Gill revision

Question 1

Inflammation pain vs obstruction pain in tummy?

Answer 1

Inflammation –> throbbing
Obstruction –> colic

Patient moving around –> colic
Patient lying still –> inflammation

Question 2

Tenderness to percussion

Answer 2

Peritonism

Question 3

Appendicitis march of events

Answer 3

1st Pain, usually epigastric or umbilical
2nd Anorexia, nausea, or vomiting
3rd Tenderness – somewhere in the abdomen or pelvis
4th Fever
5th Leucocytosis

Question 4

McBurneys

Answer 4

1/3rd of way between ASIS and tummy button

Question 5

Perforated appendice

Answer 5

Generalised pain and guarding with peritonism

Question 6

Iliopsoas test for appendicitis?

Answer 6

Stretching the iliopsoas can elicit pain

Question 7

Retrocaecal or pelvic appendix may require what?

Answer 7

May require rectal examination –> this may be the only way to elicit pain and point of tenderness
Remember that the appendix can be in loads of really weird places
RECTAL EXAMINATION ESSENTIAL IN ANY APPENDICITIS

Question 8

Cell origin of oesophagus cancers?

Answer 8

Squamous cell
Adenocarcinomas in the lower third of the oesophagus are usually gastric in origin or have developed in Barrett’s oesophagus

Question 9

Where do oesophageal carcinomas spread to?

Answer 9

Liver, lungs, bone and lymph glands

Question 10

Dysphagia without weight loss?

Answer 10

Achalasia

Question 11

Degeneration of the ganglion cells of Auerbach’s mesenteric plexus?

Answer 11

Achalasia

Question 12

Confirming diagnosis of oesophageal carcinoma?

Answer 12

Endoscopy with biopsy

barium swallow will demonstrate irregular stricture

Question 13

Primary investigation for achalasia?

Answer 13

Barium swallow
-proximal oesophagus is dilated and tortuous and merges into a smooth cone shaped narrowed segment above the gastro-oesophageal junction

Question 14

Treatment for achalasia

Answer 14

Surgery –> Heller’s cardiomyotomy

Balloon dilatation

Question 15

A low grade fever with tenderness and guarding over McBurneys point?

Answer 15

Acute appendicitis

Question 16

Complications of appendicitis?

Answer 16

Perforation

Appendix mass

Question 17

Gallstones risk factors

Answer 17

Age > 40
Female
High fat diet
Obesity
Pregnancy
Hyperlipidaemia
Five “Fs”
Bile salt loss (Crohn’s)
Diabetes
Dysmotility of GB
Prolonged fasting 
TPN

Question 18

Biliary colic

Answer 18

Stone impacts in cystic duct
Gradual build-up pain in RUQ
Radiates to back / shoulder 
May last 2-6 hours
Associated with indigestion / nausea

Question 19

Severe acute epigastric pain differentials

Answer 19

Biliary colic
Peptic ulcer disease
Oesophageal spasm
Myocardial infarction
Acute pancreatitis

Question 20

Treatment for acute cholecystitis

Answer 20

IV antibiotics and IV fluids
Nil by mouth
US to confirm diagnosis

Urgent cholecystectomy** (asap)

Interval cholecystectomy (drainage of fluid then removal of gallbladder)

Question 21

Cholecystitis

Answer 21

Inflammation of the gallbladder

Question 22

Cholangitis

Answer 22

Infection of the common bile duct

Question 23

Complications of gallstones

Answer 23

Stone may migrate into CBD:

Jaundice
Cholangitis
Acute Pancreatitis

Gallstone Ileus

Question 24

Diagnosis of common bile duct pathology (e.g. if gallstones have passed into common bile duct)

Answer 24

Itch, nausea, anorexia
Jaundice
Abnormal LFTs

ERCP:
ES + stone removal

Surgical Exploration: CBD (Open vs Lap)

Question 25

Gallstone ileus

Answer 25

Small bowel obstruction – gallstone impacted in distal ileum . Fistula gallbladder + duodenum - Large gallstone passes into small intestine. Moves down SB causing intermittent colic Present with distal SB obstruction.

Question 26

Acute pancreatitis

Answer 26

Alcohol / gallstones 10% mortality AP Autodigestion of peri-pancreatic tissues by activated enzymes Cholecystectomy during INDEX admission ERCP / ES if frail

Question 27

Treatment for gallstone ileus

Answer 27

Treatment: Urgent Laparotomy – SB enterotomy to remove stone Interval cholecystectomy in 3 months.

Question 28

Clinical presentation of cholangiocarcinoma?

Answer 28

Clinical Presentation: Usually late ! - Jaundice; Weight loss; anorexia; lethargy - 50% lymph node metastases - 20-30% peritoneal metastases at diagnosis

Question 29

Staging of cholangiocarcinoma?

Answer 29

Staging / Assessment: Duplex Ultrasound (Spiral CT / ERCP / PTC) MRI / MRCP/ MRA

Question 30

Treatment for cholangiocarcinoma?

Answer 30

Surgical resection: Bile duct and liver resection | Palliation: insertion of biliary stent

Question 31

Cholangiocarcinoma

Answer 31

Cancer of the bile ducts

Question 32

Cholangiocarcinoma grading

Answer 32

``` I) confined to confluence II) below the confluence IIIa) extended into right hepatic duct IIIb) extended into left hepatic duct IV) extension into left and right hepatic duct ```

Question 33

Bilirubin

Answer 33

Obstructive jaundice | -Urobiligen is not present in obstructive jaundice

Question 34

What should you perform in all women presenting with acute abdomen?

Answer 34

Always perform urinary bHCG to exclude pregnancy in ALL women of childbearing age, however unlikely this is!

Question 35

What do urea and creatinine show?

Answer 35

Hydration and renal status

Question 36

What does prothrombin time show?

Answer 36

Synthetic function of liver e.g. CBD stone

Question 37

Hydronephrosis

Answer 37

When one or both kidneys become stretched and swollen as a result of build up of urine in kidneys

Question 38

Investigation for AAA

Answer 38

Ultrasound

Question 39

Investigation for perforation or pancreatitis?

Answer 39

CT

Question 40

Investigation for pancreatitis?

Answer 40

CT

Question 41

Investigation for obstructive jaundice?

Answer 41

ERCP

Question 42

What would you use a water soluble contrast swallow to investigate?

Answer 42

Oesophageal rupture | -it will show contrast in mediastinum

Question 43

Grey-turners sign

Answer 43

Bruising in the flanks (last rib --> top of hip) | Acute pancreatitis

Question 44

Cullen's sign

Answer 44

Cullen's sign is yellow blue discolouration of the skin around the umbilicus. It was first reported in ruptured ectopic pregnancy but is more commonly associated with severe, acute pancreatitis. (looks like a bug bruise around the tummy button)

Question 45

Causes for immediate surgery (<1hour)

Answer 45

Bleeding, perforation, incarceration, ectopic pregnancy

Question 46

Causes for urgen surgery (<24 hours)

Answer 46

Appendicitis, uncomplicated bowel obstruction

Question 47

Scheduled surgery >24 hours

Answer 47

Cholecystitis, adhesive SBO

Question 48

Tests you should definitely do in acute abdomen?

Answer 48

urinalysis, bHCG, and PR