Week 11 - Case One

Question 1

what does an AAA refer to

Answer 1

the dilation of the abdominal aorta with a diameter of more than 3cm

Question 2

often, when is the first time a patient becomes aware of an aneurysm

Answer 2

when it ruptures, causing life-threatening bleeding into the abdominal cavity

Question 3

what is the mortality rate of a ruptured AAA

Answer 3

80%

Question 4

what are the risk factors for an AAA

Answer 4

Men are affected significantly more often and at a younger age than women
Increased age
Smoking
Hypertension
Family history
Existing cardiovascular disease

Question 5

what is the screening programme for an AAA

Answer 5

all men in England are offered a screening ultrasound scan at the age of 65 to detect asymptomatic AAA

Question 6

are women offered screening

Answer 6

not routinely offered screening as they are at much lower risk.

Question 7

what do the NICE guidelines say about screening women

Answer 7

the NICE guidelines say a routine ultrasound can be considered in women over 70 with risk factors such as existing cardiovascular disease, COPD, family history, hypertension, hyperlipidaemia or smoking

Question 8

what aortic diameter counts to refer people to the vascular team

Answer 8

patients with an aortic diameter above 3cm are referred and are referred urgently if more than 5,5cm

Question 9

what is the presentation of AAA

Answer 9

most patients are asymptomatic. it may be discovered on routine screening or when it ruptures

Question 10

what are the other ways it can present

Answer 10

non-specific abdominal pain

pulsatile and expansile mass in the abdomen when palpated with both hands

as an incidental finding on an abdominal X-ray, ultrasound or CT scan

Question 11

what is the usual investigation for establishing a diagnosis of AAA

Answer 11

an ultrasound

Question 12

why is a CT angiogram sometimes given

Answer 12

gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm

Question 13

what are the four classifications of aneurysm

Answer 13

Normal: less than 3cm
Small aneurysm: 3 – 4.4cm
Medium aneurysm: 4.5 – 5.4cm
Large aneurysm: above 5.5cm

Question 14

what can the risk of AAA progression be reduced by

Answer 14

treating reversible risk factors;
stop smoking
healthy diet and exercise
optimising the management of hypertension, diabetes and hyperlipidaemia

Question 15

what screening and surveillance programme is recommended by Public Health England

Answer 15

yearly for patients with aneurysms 3-4.4cm

3 monthly for patients with aneurysms 4.5-5.4cm

Question 16

the NICE guidelines recommend elective repair for patients with what symptoms

Answer 16

Symptomatic aneurysm
Diameter growing more than 1cm per year
Diameter above 5.5cm

Question 17

what is involved in elective surgical repair

Answer 17

inserting an artificial graft into the section of the aorta affected by the aneurysm

Question 18

what are the two methods used to insert this graft

Answer 18

open repair via a laparotomy
endovascular aneurysm repair (EVAR) using a scent inserted via the femoral arteries

Question 19

what does gov.uk advise that patients MUST do - concerning driving

Answer 19

Inform the DVLA if they have an aneurysm above 6cm
Stop driving if it is above 6.5cm
Stricter rules apply to drivers of heavy vehicles (e.g., bus or lorry drivers)

Question 20

how does a ruptured AAA present

Answer 20

Severe abdominal pain that may radiate to the back or groin
Haemodynamic instability (hypotension and tachycardia)
Pulsatile and expansile mass in the abdomen
Collapse
Loss of consciousness

Question 21

what is permissive hypotension

Answer 21

strategy of aiming for a lower than normal blood pressure when performing fluid resuscitation

the theory is that increasing the BP may increase blood loss

Question 22

what should happen to a haemodynamically unstable patient with a suspected AAA

Answer 22

should be transferred directly to theatre.

surgical repair should not be delayed by getting imaging to confirm the diagnosis.

Question 23

what can be used to diagnose or exclude ruptured AAA in haemodynamically stable patients

Answer 23

CT angiogram

Question 24

what is the difference between a true and false aneurysm

Answer 24

a true aneurysm - the wall of the artery forms the wall of the aneurysm

a false aneurysm - other surrounding tissues form the wall of the aneurysm

Question 25

where are AAA usually found

Answer 25

in the infrarenal part of thr aorta

Question 26

what are the features of pain in an AAA

Answer 26

epigastric pain radiating to the back. pain may also be present in the groin, illiac fossa or testicles

Question 27

what is a common feature of a thoracic aortic aneurysm

Answer 27

BP may be different in each arm

Question 28

what is the mechanism of referred pain

Answer 28

pain of visceral origin is referred to the site on the skin that follows the dermatome rule.

beware of overlapping dermatomes from borderline structures between foregut and midgut. (pancreatic and duodenal in particular)

Question 29

what are the possible diagnoses for colicky abdominal pain that is now constant

Answer 29

bowel obstruction with/without hernia

irritable bowel syndrome

Question 30

what are the possible diagnoses for colicky abdominal pain associated with diarrhoea

Answer 30

gastroenteritis

inflammatory bowel disease

Question 31

Give any possible diagnoses for the description of the pain:

Central abdominal pain that shifted to the right iliac fossa

Answer 31

Appendicitis
Rarely perforated Duodenal Ulcer

Question 32

Give any possible diagnoses for the description of the pain:

Sudden severe pain radiating to the back, flank and/or groin

Answer 32

Abdominal aortic aneurysm (AAA) until proven otherwise
Renal colic

Question 33

Give any possible diagnoses for the description of the pain:

Severe generalised pain with shoulder tip pain

Answer 33

Diaphragm irritation by free fluid / blood within the abdomen

Question 34

what does colicky pain that becomes constant suggest

Answer 34

that there is a partial obstruction of the hollow viscus, that has become complete and needs urgent intervention to prevent perforation/major complication

Question 35

what does pyrexia, localised tenderness and guarding suggest

Answer 35

an infection or inflammatory process in one organ

Question 36

what does radiation usually point to

Answer 36

the possible organ but it can also suggest the progression of the disease

Question 37

what are nausea, vomiting and distension related to

Answer 37

the bowel obstruction but rememeber that inflammatory causes can also cause localised ileus giving a similar but less severe picture

Question 38

what is McBurney’s point

Answer 38

classical point of maximum tenderness in appendicitis, corresponding to the position of the base of the appendix.

1/3rd of the line between anterior superior iliac spine to umbillicus

Question 39

what is the definition of a hernia

Answer 39

defined as a protrusion of an organ through its containing wall and into a different cavity

Question 40

what is the most common abdominal wall hernia

Answer 40

inguinal

Question 41

what are direct hernias

Answer 41

the leading area of weakness is the posterior wall of the inguinal canal, where viscera herniates anteriorly through Hesselbach’s triangle and not into scrotum

Question 42

what are indirect hernias

Answer 42

the leading area of weakness is the deep inguinal ring where intra-peritoneal contents herniate into the inguinal canal alongside spermatic cord, and can exit the canal through the superficial ring and into the scrotum

Question 43

what are the other four types of hernia

Answer 43

Umbilical / paraumbilical

Femoral (Below the inguinal ligament, inferior and lateral to the pubic tubercle)

Incisional (through any previous surgical scar)

Epigastric or midline hernias, where there are natural areas of weakness due to the ‘criss-crossing’ of fibres that form the linea alba

Question 44

what is a sentinel loop

Answer 44

a short segment of adynamic ileus close to an intra-abdominal inflammatory process.

the sentinel loop may aid in localising the source of inflammation.