Hernia + Miscellaneous

Question 1

Two types of inguinal hernia

Answer 1

Direct and indirect

Question 2

Difference between indirect and direct hernia [4]

Answer 2

Direct hernias project through Hesselbach’s triangle, exits thru superficial inguinal ring - which is medial to inferior epigastric artery

Indirect hernias project from the deep inguinal ring through the superficial inguinal ring

Question 3

How do you know it is indirect

Answer 3

Press down on deep ring + reduce

Won’t refill on cough impulse

Question 4

How do you know it is direct

Answer 4

Will refill on cough

Doesn;t hang into sctroum

Question 5

Where is the external ring

Answer 5

Above and medial to pubic symphsis

Question 6

Where is the femoral ring

Answer 6

Below and lateral to PS

This is where femoral hernia is

Question 7

Where is deep ring of inguinal canal

Answer 7

Between ASIS and PS

Question 8

Where is superfiical (external) ring

Answer 8

Superior and medial to pubic tubercle

Question 9

What is the anatomy of inguinal canal

Answer 9

External oblique = infront
Inguinal ligament = floor
Transverse abdominis

Question 10

What are the contents of inguinal canal [4]

Answer 10

Vas deferens
Testicular artery and vein
Genitofemoral nerve
Ilioinguinal nerve

Question 11

What are the symptoms of inguinal hernia [5]

Answer 11

Bulge
Increases with cough
Reduces lying flat
May become irreducible and painful
May obstruct

Question 12

What is a strangulated hernia
In which hernias is this a rare complication
In which hernias is this a common complication

Answer 12

Blood supply cut of
Rare in inguinal
Common in femoral

Question 13

What are the symptoms of strangulation [5]

Answer 13

Tender scrotum so always ask for this 
Red
Sudden pain
Fever
Tachycardia

Question 14

How do you examine a hernia [3]

Answer 14

Stand and get to cough
Lie flat and cough while pressing
Compare bilaterally

Question 15

What are the RF for hernia

Answer 15

Male, Obesity
Older as ring gets bigger
Weight lifting, Manual job
Chronic cough and constipation
Obstruction
Past abdo surgery 
Ascites

Question 16

What are women with hernia likely to have

Answer 16

Inguinal hernia

Question 17

Who is most likely to have a femoral

Answer 17

Women

Question 18

What imaging for hernia [2]

Answer 18

USS

Differentiate from LN

Question 19

How do you treat hernia [3]

Answer 19

Lifestyle modifications
Better to treat surgically as likely to become symptomatic
Surgical

Question 20

What are surgical options for first time hernia [3]
What conditions warrant laparoscopic? [3]
Name 2 lifestyle modifications

Answer 20

First time hernia:

• Open inguinal hernia repair with opening of inguinal canal
• Reduction of hernia and repair of defect
• Prosthetic mesh as adjunct to reinforce repair

Recurrence/female/risk of chronic pain:
- Laparoscopic repair via intra or retroperitoneal route of repair with mesh posterior to deep ring

Lifestyle mods
Weight loss
Stop smoking

Question 21

What are complications of hernia [3]

Answer 21

Incarcerated - can’t reduce
Strangulation - necrosis
Obstruction

Question 22

WHat is SMA syndrome

Answer 22

Duodenum gets obstructed by aorta and SMA

Question 23

What are symptoms of weak sphincter [3]

Answer 23

Diarrhoea
Incontinence
Key is formed stool still leading to incontience not just diarrhoea

Question 24

How do you investigate [2]

Answer 24

DRE - tone

USS

Question 25

How do you Rx

Answer 25

Sural nerve stimulation

Question 26

What do you do for loose stools

Answer 26

Send blood culture | If suspect C.diff

Question 27

What is important in colonoscopy

Answer 27

Can you scope past? | Is tissue friable or irregular?

Question 28

If tired / weight loss / diarrhoea - what investigations [5]

Answer 28

``` Hb Iron Thyroid Coaelic qFIT- tests for occult blood in stool ```

Question 29

If Hb low

Answer 29

Haematinic bloods

Question 30

What is common cause of liver abscess [2]

Answer 30

S.aures children | E.coli adult

Question 31

What do you do for abscess [2]

Answer 31

Drainage | Ax - amox + cipro + met + gent

Question 32

How can you give contrast [3]

Answer 32

Oral IV Rectal - not routine Double = oral and IV

Question 33

When do you do USS [6]

Answer 33

``` Gall stone Portal vein Intra+extra hepatic dilatation Liver texture, LIver mets Pancreatic tumour Exclude spleen / kidney / aorta pathology ```

Question 34

When do you do pancreatico-biliary EUS [3]

Answer 34

Small pancreatic tumour + bile duct stone Dx of duoedenal / pancreatic cancer Allow FNA

Question 35

When is CT useful [2]

Answer 35

Stage malignancy | Acute pancreatitis + complication

Question 36

When is MRCP used [4] | Magnetic Resonance Cholangiopancreatography

Answer 36

Hepatic + pancreatic duct if not fit for ERCP / no intervention CBD stones and biliary No contrast or invasion Miss small stone / PSC/ stricture

Question 37

What does PTC allow [3] Percutaneous Transhepatic Cholangiogram (PTC)

Answer 37

Visualisation of biliary tract Percutaneous acess + stent Use if ERCP fails as bigger risk

Question 38

What is calprotectin [2]

Answer 38

It is released into the feces when neutrophils gather at the site of any GI tract inflammation. Higher lower down the bowel

Question 39

What is QFIT

Answer 39

The faecal immunochemical test (FIT Test) can detect human haemoglobin in stool.

Question 40

How do you investigate iron anaemia [5]

Answer 40

``` FBC Ferritin (not in inflammation) Transferin TIBC Colonoscopy once confirmed ```

Question 41

What does TIBC show if iron is low

Answer 41

High if iron deficiency as want more binding receptors for iron to bind do

Question 42

What causes iron deficiency anaemia [4]

Answer 42

Blood loss Malabsorption Mentruation Pregnancy

Question 43

How do you differentiate iron deficiency from anaemia of chronic disease

Answer 43

Anaemia chronic disease has low TIBC as don't want iron available for pathogen