via the rectum

May spontaneously drain via the rectum This is the correct answerThis is the correct answer
Pelvic abscess is the most common variety of intraperitoneal abscess.

Pus can originate from a proximal source to form a pelvic abscess, for example, perforated duodenal ulcer, but not from the chest as the diaphragm will impede the passage of pus.

The abscess can irritate the bladder causing urinary frequency/nocturia.

Pneumaturia is pathognomonic of colovesical fistula.

If an abscess drains spontaneously via the rectum, they rarely require any further treatment.

Ultrasound (not CT) imaging requires a full urinary bladder to identify the pelvic organs and any abscesses present.

36

Which one of the following conditions commonly requires splenectomy in later life?
(Please select 1 option)
Beta thalassaemia
Glucose-6-phosphate dehydrogenase deficiency
Idiopathic thrombocytopenic purpura
Sickle cell disease
Sickle cell trait

beta thalassemia

Because of the risk of post-operative sepsis, splenectomy should be limited to specific indications. These include:

Splenic rupture, anatomic defects
Haemolytic anaemias, immune cytopenias
Metabolic storage diseases
Secondary hypersplenism
Surgical indications (rare)
The major risk is infection, particularly in children less than 5 years. The risk of sepsis is slightly less in splenectomies done for trauma, red cell membrane defects, and immune cytopenias than when there is a pre-existing immune deficiency such as Wiskott-Aldrich syndrome or reticuloendothelial blockage such as storage diseases or severe haemolytic anaemias.

37

Which of the following is correct regarding childhood malignancies?
(Please select 1 option)
A bone marrow biopsy should never be performed to excludeleukaemia before ITP is treated with steroids
A mediastinal mass is a infrequent finding in T cell acutlymphoblastic leukaemia
Children on chemotherapy are at low risk if exposed to measlesor chickenpox
Cranial irradiation before the age of 3 years has a lowneurocognitive morbidity
The siblings of children on active treatment for cancer can besafely immunised with the combined measles, mumps and rubellavaccine (MMR).

The siblings of children on active treatment for cancer can besafely immunised with the combined measles, mumps and rubellavaccine (MMR). This is the correct answerThis is the correct answer
A mediastinal mass is typical of T cell acute leukaemia and can also be a manifestation of T cell non-Hodgkin's lymphoma. Side effects of chemotherapy are extremely common and important. They include:

Infection from immunosuppression: Neutropenia places children at risk of septicaemia and there are specific problems with Gram negative organisms, coagulase negative Staph., Pneumocystis carinii pneumonia (PCP) and disseminated fungal infections.

Most viral infections are no worse than in other children, but measles and varicella may be life-threatening. Zoster immunoglobulin may be helpful in non-immune children who have been in contact with measles or varicella. Aciclovir is used to treat established varicella infection but no active treatment is available for measles.

The use of live vaccines in patients receiving chemotherapy should be avoided until at least six months to a year has elapsed following the completion of chemotherapy.

Bone marrow suppression: Anaemia requires transfusion, and thrombocytopenia may result in bleeding.

Gut mucosal damage: This may increase the risk of Gram negative infection and is associated with painful mouth ulcers, which can prevent eating.

Specific side effects:

Cardiotoxicity with doxorubicin
Renal failure and deafness with cisplatin
Haemorrhagic cystitis with cyclophosphamide
Neuropathy with vincristine.
Occasionally leukaemia may present with thrombocytopenia alone. In patients presenting with a low platelet count who are thought to have idiopathic thrombocytopenic purpura (ITP), a bone marrow should be done if steroids are considered as they may suppress the leukaemia enough to delay diagnosis.

38

Which one of the following is true regarding Peutz-Jegher's syndrome?
(Please select 1 option)
Is associated with a risk of malignant transformation
It is associated with adenomatous polyps of the small intestine
It is associated with the presence of pigmented lesions are seen in the axilla
It is inherited as an autosomal recessive condition
Often presents in childhood with B12 deficiency anaemia

Is associated with a risk of malignant transformation

Recent data suggest that Peutz-Jegher's syndrome is a premalignant condition with 50% of patients affected developing cancer by the age of 57.

The small intestinal polyps are hamartomas and not adenomas.

The circumoral pigmented lesions are a characteristic feature of this condition.

Peutz-Jegher's syndrome is inherited as an autosomal dominant condition. As a result children with one affected (heterozygous) parent have a 50% chance of developing the condition.

It can present as anaemia in childhood. The anaemia is a hypochromic microcytic anaemia resulting from iron deficiency.

39

Which one of the following does not constitute a vaccine?
(Please select 1 option)
DNA recombinant
Inactivated
Live attenuated
Prion
Toxoid

Prion

A prion is a proteinaceous infective material believed to be responsible for Creutzfeldt-Jakob disease.

With the possible exception of inactivated vaccines you have probably received all of the others yourself.

Live attenuated vaccines include polio, measles and BCG.

Toxoid vaccines are diphtheria and tetanus toxoids.

Inactivated vaccines are inactivated bacteria, e.g. pertussis (whooping cough) or viruses, e.g. hepatitis A, rabies.

DNA recombinant vaccines include hepatitis B surface antigen, produced in yeasts.

40

Which of the following is true of a naevus flammeus?
(Please select 1 option)
Are best treated immediately it is recognised
Is a capillary haemangioma
Is pulsatile
Often present on the nape of the neck
Usually develops in the first year of life

Often present on the nape of the neck

Treatment is by laser or tattooing at a much later date as the lesions may regress spontaneously.

The other names are naevus flammeus and capillary malformation.

It is non-pulsatile.

The majority occur in the regions supplied by the fifth cranial nerve.

These naevi are usually present at birth but may not present until later in life.

41

Surgical drains

Theme: Surgical drains


Please select the most appropriate surgical drainage system for the indication given. Each option may be used once, more than once or not at all.

A 56 year old lady undergoes and open cholecystectomy and exploration of common bile duct. The bile duct is closed over a drain.
You answered Silastic T Tube drain

The correct answer is Latex T Tube drain

Latex is used for this indication as it will encourage track formation.
A 48 year old lady undergoes a mastectomy and axillary node clearance for an invasive ductal cancer of the breast with lymph node metastasis.
You answered Corrugated drain

The correct answer is Redivac suction drain

Suction drains are commonly used following mastectomy and axillary surgery to prevent haematoma formation. Not all surgeons routinely drain the axilla.
A 75 year old man undergoes a hartmans procedure for sigmoid diverticular disease with pericolic abscess and colovesical fistula.
Wallace Robinson drain

These tube drains are often used in abdominal surgery to drain abscess cavities. Debate might occur around the use of low pressure vs no suction in this setting so this option is deliberately omitted.
Next question

Surgical drains

Drains are inserted in many surgical procedures and are of many types.
As a broad rule they can be divided into those using suction and those which do not.
The diameter of the drain will depend upon the substance being drained, for example smaller lumen drain for pneumothoraces vs haemothorax.
Drains can be associated with complications and these begin with insertion when there may be iatrogenic damage. When in situ they serve as a route for infections. In some specific situations they may cause other complications, for example suction drains left in contact with bowel for long periods may carry a risk of inducing fistulation.
Drains should be inserted for a defined purpose and removed once the need has passed.

A brief overview of types of drain and sites is given below

CNS
Low suction drain or free drainage systems may be used for situations such as drainage of sub dural haematomas.

CVS
Following cardiothoracic procedures of thoracic trauma underwater seal drains are often placed. These should be carefully secured. When an air leak is present they may be placed on suction whilst the air leak settles

Orthopaedics and trauma
In this setting drains are usually used to prevent haematoma formation (with associated risk of infection). Some orthopaedic drains may also be specially adapted to allow the drained blood to be auto transfused.

Gastro-intestinal surgery
Surgeons often place abdominal drains either to prevent or drain abscesses, or to turn an anticipated complication into one that can be easily controlled such as a bile leak following cholecystectomy. The type of drain used will depend upon the indication.

Drain types
Type of drain Features
Redivac
Suction type of drain
Closed drainage system
High pressure vacuum system
Low pressure drainage systems
Consist of small systems such as the lantern style drain that may be used for short term drainage of small wounds and cavities
Larger systems are sometimes used following abdominal surgery, they have a lower pressure than the redivac system, which decreases the risks of fistulation
May be emptied and re-pressurised
Latex tube drains
May be shaped (e.g. T Tube) or straight
Usually used in non pressurised systems and act as sump drains
Most often used when it is desirable to generate fibrosis along the drain track (e.g. following exploration of the CBD)
Chest drains
May be large or small diameter (depending on the indication)
Connected to underwater seal system to ensure one way flow of air
Corrugated drain
Thin, wide sheet of plastic, usually soft
Contains corrugations, along which fluids can track
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