2/3 Question 1-3 of 89

Theme: Acute abdominal pain

A. Ruptured abdominal aortic aneurysm

B. Perforated peptic ulcer
C. Perforated appendicitis
D. Mesenteric infarction
E. Small bowel obstruction
F. Large bowel obstruction
G. Pelvic inflammatory disease
H. Mesenteric adenitis
I. Pancreatitis
J. None of the above

Please select the most likely cause of abdominal pain for the scenario given. Each option may be used once,
more than once or not at all.

1. A 75 year old man is admitted with sudden onset severe generalised abdominal pain, vomiting and a
single episode of bloody diarrhoea. On examination he looks unwell and is in uncontrolled atrial
fibrillation. Although diffusely tender his abdomen is soft.

Mesenteric infarction

In mesenteric infarction there is sudden onset of pain together with vomiting and occasionally passage
of bloody diarrhoea. The pain present is usually out of proportion to the physical signs.

2. A 19 year old lady is admitted with lower abdominal pain. On examination she is diffusely tender. A
laparoscopy is performed and at operation multiple fine adhesions are noted between the liver and
abdominal wall. Her appendix is normal.

You answered Perforated peptic ulcer

The correct answer is Pelvic inflammatory disease

This is Fitz Hugh Curtis syndrome in which pelvic inflammatory disease (usually Chlamydia) causes
the formation of fine peri hepatic adhesions.

3. A 78 year old man is walking to the bus stop when he suddenly develops severe back pain and
collapses. On examination he has a blood pressure of 90/40 and pulse rate of 110. His abdomen is
distended and he is obese. Though tender his abdomen itself is soft.

Ruptured abdominal aortic aneurysm

This will be a retroperitoneal rupture (anterior ones generally don't survive to hospital). The debate
regarding CT varies, it is the authors opinion that a systolic BP of <100mmHg at presentation
 mandates immediate laparotomy.
Acute mesenteric ischaemia- Pain out of proportion to the
physical signs.
Atrial fibrillation is often present.

Fitz Hugh Curtis = Fine Hepatic Connections

Acute abdominal pain-diagnoses

Conditions presenting with acute abdominal pain

Condition Features Investigations Management
Appendicitis History of migratory pain. Differential white cell count Appendicectomy
Fever. Pregnancy test
Anorexia. C-Reactive protein
Evidence of right iliac Amylase
fossa tenderness. Urine dipstick testing
Mild pyrexia.
Mesenteric Usually recent upper Full blood count- may show Conservative management-
adenitis respiratory tract infection. slightly raised white cell count appendicectomy if diagnostic
High fever. Urine dipstick often normal doubt
Generalised abdominal Abdominal ultrasound scan -
discomfort- true localised usually no free fluid
pain and signs are rare.
Mittelschmerz Only seen in females. Full blood count- normal Manage conservatively if doubt
Mid cycle pain. Urine dipstick- normal or symptoms fail to settle then
Usually occurs two weeks Abdominal and pelvic laparoscopy
after last menstrual period. ultrasound- may show a trace
Pain is usually has a supra- of pelvic free fluid
pubic location.
Usually subsides over a 24-
48 hour period.
Fitz-Hugh Curtis Disseminated infection Abdominal ultrasound scan- Usually medically managed-
syndrome with Chlamydia. may show free fluid doxycycline or azithromycin
Usually seen in females. High vaginal swabs - may
Consists of evidence of show evidence of sexually
pelvic inflammatory transmitted infections
disease together with peri-
hepatic inflammation and
subsequent adhesion
formation.
Abdominal Sudden onset of abdominal Patients who are Unstable patients should
aortic aneurysm pain radiating to the back haemodynamically stable undergo immediate surgery
(ruptured) in older adults (look for should have a CT scan (unless it is not in their best
risk factors). interests).
Collapse. Those with evidence of
May be moribund on contained leak on CT should
arrival in casualty, more undergo immediate surgery
 stable if contained Increasing unruptured
haematoma. aneurysmal size is an indication
Careful clinical assessment for urgent surgical intervention
may reveal pulsatile mass. (that can wait until the next
working day)
Perforated peptic Sudden onset of pain Erect CXR may show free air. Laparotomy (laparoscopic
ulcer (usually epigastric). A CT scan may be indicated surgery for perforated peptic
Often preceding history of where there is diagnostic doubt ulcers is both safe and feasible
upper abdominal pain. in experienced hands)
Soon develop generalised
abdominal pain.
On examination may have
clinical evidence of
peritonitis.
Intestinal Colicky abdominal pain A plain abdominal film may In those with a virgin abdomen
obstruction and vomiting (the nature of help with making the and lower and earlier threshold
which depends on the level diagnosis. A CT scan may be for laparotomy should exist than
of the obstruction). useful where diagnostic in those who may have
Abdominal distension and uncertainty exists adhesional obstruction
constipation (again
depending upon site of
obstruction).
Features of peritonism may
occur where local necrosis
of bowel loops is
occurring.
Mesenteric Embolic events present Arterial pH and lactate Immediate laparotomy and
infarction with sudden pain and Arterial phase CT scanning is resection of affected segments,
forceful evacuation. the most sensitive test in acute embolic events SMA
Acute on chronic events embolectomy may be needed.
usually have a longer
history and previous weight
loss.
On examination the pain is
typically greater than the
physical signs would
suggest.

3/3 Question 4-6 of 89

Theme: Gastrointestinal bleeding

A. Haemorroids
B. Meckels diverticulum
C. Angiodysplasia
D. Colonic cancer
E. Diverticular bleed
F. Ulcerative colitis
G. Ischaemic colitis

Please select the most likely cause of colonic bleeding for the scenario given. Each option may be used once,
more than once or not at all

4. A 73 year old lady is admitted with a brisk rectal bleed. She is otherwise well and the bleed settles. On
examination her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous
lesion in the right colon, but no other abnormality.

Angiodysplasia

Angiodysplasia can be difficult to identify and treat. The colonoscopic stigmata are easily missed by
poor bowel preparation.

5. A 23 year old man complains of passing bright red blood rectally. It has been occurring over the past
week and tends to occur post defecation. He also suffers from pruritus ani.

Haemorroids

Classical haemorroidal symptoms include bright red rectal bleeding, it typically occurs post defecation
and is noticed on the toilet paper and in the toilet pan. It is usually painless, however, thrombosed
external haemorroids may be very painful.

6. A 63 year old man presents with episodic rectal bleeding the blood tends to be dark in colour and may
be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6
weeks previously.

Ischaemic colitis

The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through
the marginal may be imperfect.

Gastrointestinal bleeding

Colonic bleeding
This typically presents as bright red or dark red blood per rectum. Colonic bleeding rarely presents as malaena
type stool, this is because blood in the colon has a powerful laxative effect and is rarely retained long enough
for transformation to occur and because the digestive enzymes present in the small bowel are not present in the
colon. Up to 15% of patients presenting with haemochezia will have an upper gastrointestinal source of
haemorrhage.

As a general rule right sided bleeds tend to present with darker coloured blood than left sided bleeds.
Haemorrhoidal bleeding typically presents as bright red rectal bleeding that occurs post defecation either onto
toilet paper or into the toilet pan. It is very unusual for haemorrhoids alone to cause any degree of
haemodynamic compromise.
Causes
Cause Presenting features
Colitis Bleeding may be brisk in advanced cases, diarrhoea is commonly present. Abdominal x-ray
may show featureless colon.
Diverticular Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds
disease often occur sporadically. 75% all will cease spontaneously within 24-48 hours. Bleeding is
often dark and of large volume.
Cancer Colonic cancers often bleed and for many patients this may be the first sign of the disease.
Major bleeding from early lesions is uncommon
Haemorrhoidal Typically bright red bleeding occurring post defecation. Although patients may give
bleeding graphic descriptions bleeding of sufficient volume to cause haemodynamic compromise is
rare.
Angiodysplasia Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the
way of symptoms. The right side of the colon is more commonly affected.

Management

• Prompt correction of any haemodynamic compromise is required. Unlike upper gastrointestinal bleeding
the first line management is usually supportive. This is because in the acute setting endoscopy is rarely
helpful.
• When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable as attempts at full
colonoscopy are usually time consuming and often futile.
• In the unstable patient the usual procedure would be an angiogram (either CT or percutaneous), when
these are performed during a period of haemodynamic instability they may show a bleeding point and
may be the only way of identifying a patch of angiodysplasia.
• In others who are more stable the standard procedure would be a colonoscopy in the elective setting. In
patients undergoing angiography attempts can be made to address the lesion in question such as coiling.
Otherwise surgery will be necessary.
• In patients with ulcerative colitis who have significant haemorrhage the standard approach would be a
sub total colectomy, particularly if medical management has already been tried and is not effective.

Indications for surgery

Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension

Surgery
Selective mesenteric embolisation if life threatening bleeding. This is most helpful if conducted during a period
of relative haemodynamic instability. If all haemodynamic parameters are normal then the bleeding is most
likely to have stopped and any angiography normal in appearance. In many units a CT angiogram will replace
selective angiography but the same caveats will apply.

If the source of colonic bleeding is unclear; perform a laparotomy, on table colonic lavage and following this
attempt a resection. A blind sub total colectomy is most unwise, for example bleeding from an small bowel
arterio-venous malformation will not be treated by this manoeuvre.
Summary of Acute Lower GI bleeding recommendations
Consider admission if:
* Over 60 years
* Haemodynamically unstable/profuse PR bleeding
* On aspirin or NSAID
* Significant co morbidity

Management

• All patients should have a history and examination, PR and proctoscopy

• Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding

3/3 Question 7-9 of 89

Theme: Surgical signs

A. Rovsing's sign
B. Boas' sign
C. Psoas stretch sign
D. Cullen's sign
E. Grey-Turner's sign
F. Murphy's sign
G. None of the above

Please select the most appropriate eponymous abdominal sign for the scenario given. Each option may be used
once, more than once or not at all.

7. Severe acute peri-umbilical bruising in the setting of acute pancreatitis.

Cullen's sign

Cullens sign occurs when there has been intraabdominal haemorrage. It is seen in cases of severe
haemorrhagic pancreatitis and is associated with a poor prognosis. It is also seen in other cases of
intraabdominal haemorrhage (such as ruptured ectopic pregnancy).

8. In acute cholecystitis there is hyperaesthesia beneath the right scapula.

Boas' sign

Boas sign refers to this hyperaesthesia. It occurs because the abdominal wall innervation of this region
is from the spinal roots that lie at this level.

9. In appendicitis palpation of the left iliac fossa causes pain in the right iliac fossa.

Rovsing's sign
 Rovsings sign elicits tenderness because the deep palpation induces shift of the appendix (which is
inflamed) against the peritoneal surface. This has somatic innervation and will therefore localise the
pain. It is less reliable in pelvic appendicitis and when the appendix is truly retrocaecal

Abdominal signs

A number of eponymous abdominal signs are noted. These include:

• Rovsings sign- appendicitis

• Boas sign -cholecystitis
• Murphys sign- cholecystitis
• Cullens sign- pancreatitis (other intraabdominal haemorrhage)
• Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)

In clinical practice haemorrhagic pancreatitis is thankfully rare. The signs are important and thus shown below:

Cullen's sign

Image sourced from Wikipedia

Grey Turner's sign

3/3 Question 10-12 of 89
Theme: Surgical access

A. Gridiron
B. Lanz
C. McEvedy
D. Midline abdominal
E. Rutherford Morrison
F. Battle (abdominal)
G. Lower midline

Please select the most appropriate incision for the procedure required. Each option may be used once, more than
once or not at all.

10. A 78 year old lady is admitted with a tender lump in her right groin. It is within the femoral triangle
and there is concern that there may be small bowel obstruction developing.

McEvedy

This is one approach to an obstructed femoral hernia. It is possible to undertake a small bowel
resection through this approach. Although recourse to laparotomy may be needed if access is
difficult.

11. A 45 year old woman with end stage renal failure is due to undergo a cadaveric renal transplant. This
will be her first transplant.

Rutherford Morrison

This is the incision of choice for the extraperitoneal approach to the iliac vessels which will be
required for a renal transplant.

12. A slim 20 year old lady is suffering from appendicitis and requires an appendicectomy.

Lanz

Either a Lanz or Gridiron incision will give access for appendicectomy. However, in the case
described a Lanz incision will give better cosmesis and can be extended should pelvic surgery be
required eg for gynaecological disease.

Abdominal incisions

Midline incision • Commonest approach to the abdomen

 • Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum
(avoid falciform ligament above the umbilicus)
• Bladder can be accessed via an extraperitoneal approach through the space of
Retzius

Paramedian • Parallel to the midline (about 3-4cm)

incision • Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior
rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum
• Incision is closed in layers

Battle • Similar location to paramedian but rectus displaced medially (and thus denervated)
• Now seldom used

Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open)

Lanz Incision in right iliac fossa e.g. Appendicectomy
Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less
cosmetically acceptable than Lanz
Gable Rooftop incision
Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs
McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia
Rutherford Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac
Morrison vessels and is the approach of choice for first time renal transplantation.

3/3 Question 13-15 of 89

Theme: Hernias

A. Littres hernia
B. Richters hernia
C. Bochdalek hernia
D. Morgagni hernia
E. Spigelian hernia
F. Lumbar hernia
G. Obturator hernia

Please select the type of hernia that most closely matches the description given. Each option may be used once,
more than once or not at all.

13. A 73 year old lady presents with peritonitis and tenderness of the left groin. At operation she has a
left femoral hernia with perforation of the anti mesenteric border of ileum associated with the hernia.

Richters hernia

When part of the bowel wall is trapped in a hernia such as this it is termed a Richters hernia and may
complicate any hernia although femoral and obturator hernias are most typically implicated.

14. A 22 year old man is operated on for a left inguinal hernia, at operation the sac is opened to reveal a
large Meckels diverticulum.

Littres hernia

Hernia containing Meckels diverticulum is termed a Littres hernia.

15. A 45 year old man has recurrent colicky abdominal pain. As part of a series of investigations he
undergoes a CT scan and this demonstrates a hernia lateral to the rectus muscle at the level of the
arcuate line.

Spigelian hernia

This is the site for a spigelian hernia.

Hernia

Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. Specific hernias
are covered under their designated titles the remainder are addressed here.

Spigelian hernia

• Interparietal hernia occurring at the level of the arcuate line.

• Rare.
• May lie beneath internal oblique muscle. Usually between internal and external oblique.
• Equal sex distribution.
• Position is lateral to rectus abdominis.
• Both open and laparoscopic repair are possible, the former in cases of strangulation.
Lumbar hernia

• The lumbar triangle (through which these may occur) is bounded by:

Crest of ilium (inferiorly)

External oblique (laterally)
Latissimus dorsi (medially)

• Primary lumbar herniae are rare and most are incisional hernias following renal surgery.
• Direct anatomical repair with or without mesh re-enforcement is the procedure of choice.

Obturator hernia

• Herniation through the obturator canal.

• Commoner in females.
• Usually lies behind pectineus muscle.
• Elective diagnosis is unusual most will present acutely with obstruction.
• When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection
if indicated).

Richters hernia

• Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is
strangulated within a hernia (of any type).
• They do not present with typical features of intestinal obstruction as luminal patency is preserved.
• Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these
hernias may perforate).

Incisional hernia

• Occur through sites of surgical access into the abdominal cavity.

• Most common following surgical wound infection.
• To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a
suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge.
• Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are
described.

Bochdalek hernia

• Typically congenital diaphragmatic hernia.

• 85% cases are located in the left hemi diaphragm.
• Associated with lung hypoplasia on the affected side.
• More common in males.
• Associated with other birth defects.
• May contain stomach.
• May be treated by direct anatomical apposition or placement of mesh. In infants that have severe
respiratory compromise mechanical ventilation may be needed and mortality rate is high.
Morgagni Hernia

• Rare type of diaphragmatic hernia (approx 2% cases).

• Herniation through foramen of Morgagni.
• Usually located on the right and tend to be less symptomatic.
• More advanced cases may contain transverse colon.
• As defects are small pulmonary hypoplasia is less common.
• Direct anatomical repair is performed.

Umbilical hernia

• Hernia through weak umbilicus.

• Usually presents in childhood.
• Often symptomatic.
• Equal sex incidence.
• 95% will resolve by the age of 2 years. Thereafter surgical repair is warranted.

Paraumbilical hernia

• Usually a condition of adulthood.

• Defect is in the linea alba.
• More common in females.
• Multiparity and obesity are risk factors.
• Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if
small bowel resection is required owing to acute strangulation.

Littres hernia

• Hernia containing Meckels diverticulum.

• Resection of the diverticulum is usually required and this will preclude a mesh repair.

3/3 Question 16-18 of 89

Theme: Groin masses

A. Femoral hernia
B. Lymphadenitis
C. Inguinal hernia
D. Psoas abscess
E. Saphenous varix
F. Femoral artery aneurysm
G. Metastatic lymphadenopathy
H. Lymphoma
I. False femoral artery aneurysm
What is the likely diagnosis for groin mass described? Each option may be used once, more than once, or not at
all.

16. A 52 year old obese lady reports a painless grape sized mass in her groin area. She has no medical
conditions apart from some varicose veins. There is a cough impulse and the mass disappears on
lying down.

Saphenous varix

The history of varicose veins should indicate a more likely diagnosis of a varix. The varix can enlarge
during coughing/sneezing. A blue discolouration may be noted.

17. A 32 year old male is noted to have a tender mass in the right groin area. There are also red streaks on
the thigh, extending from a small abrasion.

Lymphadenitis

The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels.
Lymphadenitis is infection of the local lymph nodes.

18. A 23 year old male suffering from hepatitis C presents with right groin pain and swelling. On
examination there is a large abscess in the groin. Adjacent to this is an expansile swelling. There is no
cough impulse.

False femoral artery aneurysm

False aneurysms may occur following arterial trauma in IVDU. They may have associated blood
borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not
contain all layers of the arterial wall.

Groin masses clinical

Groin masses are common and include:

• Herniae
• Lipomas
• Lymph nodes
• Undescended testis
• Femoral aneurysm
• Saphena varix (more a swelling than a mass!)

In the history features relating to systemic illness and tempo of onset will often give a clue as to the most likely
underlying diagnosis.
Groin lumps- some key questions

• Is there a cough impulse

• Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm)
• Are both testes intra scrotal
• Any lesions in the legs such as malignancy or infections (?lymph nodes)
• Examine the ano rectum as anal cancer may metastasise to the groin
• Is the lump soft, small and very superficial (?lipoma)

Scrotal lumps - some key questions

• Is the lump entirely intra scrotal

• Does it transilluminate (?hydrocele)
• Is there a cough impulse (?hernia)

In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound scan is often the most
convenient next investigation.

2/3 Question 19-21 of 89

Theme: Right iliac fossa pain

A. Urinary tract infection

B. Appendicitis
C. Mittelschmerz
D. Mesenteric adenitis
E. Crohns disease
F. Ulcerative colitis
G. Meckels diverticulum

Please select the most likely cause for right iliac fossa pain for the scenario given. Each option may be used
once, more than once or not at all.

19. A 17 year old male is admitted with lower abdominal discomfort. He has been suffering from
intermittent right iliac fossa pain for the past few months. His past medical history includes a negative
colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals.
Inflammatory markers are normal.

Meckels diverticulum

This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which
may secrete acid with subsequent bleeding and ulceration.

20. A 14 year old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and
 on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick
is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative.

Mittelschmerz

Typical story and timing for mid cycle pain. Mid cycle pain typically occurs because a small amount
of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours.

21. A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers
from episodic diarrhoea and has lost 2 kilos in weight. On examination he has some right iliac fossa
tenderness and is febrile.

You answered Mesenteric adenitis

The correct answer is Crohns disease

Weight loss and chronic symptoms coupled with change in bowel habit should raise suspicion for
Crohns. The presence of intermittent right iliac fossa pain is far more typical of terminal ileal Crohns
disease. Both UC and Crohns may be associated with a low grade pyrexia. The main concern here
would be locally perforated Crohns disease with a small associated abscess.

Right iliac fossa pain

Differential diagnosis

Appendicitis • Pain radiating to right iliac fossa

• Anorexia
• Typically short history
• Diarrhoea and profuse vomiting rare

Crohn's disease • Often long history

• Signs of malnutrition
• Change in bowel habit, especially diarrhoea

Mesenteric adenitis • Mainly affects children

• Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic
Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus
viridans and Yersinia spp.
• Patients have a higher temperature than those with appendicitis
• If laparotomy is performed, enlarged mesenteric lymph nodes will be
present

Diverticulitis • Both left and right sided disease may present with right iliac fossa pain
• Clinical history may be similar, although some change in bowel habit is
usual
 • When suspected a CT scan may help in refining the diagnosis

Meckel's diverticulitis • A Meckel's diverticulum is a congenital abnormality that is present in

about 2% of the population
• Typically 2 feet proximal to the ileocaecal valve
• May be lined by ectopic gastric mucosal tissue and produce bleeding

Perforated peptic ulcer • This usually produces upper quadrant pain but pain may be lower
• Perforations typically have a sharp sudden onset of pain in the history

Incarcerated right inguinal • Usually only right iliac fossa pain if right sided or bowel obstruction.
or femoral hernia
Bowel perforation secondary • Seldom localised to right iliac fossa, although complete large bowel
to caecal or colon carcinoma obstruction with caecal distension may cause pain prior to perforation.

Gynaecological causes • Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic

pregnancy/Ovarian torsion/Threatened or complete
abortion/Mittelschmerz

Urological causes • Ureteric colic/UTI/Testicular torsion

Other causes • TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Question 22 of 89
A 78 year old lady presents with colicky abdominal pain and a tender mass in her groin. On examination there
is a small firm mass below and lateral to the pubic tubercle. Which of the following is the most likely
underlying diagnosis?

A. Incarcerated inguinal hernia

B. Thrombophlebitis of a saphena varix

C. Incarcerated femoral hernia

D. Incarcerated obturator hernia

E. Deep vein thrombosis

Femoral hernia = High risk of strangulation
(repair urgently)

Femoral herniae account for <10% of all groin hernias. In the scenario the combination of symptoms of
intestinal compromise with a mass in the region of the femoral canal points to femoral hernia as the most likely
cause.
Femoral canal

The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel
containing both the femoral artery laterally and femoral vein medially. The canal lies medial to the vein.
Borders of the femoral canal
Laterally Femoral vein
Medially Lacunar ligament
Anteriorly Inguinal ligament
Posteriorly Pectineal ligament

Image showing dissection of femoral canal

Image sourced from Wikipedia

Contents

• Lymphatic vessels
• Cloquet's lymph node

Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower limbs.

Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at high risk of
strangulation.

Question 23 of 89
Which of the following is not a typical feature of acute appendicitis?

A. Neutrophilia

B. Profuse vomiting

C. Anorexia

D. Low grade pyrexia

E. Small amounts of protein on urine analysis

Profuse vomiting and diarrhoea are rare in
early appendicitis

Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis
or an ileus. A trace of protein is not an uncommon occurrence in acute appendicitis. A free lying pelvic
appendix may result in localised bladder irritation, with inflammation occurring as a secondary phenomena.
This latter feature may result in patients being incorrectly diagnosed as having a urinary tract infection. A urine
dipstick test is useful in differentiating between the two conditions.

Appendicitis

History

• Peri umbilical abdominal pain (visceral stretching of appendix lumen and appendix is mid gut structure)
radiating to the right iliac fossa due to localised parietal peritoneal inflammation.
• Vomit once or twice but marked and persistent vomiting is unusual.
• Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose
stools. A pelvic abscess may also cause diarrhoea.
• Mild pyrexia is common - temperature is usually 37.5 -38oC. Higher temperatures are more typical of
conditions like mesenteric adenitis.
• Anorexia is very common. It is very unusual for patients with appendicitis to be hungry.

Examination

• Generalised peritonitis if perforation has occurred or localised peritonism.

• Retrocaecal appendicitis may have relatively few signs.
• Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even tenderness
with a pelvic appendix.

Diagnosis

• Typically raised inflammatory markers coupled with compatible history and examination findings
should be enough to justify appendicectomy.
• Urine analysis may show mild leucocytosis but no nitrites.
• Ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always
possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in
 males) should raise suspicion.

Ultrasound examination may show evidence of lumenal obstruction and thickening of the appendiceal wall as
shown below

Image sourced from Wikipedia

Treatment

• Appendicectomy which can be performed via either an open or laparoscopic approach.

• Administration of metronidazole reduces wound infection rates.
• Patients with perforated appendicitis require copious abdominal lavage.
• Patients without peritonitis who have an appendix mass should receive broad spectrum antibiotics and
consideration given to performing an interval appendicectomy.
• Be wary in the older patients who may have either an underlying caecal malignancy or perforated
sigmoid diverticular disease.

Laparoscopic appendicectomy is becoming increasing popular as demonstrated below

 Question 24 of 89
An 28 year old man presents with a direct inguinal hernia. A decision is made to perform an open inguinal
hernia repair. Which of the following is the best option for abdominal wall reconstruction in this case?

A. Suture plication of the transversalis fascia using PDS only

B. Suture plication of the hernial defect with nylon and placement of

prolene mesh anterior to external oblique

C. Suture plication of the hernia defect using nylon and re-enforcing

with a sutured repair of the abdominal wall

D. Sutured repair of the hernial defect with prolene and placement of

prolene mesh over the cord structures in the inguinal canal

E. Sutured repair of the hernial defect using nylon and placement of a

prolene mesh posterior to the cord structures
Laparoscopic repair- bilateral and
recurrent cases

During an inguinal hernia repair in males the cord structures will always lie anterior to the mesh. In the
conventional open repairs the cord structures are mobilised and the mesh placed behind them, with a slit made
to allow passage of the cord structures through the deep inguinal ring. Placement of the mesh over the cord
structures results in chronic pain and usually a higher risk of recurrence.

Laparoscopic inguinal hernia repair is the procedure of choice for bilateral inguinal hernias.

Types of surgery include:

• Onlay mesh repair (Litchenstein style)

• Inguinal herniorrhaphy
• Shouldice repair
 • Darn repair
• Laparoscopic mesh repair

Open mesh repair and laparoscopic repair are the two main procedures in mainstream use. The Shouldice repair
is a useful procedure in cases where a mesh repair would be associated with increased risk of infection, e.g.
repair of case with strangulated bowel, as it avoids the use of mesh. It is, however, far more technically
challenging to perform.

Inguinal hernia surgery

Inguinal hernias occur when the abdominal viscera protrude through the anterior abdominal wall into the
inguinal canal. They may be classified as being either direct or indirect. The distinction between these two rests
on their relation to Hesselbach's triangle.

Boundaries of Hesselbach's Triangle

• Medial: Rectus abdominis

• Lateral: Inferior epigastric vessels
• Inferior: Inguinal ligament

Image sourced from Wikipedia

Hernias occurring within the triangle tend to be direct and those outside - indirect.

Diagnosis
Most cases are diagnosed clinically, a reducible swelling may be located at the level of the inguinal canal. Large
hernia may extend down into the male scrotum, these will not trans-illuminate and it is not possible to "get
above" the swelling.
Cases that are unclear on examination, but suspected from the history, may be further investigated using
ultrasound or by performing a herniogram.

Treatment
Hernias associated with few symptoms may be managed conservatively. Symptomatic hernias or those which
are at risk of developing complications are usually treated surgically.
First time hernias may be treated by performing an open inguinal hernia repair; the inguinal canal is opened, the
hernia reduced and the defect repaired. A prosthetic mesh may be placed posterior to the cord structures to re-
inforce the repair and reduce the risk of recurrence.
Recurrent hernias and those which are bilateral are generally managed with a laparoscopic approach. This may
be via an intra or extra peritoneal route. As in open surgery a mesh is deployed. However, it will typically lie
posterior to the deep ring.

Inguinal hernia in children

Inguinal hernias in children are almost always of an indirect type and therefore are usually dealt with by
herniotomy, rather than herniorraphy. Neonatal hernias especially in those children born prematurely are at
highest risk of strangulation and should be repaired urgently. Other hernias may be repaired on an elective
basis.

3/3 Question 25-27 of 89

Theme: Abdominal closure methods

A. Looped 1/0 PDS (polydiaxone)

B. Looped 1/0 silk
C. 1/0 Vicryl (polyglactin)
D. 1/0 Vicryl rapide
E. 2/0 Prolene (Polypropylene)
F. Re-inforced 1/0 Nylon
G. Re-inforced 1/0 Silk
H. Application of VAC system without separation film
I. Application of VAC System with separation film
J. Application of a 'Bogota Bag'

Please select the most appropriate wound closure method (for the deep layer) for the abdominal surgery
described.

25. A 59 year old man with morbid obesity undergoes a laparotomy and Hartmans procedure for
perforated sigmoid diverticular disease. At the conclusion of the procedure the abdomen cannot be
primarily closed. The Vac system is not available for use.

Application of a 'Bogota Bag'

Application of a Bogota bag is safest as attempted closure will almost certainly fail. Repeat look at 48
hours to determine the best definitive option is needed.
 26. A 73 year old lady undergoes a low anterior resection for carcinoma of the rectum.

Looped 1/0 PDS (polydiaxone)

Mass closure obeying Jenkins rule is required and this states that the suture must be 4 times the length
of the wound with tissue bites 1cm deep and 1 cm apart.

27. A 67 year old is returned to theatre after developing a burst abdomen on the ward. She has originally
undergone a right hemicolectomy and the SHO who closed the wound had failed to tie the midline
suture correctly. The wound edges appear healthy.

Re-inforced 1/0 Nylon

Attempt at re-closing the wound is reasonable in which case 1/0 nylon (reinforced with drainage
tubing) is often used.

Abdominal wound dehiscence

• This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis.
Traditionally it is said to occur when all layers of an abdominal mass closure fail and the viscera
protrude externally (associated with 30% mortality).
• It can be subdivided into superficial, in which the skin wound alone fails and complete, implying
failure of all layers.

Factors which increase the risk are:

* Malnutrition
* Vitamin deficiencies
* Jaundice
* Steroid use
* Major wound contamination (e.g. faecal peritonitis)
* Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)

When sudden full dehiscence occurs the management is as follows:

* Analgesia
* Intravenous fluids
* Intravenous broad spectrum antibiotics
* Coverage of the wound with saline impregnated gauze (on the ward)
* Arrangements made for a return to theatre

Surgical strategy

• Correct the underlying cause (eg TPN or NG feed if malnourished)

• Determine the most appropriate strategy for managing the wound
Options
Resuturing of the This may be an option if the wound edges are healthy and there is enough tissue for
wound sufficient coverage. Deep tension sutures are traditionally used for this purpose.
Application of a This is a clear dressing with removable front. Particularly suitable when some granulation
wound manager tissue is present over the viscera or where there is a high output bowel fistula present in the
dehisced wound.
Application of a This is a clear plastic bag that is cut and sutured to the wound edges and is only a
'Bogota bag' temporary measure to be adopted when the wound cannot be closed and will necessitate a
return to theatre for definitive management.
Application of a These can be safely used BUT ONLY if the correct layer is interposed between the suction
VAC dressing device and the bowel. Failure to adhere to this absolute rule will almost invariably result in
system the development of multiple bowel fistulae and create an extremely difficult management
problem.

3/3 Question 28-30 of 89

Theme: Hernias

A. Umbilical hernia
B. Para umbilical hernia
C. Morgagni hernia
D. Littres hernia
E. Bochdalek hernia
F. Richters hernia
G. Obturator hernia

Please select the hernia that most closely matches the description given. Each option may be used once, more
than once or not at all.

28. A 1 day old infant is born with severe respiratory compromise. On examination he has a scaphoid
abdomen and an absent apex beat.

Bochdalek hernia

Theme from 2011 exam

The large hernia may displace the heart although true dextrocardia is not present. The associated
pulmonary hypoplasia will compromise lung development.

29. A 2 month old infant is troubled by recurrent colicky abdominal pain and intermittent intestinal
obstruction. On imaging the transverse colon is herniated into the thoracic cavity, through a mid line
defect.

Morgagni hernia

Morgagni hernia may contain the transverse colon. Unless there is substantial herniation pulmonary
 hypoplasia is uncommon.

30. A 78 year old lady is admitted with small bowel obstruction, on examination she has a distended
abdomen and the leg is held semi flexed. She has some groin pain radiating to the ipsilateral knee.

Obturator hernia

The groin swelling in obturator hernia is subtle and hard to elicit clinically.

Hernia

Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. Specific hernias
are covered under their designated titles the remainder are addressed here.

Spigelian hernia

• Interparietal hernia occurring at the level of the arcuate line.

• Rare.
• May lie beneath internal oblique muscle. Usually between internal and external oblique.
• Equal sex distribution.
• Position is lateral to rectus abdominis.
• Both open and laparoscopic repair are possible, the former in cases of strangulation.

Lumbar hernia

• The lumbar triangle (through which these may occur) is bounded by:

Crest of ilium (inferiorly)

External oblique (laterally)
Latissimus dorsi (medially)

• Primary lumbar herniae are rare and most are incisional hernias following renal surgery.
• Direct anatomical repair with or without mesh re-enforcement is the procedure of choice.

Obturator hernia

• Herniation through the obturator canal.

• Commoner in females.
• Usually lies behind pectineus muscle.
• Elective diagnosis is unusual most will present acutely with obstruction.
• When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection
if indicated).

Richters hernia
 • Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is
strangulated within a hernia (of any type).
• They do not present with typical features of intestinal obstruction as luminal patency is preserved.
• Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these
hernias may perforate).

Incisional hernia

• Occur through sites of surgical access into the abdominal cavity.

• Most common following surgical wound infection.
• To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a
suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge.
• Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are
described.

Bochdalek hernia

• Typically congenital diaphragmatic hernia.

• 85% cases are located in the left hemi diaphragm.
• Associated with lung hypoplasia on the affected side.
• More common in males.
• Associated with other birth defects.
• May contain stomach.
• May be treated by direct anatomical apposition or placement of mesh. In infants that have severe
respiratory compromise mechanical ventilation may be needed and mortality rate is high.

Morgagni Hernia

• Rare type of diaphragmatic hernia (approx 2% cases).

• Herniation through foramen of Morgagni.
• Usually located on the right and tend to be less symptomatic.
• More advanced cases may contain transverse colon.
• As defects are small pulmonary hypoplasia is less common.
• Direct anatomical repair is performed.

Umbilical hernia

• Hernia through weak umbilicus.

• Usually presents in childhood.
• Often symptomatic.
• Equal sex incidence.
• 95% will resolve by the age of 2 years. Thereafter surgical repair is warranted.

Paraumbilical hernia
 • Usually a condition of adulthood.
• Defect is in the linea alba.
• More common in females.
• Multiparity and obesity are risk factors.
• Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if
small bowel resection is required owing to acute strangulation.

Littres hernia

• Hernia containing Meckels diverticulum.

• Resection of the diverticulum is usually required and this will preclude a mesh repair.

1/3 Question 31-33 of 89

Theme: Right iliac fossa pain

A. Open Appendicectomy
B. Laparoscopic appendicectomy
C. Laparotomy
D. CT Scan
E. Colonoscopy
F. Ultrasound scan abdomen/pelvis
G. Active observation

For each scenario please select the most appropriate management option from the list. Each option may be used
once, more than once or not at all.

31. A 21 year old women is admitted with a 48 hour history of worsening right iliac fossa pain. She has
been nauseated and vomited twice. On examination she is markedly tender in the right iliac fossa with
localised guarding. Vaginal examination is unremarkable. Urine dipstick is negative. Blood tests
show a WCC of 13.5 and CRP 70.

You answered Open Appendicectomy

The correct answer is Laparoscopic appendicectomy

She is likely to have appendicitis. In women of this age there is always diagnostic uncertainty. With a
normal vaginal exam laparoscopy would be preferred over USS.

32. An 8 year old boy presents with a 4 hour history of right iliac fossa pain with nausea and vomiting.
He has been back at school for two days after being kept home with a flu like illness. On examination
he is tender in the right iliac fossa, although his abdomen is soft. Temperature is 38.3oc. Blood tests
show a CRP of 40 and a WCC of 8.1.

You answered Laparoscopic appendicectomy

 The correct answer is Active observation

This is mesenteric adenitis. Note history of flu like illness and temp > 38o c.
The decision as to how to manage this situation is based on the abdominal findings. Patients with
localising signs such as guarding or peritonism should undergo surgery.

33. A 21 year old women presents with right iliac fossa pain. She reports some bloodstained vaginal
discharge. She has a HR of 65 bpm.

Ultrasound scan abdomen/pelvis

This patient is suspected of having an ectopic pregnancy. She needs an urgent β HCG and USS of the
pelvis. If she were haemodynamically unstable then laparotomy would be indicated.

Right iliac fossa pain

Differential diagnosis

Appendicitis • Pain radiating to right iliac fossa

• Anorexia
• Typically short history
• Diarrhoea and profuse vomiting rare

Crohn's disease • Often long history

• Signs of malnutrition
• Change in bowel habit, especially diarrhoea

Mesenteric adenitis • Mainly affects children

• Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic
Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus
viridans and Yersinia spp.
• Patients have a higher temperature than those with appendicitis
• If laparotomy is performed, enlarged mesenteric lymph nodes will be
present

Diverticulitis • Both left and right sided disease may present with right iliac fossa pain
• Clinical history may be similar, although some change in bowel habit is
usual
• When suspected a CT scan may help in refining the diagnosis

Meckel's diverticulitis • A Meckel's diverticulum is a congenital abnormality that is present in

about 2% of the population
• Typically 2 feet proximal to the ileocaecal valve
• May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer • This usually produces upper quadrant pain but pain may be lower
• Perforations typically have a sharp sudden onset of pain in the history

Incarcerated right inguinal • Usually only right iliac fossa pain if right sided or bowel obstruction.
or femoral hernia
Bowel perforation secondary • Seldom localised to right iliac fossa, although complete large bowel
to caecal or colon carcinoma obstruction with caecal distension may cause pain prior to perforation.

Gynaecological causes • Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic

pregnancy/Ovarian torsion/Threatened or complete
abortion/Mittelschmerz

Urological causes • Ureteric colic/UTI/Testicular torsion

Other causes • TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Question 34 of 89
Which of the following is not a typical feature of irritable bowel syndrome?

A. A change in the consistency of stools

B. Abdominal pain relieved with defecation

C. A change in frequency of defecation

D. Abdominal bloating

E. Pain at a single fixed site

The pain or discomfort of IBS is typically migratory and variable in intensity. Pain at a fixed site is suggestive
of malignancy.
Abdominal bloating is an extremely common feature.

Irritable bowel syndrome

The diagnosis of irritable bowel syndrome is made according to the ROME III diagnostic criteria which state:

Recurrent abdominal pain or discomfort at 3 days per month for the past 3 months associated with two
or more of the following:

• Improvement with defecation.

• Onset associated with a change in the frequency of stool.
• Onset associated with a change in the form of the stool.

Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis

Red flag features should be inquired about:

 • Rectal bleeding
• Unexplained/unintentional weight loss
• Family history of bowel or ovarian cancer
• Onset after 60 years of age

Suggested investigations are:

• Full blood count

• ESR/CRP
• Coeliac disease screen (tissue transglutaminase antibodies)
• Colonoscopy (if worrying symptoms, positive family history)
• Thyroid function tests
• Glucose (ensure not diabetic)

The NICE criteria state that blood tests alone will suffice in people fulfilling the diagnostic criteria. We would
point out that luminal colonic studies should be considered early in patients with altered bowel habit referred to
hospital and a diagnosis of IBS should still be largely one of exclusion.

Treatment

• Usually reduce fibre intake.

• Tailored prescriptions of laxatives or loperamide according to clinical picture.
• Dietary modification (caffeine avoidance, less carbonated drinks).
• Consider low dose tricyclic antidepressants if pain is a dominant symptom.
• Biofeedback may help.

3/3 Question 35-37 of 89

Theme: Causes of abdominal pain

A. Acute on chronic mesenteric ischaemia

B. Ruptured aortic aneurysm
C. Acute Pancreatitis
D. Acute mesenteric embolus
E. Acute appendicitis
F. Chronic pancreatitis
G. Mesenteric vein thrombosis

Please select the most likely underlying diagnosis from the list above. Each option may be used once, more than
once or not at all.

35. A 41 year old man is admitted with peritonitis secondary to a perforated appendix. He is treated with
a laparoscopic appendicectomy but has a stormy post operative course. He is now developing
increasing abdominal pain and has been vomiting. A laparotomy is performed and at operation a large
amount of small bowel shows evidence of patchy areas of infarction.
 Mesenteric vein thrombosis

Mesenteric vein thrombosis may complicate severe intra abdominal sepsis and when it progresses
may impair bowel perfusion. The serosa is quite resistant to ischaemia so in this case the appearances
are usually patchy.

36. A 68 year old man is admitted with abdominal pain and vomiting of 48 hours duration, the pain
radiates to his back and he has required a considerable amount of volume replacement. Amylase is
741.

Acute Pancreatitis

Although back pain and abdominal pain coupled with haemodynamic compromise may suggest
ruptured AAA the 48 hour history and amylase >3 times normal go against this diagnosis.

37. A 79 year old lady develops sudden onset of abdominal pain and collapses, she has passed a large
amount of diarrhoea. In casualty her pH is 7.35 and WCC is 18.

Acute mesenteric embolus

Although mesenteric infarct may raise the lactate the pH may be raised often secondary to vomiting.

Mesenteric vessel disease

Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused by arterial
embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that
are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

Types
Acute mesenteric • Sudden onset abdominal pain followed by profuse diarrhoea.
embolus (commonest • May be associated with vomiting.
50%) • Rapid clinical deterioration.
• Serological tests: WCC, lactate, amylase may all be abnormal particularly in
established disease. These can be normal in the early phases.

Acute on chronic • Usually longer prodromal history.

mesenteric ischaemia • Post prandial abdominal discomfort and weight loss are dominant features.
Patients will usually present with an acute on chronic event, but otherwise will
tend not to present until mesenteric flow is reduced by greater than 80%.
• When acute thrombosis occurs presentation may be as above. In the chronic
setting the symptoms will often be those of ischaemic colitis (mucosa is the
most sensitive area to this insult).

Mesenteric vein • Usually a history over weeks.

thrombosis • Overt abdominal signs and symptoms will not occur until venous thrombosis
 has reached a stage to compromise arterial inflow.
• Thrombophilia accounts for 60% of cases.

Low flow mesenteric • This occurs in patients with multiple co morbidities in whom mesenteric
infarction perfusion is significantly compromised by overuse of inotropes or background
cardiovascular compromise.
• The end result is that the bowel is not adequately perfused and infarcts occur
from the mucosa outwards.

Diagnosis

• Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease).
• Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the
arterial phase with thin slices (<5mm). Venous phase contrast is not helpful.
• SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with chronic
mesenteric ischaemia.
• MRI is of limited use due to gut peristalsis and movement artefact.

Management

• Overt signs of peritonism: Laparotomy

• Mesenteric vein thrombosis: If no peritonism: Medical management with IV heparin
• At operation limited resection of frankly necrotic bowel with view to relook laparotomy at 24-48h. In
the interim urgent bowel revascularisation via endovascular (preferred) or surgery.

Prognosis
Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery occurs within 12h.
Survival may be 50%. This falls to 30% with treatment delay. The other conditions carry worse survival figures.

3/3 Question 38-40 of 89

Theme: Groin masses

A. Femoral aneurysm
B. Lymphadenitis
C. Saphena varix
D. Femoral hernia
E. Indirect inguinal hernia
F. Direct inguinal hernia
G. Psoas abscess

What is the likely diagnosis for the groin mass described? Each option may be used once, more than once or not
at all.
 38. A 3 year old boy is referred to the clinic with a scrotal swelling. On examination the mass does not
transilluminate and it is impossible to palpate normal cord above it.

Indirect inguinal hernia

This is likely to be an indirect hernia. In children these arise from persistent processus vaginalis and
require herniotomy.

39. A 52 year old obese lady reports a painless mass in the groin area. A mass is noted on coughing. It is
below and lateral to the pubic tubercle.

Femoral hernia

A mass below and lateral to the pubic tubercle is indicative of a femoral hernia.

40. A 21 year old man is admitted with a tender mass in the right groin, fevers and sweats. He is on
multiple medical therapy for HIV infection. On examination he has a swelling in his right groin, hip
extension exacerbates the pain.

Psoas abscess

Psoas abscesses may be either primary or secondary. Primary cases often occur in the
immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may
complicated intra abdominal diseases such as Crohns. Patients usually present with low back pain and
if the abscess is extensive a mass that may be localised to the inguinal region or femoral triangle .
Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous
route fails, then surgery (via a retroperitoneal approach) should be performed.

Groin masses clinical

Groin masses are common and include:

• Herniae
• Lipomas
• Lymph nodes
• Undescended testis
• Femoral aneurysm
• Saphena varix (more a swelling than a mass!)

In the history features relating to systemic illness and tempo of onset will often give a clue as to the most likely
underlying diagnosis.

Groin lumps- some key questions

 • Is there a cough impulse
• Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm)
• Are both testes intra scrotal
• Any lesions in the legs such as malignancy or infections (?lymph nodes)
• Examine the ano rectum as anal cancer may metastasise to the groin
• Is the lump soft, small and very superficial (?lipoma)

Scrotal lumps - some key questions

• Is the lump entirely intra scrotal

• Does it transilluminate (?hydrocele)
• Is there a cough impulse (?hernia)

In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound scan is often the most
convenient next investigation.

Question 41 of 89
A 56 year old lady is admitted with colicky abdominal pain. A plain x-ray is performed. Which of the following
should not show fluid levels on a plain abdominal film?

A. Stomach

B. Jejunum

C. Ileum

D. Caecum

E. Descending colon

Fluid levels in the distal colon are nearly always pathological. In general contents of the left colon transit
quickly and are seldom held in situ for long periods, the content is also more solid.

Abdominal radiology

Plain abdominal x-rays are often used as a first line investigation in patients with acute abdominal pain. A plain
abdominal film may demonstrate free air, evidence of bowel obstruction and possibly other causes of pain (e.g.
renal or gallbladder stones).
Investigation of potential visceral perforation is usually best performed by obtaining an erect chest x-ray, as this
is a more sensitive investigation for suspected visceral perforation.

Features which are usually abnormal

• Large amounts of free air (colonic perforation), smaller volumes seen with more proximal perforations.
• A positive Riglers sign (gas on both sides of the bowel wall).
• Caecal diameter of >8cm
 • Fluid levels in the colon
• Ground glass appearance to film (usually due to large amounts of free fluid).
• Sentinel loop in patients with inflammation of other organs (e.g. pancreatitis).

Features which should be expected/ or occur without pathology

• In Chialditis syndrome, a loop of bowel may be interposed between the liver and diaphragm, giving the
mistaken impression that free air is present.
• Following ERCP (and sphincterotomy) air may be identified in the biliary tree.
• Free intra abdominal air following laparoscopy / laparotomy, although usually dissipates after 48-72
hours.

Question 42 of 89
A 56 year old lady presents with a large bowel obstruction and abdominal distension. Which of the following
confirmatory tests should be performed prior to surgery?

A. Abdominal ultrasound scan

B. Barium enema

C. Rectal MRI Scan

D. Endoanal ultrasound scan

E. Gastrograffin enema

Patients with clinical evidence of large bowel obstruction, should have the presence or absence of an
obstructing lesion confirmed prior to surgery. This is because colonic pseudo-obstruction may produce a similar
radiological picture. A gastrograffin enema is the traditional test, as barium is too toxic if it spills into the
abdominal cavity. An MRI scan will not provide the relevant information, unless the lesion is rectal and below
the peritoneal reflection.

Abdominal radiology

Plain abdominal x-rays are often used as a first line investigation in patients with acute abdominal pain. A plain
abdominal film may demonstrate free air, evidence of bowel obstruction and possibly other causes of pain (e.g.
renal or gallbladder stones).
Investigation of potential visceral perforation is usually best performed by obtaining an erect chest x-ray, as this
is a more sensitive investigation for suspected visceral perforation.

Features which are usually abnormal

• Large amounts of free air (colonic perforation), smaller volumes seen with more proximal perforations.
• A positive Riglers sign (gas on both sides of the bowel wall).
• Caecal diameter of >8cm
• Fluid levels in the colon
• Ground glass appearance to film (usually due to large amounts of free fluid).
 • Sentinel loop in patients with inflammation of other organs (e.g. pancreatitis).

Features which should be expected/ or occur without pathology

• In Chialditis syndrome, a loop of bowel may be interposed between the liver and diaphragm, giving the
mistaken impression that free air is present.
• Following ERCP (and sphincterotomy) air may be identified in the biliary tree.
• Free intra abdominal air following laparoscopy / laparotomy, although usually dissipates after 48-72
hours.

2/3 Question 43-45 of 89

Theme: Management of splenic trauma

A. Splenectomy
B. Angiography
C. CT Scan
D. Admit for bed rest and observation
E. Ultrasound scan
F. Splenic conservation
G. MRI of the abdomen

Please select the most appropriate intervention for the scenario given. Each option may be used once, more than
once or not at all.

43. A 7 year old boy falls off a wall the distance is 7 feet. He lands on his left side and there is left flank
bruising. There is no haematuria. He is otherwise stable and haemoglobin is within normal limits.

You answered Admit for bed rest and observation

The correct answer is Ultrasound scan

This will demonstrate any overt splenic injury. A CT scan carries a significant dose of radiation. In
the absence of haemodynamic instability or other major associated injuries the use of USS to exclude
intraabdominal free fluid (blood) would seem safe when coupled with active observation. An USS
will also show splenic haematomas.

44. A 42 year old motorcyclist is involved in a road traffic accident. A FAST scan in the emergency
department shows free intrabdominal fluid and a laparotomy is performed. At operation there is
evidence of small liver laceration that has stopped bleeding and a tear to the inferior pole of the
spleen.

Splenic conservation

As minimum damage, attempt conservation.

 45. An 18 year old man is involved in a road traffic accident. A CT scan shows disruption of the splenic
hilum and a moderate sized perisplenic haematoma.

Splenectomy

Hilar injuries usually mandate splenectomy. The main risk with conservative management here is that
he will rebleed and with hilar injuries this can be dramatic.

Splenic trauma

• The spleen is one of the more commonly injured intra abdominal organs
• In most cases the spleen can be conserved. The management is dictated by the associated injuries,
haemodynamic status and extent of direct splenic injury.

Management of splenic trauma

Conservative Small subcapsular haematoma
Minimal intra abdominal blood
No hilar disruption
Laparotomy with conservation Increased amounts of intraabdominal blood
Moderate haemodynamic compromise
Tears or lacerations affecting <50%
Resection Hilar injuries
Major haemorrhage
Major associated injuries

Splenectomy
Technique
Trauma

• GA
• Long midline incision
• If time permits insert a self retaining retractor (e.g. Balfour/ omnitract)
• Large amount of free blood is usually present. Pack all 4 quadrants of the abdomen. Allow the
anaesthetist to 'catch up'
• Remove the packs and assess the viability of the spleen. Hilar injuries and extensive parenchymal
lacerations will usually require splenectomy.
• Divide the short gastric vessels and ligate them.
• Clamp the splenic artery and vein. Two clamps on the patient side are better and allow for double
ligation and serve as a safety net if your assistant does not release the clamp smoothly.
• Be careful not to damage the tail of the pancreas, if you do then this will need to be formally removed
and the pancreatic duct closed.
• Wash out the abdomen and place a tube drain to the splenic bed.
• Some surgeons implant a portion of spleen into the omentum, whether you decide to do this is a matter
of personal choice.
• Post operatively the patient will require prophylactic penicillin V and pneumococcal vaccine.
Elective
Elective splenectomy is a very different operation from that performed in the emergency setting. The spleen is
often large (sometimes massive). Most cases can be performed laparoscopically. The spleen will often be
macerated inside a specimen bag to facilitate extraction.

Complications

• Haemorrhage (may be early and either from short gastrics or splenic hilar vessels
• Pancreatic fistula (from iatrogenic damage to pancreatic tail)
• Thrombocytosis: prophylactic aspirin
• Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria
meningitidis

Question 46 of 89
Which of the following does not increase the risk of abdominal wound dehiscence following laparotomy?

A. Jaundice

B. Abdominal compartment syndrome

C. Poorly controlled diabetes mellitus

D. Administration of intravenous steroids

E. Use of Ketamine as an anaesthetic agent

Ketamine does not affect healing. All the other situations in the list carry a strong association with poor healing
and risk of dehisence.

Abdominal wound dehiscence

• This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis.
Traditionally it is said to occur when all layers of an abdominal mass closure fail and the viscera
protrude externally (associated with 30% mortality).
• It can be subdivided into superficial, in which the skin wound alone fails and complete, implying
failure of all layers.

Factors which increase the risk are:

* Malnutrition
* Vitamin deficiencies
* Jaundice
* Steroid use
* Major wound contamination (e.g. faecal peritonitis)
* Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)

When sudden full dehiscence occurs the management is as follows:

* Analgesia
* Intravenous fluids
* Intravenous broad spectrum antibiotics
* Coverage of the wound with saline impregnated gauze (on the ward)
* Arrangements made for a return to theatre

Surgical strategy

• Correct the underlying cause (eg TPN or NG feed if malnourished)

• Determine the most appropriate strategy for managing the wound

Options
Resuturing of the This may be an option if the wound edges are healthy and there is enough tissue for
wound sufficient coverage. Deep tension sutures are traditionally used for this purpose.
Application of a This is a clear dressing with removable front. Particularly suitable when some granulation
wound manager tissue is present over the viscera or where there is a high output bowel fistula present in the
dehisced wound.
Application of a This is a clear plastic bag that is cut and sutured to the wound edges and is only a
'Bogota bag' temporary measure to be adopted when the wound cannot be closed and will necessitate a
return to theatre for definitive management.
Application of a These can be safely used BUT ONLY if the correct layer is interposed between the suction
VAC dressing device and the bowel. Failure to adhere to this absolute rule will almost invariably result in
system the development of multiple bowel fistulae and create an extremely difficult management
problem.

1/3 Question 47-49 of 89

Theme: Causes of diarrhoea

A. Campylobacter jejuni infection

B. Salmonella gastroenteritis infection
C. Crohns disease
D. Ulcerative colitis
E. Irritable bowel syndrome
F. Ischaemic colitis
G. Laxative abuse
H. Clostridium difficile infection

Please select the most likely cause of diarrhoea for each scenario given. Each option may be used once, more
than once or not at all.

47. A 23 year old lady has suffered from diarrhoea for 8 months, she has also lost 2 Kg in weight. At
colonoscopy appearances of melanosis coli are identified and confirmed on biopsy

You answered Crohns disease

 The correct answer is Laxative abuse

This may occur as a result of laxative abuse and consists of lipofuschin laden marcophages that
appear brown.

48. A 68 year old lady has recently undergone an abdominal aortic aneurysm repair. The operation was
performed electively and was uncomplicated. Since surgery she has had repeated episodes of
diarrhoea.

Ischaemic colitis

The IMA is commonly ligated during and AAA repair and this may then render the left colon
relatively ischaemic, thereby causing mesenteric colitis. Treatment is supportive and most cases will
settle with conservative management.

49. A 23 year old man is admitted to hospital with diarrhoea and severe abdominal pain. He was
previously well and his illness has lasted 18 hours.

You answered Salmonella gastroenteritis infection

The correct answer is Campylobacter jejuni infection

Severe abdominal pain tends to favour Campylobacter infection.

Diarrhoea

World Health Organisation definitions

Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days

Acute Diarrhoea
Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting
Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever
Antibiotic therapy More common with broad spectrum antibiotics
Clostridium difficile is also seen with antibiotic use
Constipation causing overflow A history of alternating diarrhoea and constipation may be given
May lead to faecal incontinence in the elderly

Chronic Diarrhoea
Irritable bowel Extremely common. The most consistent features are abdominal pain, bloating and change in
syndrome bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those
with constipation predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common.
colitis Faecal urgency and tenesmus may occur
Crohn's disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative
colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal
obstruction
Colorectal Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia
cancer and constitutional symptoms e.g. Weight loss and anorexia
Coeliac disease • In children may present with failure to thrive, diarrhoea and abdominal distension
• In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune
conditions may coexist

Other conditions associated with diarrhoea include:

• Thyrotoxicosis
• Laxative abuse
• Appendicitis with pelvic abscess or pelvic appendix
• Radiation enteritis

Diagnosis
Stool culture
Abdominal and digital rectal examination
Consider colonoscopy (radiological studies unhelpful)
Thyroid function tests, serum calcium, anti endomysial antibodies, glucose

Question 50 of 89
A 6 year old child presents with colicky abdominal pain, vomiting and the passage of red current jelly stool per
rectum. On examination the child has a tender abdomen and a palpable mass in the right upper quadrant.
Imaging shows an intussusception. Which of the conditions below is least recognised as a precipitant?

A. Inflammation of Payers patches

B. Cystic fibrosis

C. Meckels diverticulum

D. Mesenteric cyst

E. Mucosal polyps

Mesenteric cysts may be associated with intra abdominal catastrophes where these occur they are typically
either intestinal volvulus or intestinal infarction. They seldom cause intussusception. Cystic fibrosis may lead to
the formation of meconium ileus equivalent and plugs may occasionally serve as the lead points for an
intussusception.

Intussusception- Paediatric

Intussusception typically presents with colicky abdominal pain and vomiting. The telescoping of the bowel
produces mucosal ischaemia and bleeding may occur resulting in the passage of "red current jelly" stools.
Recognised causes include lumenal pathologies such as polyps, lymphadenopathy and diseases such as cystic
fibrosis. Idiopathic intussceception of the ileocaecal valve and terminal ileum is the most common variant and
typically affects young children and toddlers.
The diagnosis is usually made by abdominal ultrasound investigation. The decision as to the optimal treatment
is dictated by the patients physiological status and abdominal signs. In general, children who are unstable with
localising peritoneal signs should undergo laparotomy, as should those in whom attempted radiological
reduction has failed.
In relatively well children without localising signs attempted pneumatic reduction under fluroscopic guidance is
the usual treatment.

Question 51 of 89
Which one of the following is least likely to cause malabsorption?

A. Primary biliary cirrhosis

B. Ileo-colic bypass

C. Chronic pancreatitis

D. Whipples disease

E. Hartmans procedure

In a Hartmans procedure the sigmoid colon is removed and an end colostomy is fashioned. The bowel remains
in continuity and no absorptive ability is lost.
An ileo-colic bypass leaves a redundant loop of small bowel in continuity, where the contents will stagnate and
bacterial overgrowth will occur. Therefore this is recognised cause of malabsorption.

Malabsorption

Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into
intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production or secretion) and biliary
(deficiency of bile-salts needed for emulsification of fats)

Intestinal causes of malabsorption

• coeliac disease
• Crohn's disease
• tropical sprue
• Whipple's disease
• Giardiasis
• brush border enzyme deficiencies (e.g. lactase insufficiency)

Pancreatic causes of malabsorption

• chronic pancreatitis
 • cystic fibrosis
• pancreatic cancer

Biliary causes of malabsorption

• biliary obstruction
• primary biliary cirrhosis

Other causes

• bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop)

• short bowel syndrome
• lymphoma

3/3 Question 52-54 of 89

Theme: Intra abdominal malignancies

A. Metastatic adenocarcinoma of the pancreas

B. Metastatic appendiceal carcinoid
C. Metastatic colonic cancer
D. Pseudomyxoma peritonei
E. MALT lymphoma
F. Retroperitoneal liposarcoma
G. Retroperitoneal fibrosis

For the disease given please give the most likely primary disease process. Each option may be used once, more
than once or not at all.

52. 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.

53. 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.

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

54. 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.
Pseudomyxoma peritoneii- Curative treatment is peritonectomy (Sugarbaker procedure) and heated intra
peritoneal chemotherapy.

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.

1/3 Question 55-57 of 89

Theme: Abdominal pain

A. Acute mesenteric embolus

B. Acute on chronic mesenteric ischaemia
C. Mesenteric vein thrombosis
D. Ruptured abdominal aortic aneurysm
E. Pancreatitis
F. Appendicitis
G. Acute cholecystitis
Please select the most likely underlying diagnosis from the list above. Each option may be used once, more than
once or not at all.

55. A 72 year old man collapses with sudden onset abdominal pain. He has been suffering from back pain
recently and has been taking ibuprofen.

Ruptured abdominal aortic aneurysm

Back pain is a common feature with expanding aneurysms and may be miss classified as being of
musculoskeletal origin.

56. A 73 year old women collapses with sudden onset of abdominal pain and the passes a large amount of
diarrhoea. On admission she is vomiting repeatedly. She has recently been discharged from hospital
following a myocardial infarct but recovered well.

You answered Acute on chronic mesenteric ischaemia

The correct answer is Acute mesenteric embolus

Sudden onset of abdominal pain and forceful bowel evacuation are features of acute mesenteric
infarct.

57. A 66 year old man has been suffering from weight loss and develops severe abdominal pain. He is
admitted to hospital and undergoes a laparotomy. At operation the entire small bowel is infarcted and
only the left colon is viable.

You answered Mesenteric vein thrombosis

The correct answer is Acute on chronic mesenteric ischaemia

This man is likely to have underlying chronic mesenteric vascular disease. Only 15% of emboli will
occlude SMA orifice leading to entire small bowel infarct. The background history of weight loss
also favours an acute on chronic event.

Mesenteric vessel disease

Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused by arterial
embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that
are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

Types
Acute mesenteric • Sudden onset abdominal pain followed by profuse diarrhoea.
embolus (commonest • May be associated with vomiting.
50%) • Rapid clinical deterioration.
 • Serological tests: WCC, lactate, amylase may all be abnormal particularly in
established disease. These can be normal in the early phases.

Acute on chronic • Usually longer prodromal history.

mesenteric ischaemia • Post prandial abdominal discomfort and weight loss are dominant features.
Patients will usually present with an acute on chronic event, but otherwise will
tend not to present until mesenteric flow is reduced by greater than 80%.
• When acute thrombosis occurs presentation may be as above. In the chronic
setting the symptoms will often be those of ischaemic colitis (mucosa is the
most sensitive area to this insult).

Mesenteric vein • Usually a history over weeks.

thrombosis • Overt abdominal signs and symptoms will not occur until venous thrombosis
has reached a stage to compromise arterial inflow.
• Thrombophilia accounts for 60% of cases.

Low flow mesenteric • This occurs in patients with multiple co morbidities in whom mesenteric
infarction perfusion is significantly compromised by overuse of inotropes or background
cardiovascular compromise.
• The end result is that the bowel is not adequately perfused and infarcts occur
from the mucosa outwards.

Diagnosis

• Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease).
• Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the
arterial phase with thin slices (<5mm). Venous phase contrast is not helpful.
• SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with chronic
mesenteric ischaemia.
• MRI is of limited use due to gut peristalsis and movement artefact.

Management

• Overt signs of peritonism: Laparotomy

• Mesenteric vein thrombosis: If no peritonism: Medical management with IV heparin
• At operation limited resection of frankly necrotic bowel with view to relook laparotomy at 24-48h. In
the interim urgent bowel revascularisation via endovascular (preferred) or surgery.

Prognosis
Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery occurs within 12h.
Survival may be 50%. This falls to 30% with treatment delay. The other conditions carry worse survival figures.

1/3 Question 58-60 of 89

Theme: Surgical incisions

A. Lanz incision
B. Gridiron incision
C. Kochers incision
D. Rutherford Morrison
E. Rooftop incision
F. McEvedy Incision
G. Lothissen Incision

Please select the most appropriate incision for the procedure described. Each option may be used once, more
than once or not at all.

58. A 78 year old lady is admitted with an incarcerated femoral hernia. Abdominal signs are absent and
there are no symptoms of obstruction. AXR is normal.

You answered Lothissen Incision

The correct answer is McEvedy Incision

From the list the McEvedy approach is the most appropriate. The Lothissen incision may compromise
the posterior wall of the inguinal canal and is best avoided. The author prefers a limited pfannenstial
type incision for this procedure, as it gives better control of the hernia, but this is not on the list.

59. A 15 year old girl presents with right iliac fossa pain and guarding, pregnancy test is negative and
WCC is 16.

Lanz incision

She requires an appendicectomy although there is an increasing vogue for performing this procedure
laparoscopically an open procedure is entirely suitable. However, although both a Gridiron and Lanz
incision are suitable for appendicectomy a Lanz will give a superior cosmetic result and would be the
preferred option for most young females.

60. A 45 year old man is due to undergo a live donor renal transplant. This will be his first procedure.

You answered Rooftop incision

The correct answer is Rutherford Morrison

The Rutherford Morrison incision will typically give access to the iliac vessels and bladder for the
procedure

2/3 Question 61-63 of 89

Theme: Acute abdominal pain

A. Appendicitis
B. Henoch Schonlein purpura
C. Diabetes mellitus
D. Intussusception
E. Mittelschmerz
F. Pneumonia
G. Sickle cell crisis
H. Spontaneous bacterial peritonitis
I. Rupure of follicular cyst

Please select the most likely cause of abdominal pain for the scenario given. Each option may be used once,
more than once or not at all.

61. An 11 month-old girl develops sudden onset abdominal pain. She has a high pitched scream and
draws up her legs. Her BP is 90/40 mm/Hg, her pulse 118/min and abdominal examination is normal.

Intussusception

Intussusception should be considered in toddlers and infants presenting with screaming attacks. The
child often has a history of being unwell for one to three days prior to presentation. The child may
pass bloody mucus stool, which is a late sign. Examination of the abdomen is often normal as the
sausage mass in the right upper quadrant is difficult to feel.

62. An 8 year-old West Indian boy presents with periumbilical abdominal pain. He has vomited twice
and is refusing fluids. His temperature is 38.1oC and blood tests are as follows: Haemoglobin 8 g/dl,
WCC 13 x 109/l, with a neutrophilia.

Sickle cell crisis

Sickle cell anaemia is characterised by severe chronic haemolytic anaemia resulting from poorly
formed erythrocytes. Painful crises result from vaso-occlusive episodes, which may occur
spontaneously or may be precipitated by infection. Consider this diagnosis in all children of
appropriate ethnic background.

63. A 15-month-old girl presents with a three day history of periorbital oedema. She is brought to
hospital. On examination she has facial oedema and a tender distended abdomen. Her temperature is
39oC and her blood pressure is 90/45 mmHg. There is clinical evidence of poor peripheral perfusion.

You answered Henoch Schonlein purpura

The correct answer is Spontaneous bacterial peritonitis

The 15-month-old girl is a patient with nephrotic syndrome. Patients with this condition are at risk of
septicaemia and peritonitis from Streptococcus pneumoniae, due to the loss of immunoglobulins and
opsonins in the urine.

Acute abdominal pain-diagnoses

Conditions presenting with acute abdominal pain
Condition Features Investigations Management
Appendicitis History of migratory pain. Differential white cell count Appendicectomy
Fever. Pregnancy test
Anorexia. C-Reactive protein
Evidence of right iliac Amylase
fossa tenderness. Urine dipstick testing
Mild pyrexia.
Mesenteric Usually recent upper Full blood count- may show Conservative management-
adenitis respiratory tract infection. slightly raised white cell count appendicectomy if diagnostic
High fever. Urine dipstick often normal doubt
Generalised abdominal Abdominal ultrasound scan -
discomfort- true localised usually no free fluid
pain and signs are rare.
Mittelschmerz Only seen in females. Full blood count- normal Manage conservatively if doubt
Mid cycle pain. Urine dipstick- normal or symptoms fail to settle then
Usually occurs two weeks Abdominal and pelvic laparoscopy
after last menstrual period. ultrasound- may show a trace
Pain is usually has a supra- of pelvic free fluid
pubic location.
Usually subsides over a 24-
48 hour period.
Fitz-Hugh Curtis Disseminated infection Abdominal ultrasound scan- Usually medically managed-
syndrome with Chlamydia. may show free fluid doxycycline or azithromycin
Usually seen in females. High vaginal swabs - may
Consists of evidence of show evidence of sexually
pelvic inflammatory transmitted infections
disease together with peri-
hepatic inflammation and
subsequent adhesion
formation.
Abdominal Sudden onset of abdominal Patients who are Unstable patients should
aortic aneurysm pain radiating to the back haemodynamically stable undergo immediate surgery
(ruptured) in older adults (look for should have a CT scan (unless it is not in their best
risk factors). interests).
Collapse. Those with evidence of
May be moribund on contained leak on CT should
arrival in casualty, more undergo immediate surgery
stable if contained Increasing unruptured
haematoma. aneurysmal size is an indication
Careful clinical assessment for urgent surgical intervention
may reveal pulsatile mass. (that can wait until the next
working day)
Perforated peptic Sudden onset of pain Erect CXR may show free air. Laparotomy (laparoscopic
ulcer (usually epigastric). A CT scan may be indicated surgery for perforated peptic
Often preceding history of where there is diagnostic doubt ulcers is both safe and feasible
upper abdominal pain. in experienced hands)
Soon develop generalised
abdominal pain.
 On examination may have
clinical evidence of
peritonitis.
Intestinal Colicky abdominal pain A plain abdominal film may In those with a virgin abdomen
obstruction and vomiting (the nature of help with making the and lower and earlier threshold
which depends on the level diagnosis. A CT scan may be for laparotomy should exist than
of the obstruction). useful where diagnostic in those who may have
Abdominal distension and uncertainty exists adhesional obstruction
constipation (again
depending upon site of
obstruction).
Features of peritonism may
occur where local necrosis
of bowel loops is
occurring.
Mesenteric Embolic events present Arterial pH and lactate Immediate laparotomy and
infarction with sudden pain and Arterial phase CT scanning is resection of affected segments,
forceful evacuation. the most sensitive test in acute embolic events SMA
Acute on chronic events embolectomy may be needed.
usually have a longer
history and previous weight
loss.
On examination the pain is
typically greater than the
physical signs would
suggest.

Question 64 of 89
Which of the following interventions is most likely to reduce the incidence of intra abdominal adhesions?

A. Peritoneal lavage with cetrimide following elective right

hemicolectomy

B. Use of a laparoscopic approach over open surgery

C. Use of talc to coat surgical gloves

D. Performing a Nobles plication of the small bowel

E. Using stapled rather than a hand sewn anastamosis

Laparoscopy results in fewer adhesions. When talc was used to coat surgical gloves it was a major cause of
adhesion formation and withdrawn for that reason. A Nobles plication is an old fashioned operation which has
no place in the prevention of adhesion formation. Use of an anastamotic stapling device will not influence the
development of adhesions per se although clearly an anastamotic leak will result in more adhesion formation

Surgical complications
Complications occur in all branches of surgery and require vigilance in their detection. In many cases
anticipating the likely complications and appropriate avoidance will minimise their occurrence. For the
purposes of the MRCS the important principles to appreciate are:

• The anatomical principles that underpin complications

• The physiological and biochemical derangements that occur
• The most appropriate diagnostic modalities to utilise
• The principles which underpin their management

This is clearly a very broad area and impossible to cover comprehensively. There is considerable overlap with
other topic areas within the website.

Avoiding complications

Some points to hopefully avert complications:

• World Health Organisation checklist- now mandatory prior to all operations

• Prophylactic antibiotics - right dose, right drug, right time.
• Assess DVT/ PE risk and ensure adequate prophylaxis
• MARK site of surgery
• Use tourniquets with caution and with respect for underlying structures
• Remember the danger of end arteries and in situations where they occur avoid using adrenaline
containing solutions and monopolar diathermy.
• Handle tissues with care- devitalised tissue serves as a nidus for infection
• Be very wary of the potential for coupling injuries when using diathermy during laparoscopic surgery
• The inferior epigastric artery is a favourite target for laparoscopic ports and surgical drains!

Anatomical principles

Understanding the anatomy of a surgical field will allow appreciation of local and systemic complications that
may occur. For example nerve injuries may occur following surgery in specific regions the table below lists
some of the more important nerves to consider and mechanisms of injury

Nerve Mechanism
Accessory Posterior triangle lymph node biopsy
Sciatic Posterior approach to hip
Common peroneal Legs in Lloyd Davies position
Long thoracic Axillary node clearance
Pelvic autonomic nerves Pelvic cancer surgery
Recurrent laryngeal nerves During thyroid surgery
Hypoglossal nerve During carotid endarterectomy
Ulnar and median nerves During upper limb fracture repairs

These are just a few. The detailed functional sequelae are particularly important and will often be tested. In
addition to nerve injuries certain procedures carry risks of visceral or structural injury. Again some particular
favourites are given below:

Structure Mechanism
Thoracic duct During thoracic surgery e.g. Pneumonectomy, oesphagectomy
Parathyroid glands During difficult thyroid surgery
Ureters During colonic resections/ gynaecological surgery
Bowel perforation Use of Verres Needle to establish pneumoperitoneum
Bile duct injury Failure to delineate Calots triangle carefully and careless use of diathermy
Facial nerve Always at risk during Parotidectomy
Tail of pancreas When ligating splenic hilum
Testicular vessels During re-do open hernia surgery
Hepatic veins During liver mobilisation

Again many could be predicted from the anatomy of the procedure.

Physiological derangements

A very common complication is bleeding and this is covered under the section of haemorrhagic shock. Another
variant is infection either superficial or deep seated. The organisms are covered under microbiology and the
features of sepsis covered under shock. Do not forget that immunocompromised and elderly patients may
present will atypical physiological parameters.

Selected physiological and biochemical issues are given below:

Complication Physiological/ Biochemical Problem

Arrhythmias following cardiac Susceptibility to hypokalaemia (K+ <4.0 in cardiac patients)
surgery
Neurosurgical electrolyte SIADH following cranial surgery causing hyponatraemia
disturbance
Ileus following gastrointestinal Fluid sequestration and loss of electrolytes
surgery
Pulmonary oedema following Loss of lung volume makes these patients very sensitive to fluid overload
pneumonectomy
Anastamotic leak Generalised sepsis causing mediastinitis or peritonitis depending on site of
leak
Myocardial infarct May follow any type of surgery and in addition to direct cardiac effects the
decreased cardiac output may well compromise grafts etc.

Try making a short list of problems and causes specific to your own clinical area.

Diagnostic modalities

Depends largely on the suspected complication. In the acutely unwell surgical patient the following baseline
investigations are often helpful:
 • Full blood count, urea and electrolytes, C- reactive protein (trend rather than absolute value), serum
calcium, liver function tests, clotting (don't forget to repeat if on-going bleeding)
• Arterial blood gases
• ECG (+cardiac enzymes if MI suspected)
• Chest x-ray to identify collapse/ consolidation
• Urine analysis for UTI

These will often identify the most common complications.

Special tests

• CT scanning for identification of intra-abdominal abscesses, air and if luminal contrast is used an
anastamotic leak
• Gatrograffin enema- for rectal anastamotic leaks
• Doppler USS of leg veins- for identification of DVT
• CTPA for PE
• Sending peritoneal fluid for U+E (if ureteric injury suspected) or amylase (if pancreatic injury
suspected)
• Echocardiogram if pericardial effusion suspected post cardiac surgery and no pleural window made.

Management of complications

The guiding principal should be safe and timely intervention. Patients should be stabilised and if an operation
needs to occur in tandem with resuscitation then generally this should be of a damage limitation type procedure
rather than definitive surgery (which can be more safely undertaken in a stable patient the following day).

Remember that recent surgery is a contra indication to thrombolysis and that in some patients IV heparin may
be preferable to a low molecular weight heparin (easier to reverse).

As a general rule laparotomies for bleeding should follow the core principle of quadrant packing and then
subsequent pack removal rather than plunging large clamps into pools of blood. The latter approach invariable
worsens the situation is often accompanied by significant visceral injury particularly when done by the
inexperienced. If packing controls a situation it is entirely acceptable practice to leave packs in situ and return
the patient to ITU for pack removal the subsequent day.

3/3 Question 65-67 of 89

Theme: Abdominal pain

A. Appendicitis
B. Threatened miscarriage
C. Ectopic pregnancy
D. Irritable bowel syndrome
E. Mittelschmerz
F. Pelvic inflammatory disease
G. Adnexial torsion
H. Endometriosis
 I. Degenerating fibroid

Please select the most likely cause of abdominal pain for the clinical scenario given. Each option may be used
once, more than once or not at all.

65. An 18 year-old girl presents to the Emergency Department with sudden onset sharp, tearing pelvic
pain associated with a small amount of vaginal bleeding. She also complains of shoulder tip pain. On
examination she is hypotensive, tachycardic and has marked cervical excitation.

Ectopic pregnancy

The history of tearing pain and haemodynamic compromise in a women of child bearing years should
prompt a diagnosis of ectopic pregnancy.

66. A 25 year-old lady presents to her GP complaining of a two day history of right upper quadrant pain,
fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic
pain and dyspareunia.

Pelvic inflammatory disease

The most likely diagnosis is pelvic inflammatory disease. Right upper quadrant pain occurs as part of
the Fitz Hugh Curtis syndrome in which peri hepatic inflammation occurs.

67. A 16 year old female presents to the emergency department with a 12 hour history of pelvic
discomfort. She is otherwise well and her last normal menstrual period was 2 weeks ago. On
examination she has a soft abdomen with some mild supra pubic discomfort.

Mittelschmerz

Mid cycle pain is very common and is due to the small amount of fluid released during ovulation.
Inflammatory markers are usually normal and the pain typically subsides over the next 24-48 hours.

Gynaecological causes of abdominal pain

A number of women will present with abdominal pain and subsequently be diagnosed with a gynaecological
disorder. In addition to routine diagnostic work up of abdominal pain, all female patients should also undergo a
bimanual vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound
scanning.
When diagnostic doubt persists a laparoscopy provides a reliable method of assessing suspected tubulo-ovarian
pathology.

Differential diagnoses of abdominal pain in females

Diagnosis Features Investigation Treatment
Mittelschmerz Usually mid cycle pain. Full blood count- Conservative
Often sharp onset. usually normal
 Little systemic disturbance. Ultrasound- may
May have recurrent episodes. show small quantity
Usually settles over 24-48 of free fluid
hours.
Endometriosis 25% asymptomatic, in a further Ultrasound- may Usually managed medically, complex
25% associated with other show free fluid disease will often require surgery and
pelvic organ pathology. Laparoscopy will some patients will even require formal
Remaining 50% may have usually show lesions colonic and rectal resections if these
menstrual irregularity, areas are involved
infertility, pain and deep
dyspareurina.
Complex disease may result in
pelvic adhesional formation
with episodes of intermittent
small bowel obstruction.
Intra-abdominal bleeding may
produce localised peritoneal
inflammation.
Recurrent episodes are
common.
Ovarian torsion Usually sudden onset of deep Ultrasound may show Laparoscopy
seated colicky abdominal pain. free fluid
Associated with vomiting and Laparoscopy is
distress. usually both
Vaginal examination may reveal diagnostic and
adnexial tenderness. therapeutic
Ectopic Symptoms of pregnancy Ultrasound showing Laparoscopy or laparotomy is
gestation without evidence of intra uterine no intra uterine haemodynamically unstable. A
gestation. pregnancy and beta salphingectomy is usually performed.
Present as an emergency with HCG that is elevated
evidence of rupture or May show intra
impending rupture. abdominal free fluid
Open tubular ruptures may have
sudden onset of abdominal pain
and circulatory collapse, in
other the symptoms may be
more prolonged and less
marked.
Small amount of vaginal
discharge is common.
There is usually adnexial
tenderness.
Pelvic Bilateral lower abdominal pain Full blood count- Usually medical management
inflammatory associated with vaginal Leucocytosis
disease discharge. Pregnancy test
Dysuria may also be present. negative (Although
Peri-hepatic inflammation infection and
secondary to Chlamydia (Fitz pregnancy may co-
Hugh Curtis Syndrome) may exist)
produce right upper quadrant Amylase - usually
 discomfort. normal or slightly
Fever >38o raised
High vaginal and
urethral swabs

Question 68 of 89
Which of the following statements relating to a burst abdomen is false?

A. Is seen in 1-2% of modern laparotomies

B. Is more common in faecal peritonitis

C. Is less common when a 'mass closure' technique is used

D. When it does occur is most common at 15 days

E. Is similar in incidence regardless of whether 1/0 polydiaxone or 1/0

polypropylene are used

When it does occur a burst abdomen is most common at 6 days and is usually the result of technical error when
Jenkins rule is not followed and sutures are placed in the zone of collagenolysis. The choice of materials given
above does not influence dehisence rates.

Abdominal wound dehiscence

• This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis.
Traditionally it is said to occur when all layers of an abdominal mass closure fail and the viscera
protrude externally (associated with 30% mortality).
• It can be subdivided into superficial, in which the skin wound alone fails and complete, implying
failure of all layers.

Factors which increase the risk are:

* Malnutrition
* Vitamin deficiencies
* Jaundice
* Steroid use
* Major wound contamination (e.g. faecal peritonitis)
* Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)

When sudden full dehiscence occurs the management is as follows:

* Analgesia
* Intravenous fluids
* Intravenous broad spectrum antibiotics
* Coverage of the wound with saline impregnated gauze (on the ward)
* Arrangements made for a return to theatre

Surgical strategy
 • Correct the underlying cause (eg TPN or NG feed if malnourished)
• Determine the most appropriate strategy for managing the wound

Options
Resuturing of the This may be an option if the wound edges are healthy and there is enough tissue for
wound sufficient coverage. Deep tension sutures are traditionally used for this purpose.
Application of a This is a clear dressing with removable front. Particularly suitable when some granulation
wound manager tissue is present over the viscera or where there is a high output bowel fistula present in the
dehisced wound.
Application of a This is a clear plastic bag that is cut and sutured to the wound edges and is only a
'Bogota bag' temporary measure to be adopted when the wound cannot be closed and will necessitate a
return to theatre for definitive management.
Application of a These can be safely used BUT ONLY if the correct layer is interposed between the suction
VAC dressing device and the bowel. Failure to adhere to this absolute rule will almost invariably result in
system the development of multiple bowel fistulae and create an extremely difficult management
problem.
Question 69 of 89
Which of the following statements about diarrhoea is false?

A. Nocturnal diarrhoea is uncommon in irritable bowel syndrome

B. World Health Organisation definition of diarrhoea is greater than 3

episodes of loose or watery stool a day

C. Pancreatic disease causes osmotic diarrhoea

D. Vitamin C deficiency causes diarrhoea

E. The World Health Organisation definition of chronic diarrhoea is

greater than 14 days of diarrhoea

Vitamin C toxicity causes osmotic diarrhoea.

Diarrhoea

World Health Organisation definitions

Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days

Acute Diarrhoea
Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting
Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever
Antibiotic therapy More common with broad spectrum antibiotics
Clostridium difficile is also seen with antibiotic use
Constipation causing overflow A history of alternating diarrhoea and constipation may be given
 May lead to faecal incontinence in the elderly

Chronic Diarrhoea
Irritable bowel Extremely common. The most consistent features are abdominal pain, bloating and change in
syndrome bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those
with constipation predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common.
colitis Faecal urgency and tenesmus may occur
Crohn's disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative
colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal
obstruction
Colorectal Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia
cancer and constitutional symptoms e.g. Weight loss and anorexia
Coeliac disease • In children may present with failure to thrive, diarrhoea and abdominal distension
• In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune
conditions may coexist

Other conditions associated with diarrhoea include:

• Thyrotoxicosis
• Laxative abuse
• Appendicitis with pelvic abscess or pelvic appendix
• Radiation enteritis

Diagnosis
Stool culture
Abdominal and digital rectal examination
Consider colonoscopy (radiological studies unhelpful)
Thyroid function tests, serum calcium, anti endomysial antibodies, glucose

Question 70 of 89
A 40 year old man presents with a long standing inguinal hernia. On examination he has a small, direct inguinal
hernia. He inquires as to the risk of strangulation over the next twelve months should he decide not to undergo
surgery. Which of the following most closely matches the likely risk of strangulation over the next 12 months?

A. 50%

B. 40%

C. 25%

D. 15%

E. <5%
The annual probability of strangulation is up to 3% and is more common in indirect hernias. Elective repair
poses few risks. However, emergency repair is associated with increased mortality, particularly in the elderly.

Inguinal hernia surgery

Inguinal hernias occur when the abdominal viscera protrude through the anterior abdominal wall into the
inguinal canal. They may be classified as being either direct or indirect. The distinction between these two rests
on their relation to Hesselbach's triangle.

Boundaries of Hesselbach's Triangle

• Medial: Rectus abdominis

• Lateral: Inferior epigastric vessels
• Inferior: Inguinal ligament

Image sourced from Wikipedia

Hernias occurring within the triangle tend to be direct and those outside - indirect.

Diagnosis
Most cases are diagnosed clinically, a reducible swelling may be located at the level of the inguinal canal. Large
hernia may extend down into the male scrotum, these will not trans-illuminate and it is not possible to "get
above" the swelling.
Cases that are unclear on examination, but suspected from the history, may be further investigated using
ultrasound or by performing a herniogram.

Treatment
Hernias associated with few symptoms may be managed conservatively. Symptomatic hernias or those which
are at risk of developing complications are usually treated surgically.
First time hernias may be treated by performing an open inguinal hernia repair; the inguinal canal is opened, the
hernia reduced and the defect repaired. A prosthetic mesh may be placed posterior to the cord structures to re-
inforce the repair and reduce the risk of recurrence.
Recurrent hernias and those which are bilateral are generally managed with a laparoscopic approach. This may
be via an intra or extra peritoneal route. As in open surgery a mesh is deployed. However, it will typically lie
posterior to the deep ring.

Inguinal hernia in children

Inguinal hernias in children are almost always of an indirect type and therefore are usually dealt with by
herniotomy, rather than herniorraphy. Neonatal hernias especially in those children born prematurely are at
highest risk of strangulation and should be repaired urgently. Other hernias may be repaired on an elective
basis.

Question 71 of 89
A 60 year old women has fully recovered from an attack of pancreatitis. Over the following 12 months she
develops episodic epigastric discomfort. Un upper GI endoscopy shows gastric varices only. An abdominal CT
scan demonstrates a splenic vein thrombosis. What is the treatment of choice?

A. Splenectomy

B. Insertion of transjugular porto-systemic shunt

C. Surgical bypass of the splenic vein

D. Gastrectomy

E. Stapling of the gastro-oesophgeal junction

Splenic vein thrombosis

Thrombosis of the splenic vein may complicate pancreatitis, pancreatic carcinoma, iatrogenic trauma and
hypercoagulable diseases. The condition may predispose to the development of gastric varices, oesophageal
varices are uncommon in splenic vein thrombosis alone.
Diagnosis is made by CT angiography.
Treatment is with splenectomy.

3/3 Question 72-74 of 89

Theme: Surgical signs

A. Rovsing's sign
B. Boas' sign
C. Psoas stretch sign
D. Cullen's sign
E. Grey-Turner's sign
F. Murphy's sign
G. None of the above

Please match the clinical sign to the clinical scenario described. Each option may be used once, more than once
or not at all.

72. Acute retrocaecal appendicitis is indicated when the right thigh is passively extended with the patient
lying on their side with their knees extended.

Psoas stretch sign

73. In acute pancreatitis there is bruising in the flanks.

Grey-Turner's sign

Grey-Turners sign occurs in patients with severe haemorrhagic pancreatitis. In this situation the major
vessels surrounding the pancreas bleed. The pancreatitis process also results in local fat destruction,
this results in blood tracking in the tissue planes of the retroperitoneum and appearing as flank
bruising.

74. In cholecystitis there is pain/catch of breath elicited on palpation of the right hypochondrium during
inspiration.

Murphy's sign

Invariably present when patients are assessed in the emergency department! This sign occurs because
the inflamed gallbladder irritates the parietal peritoneum in this manoeuvre.

Question 75 of 89
Which of the following is commonest cause of acute abdominal pain in acute unselected surgical 'take'?

A. Non specific abdominal pain

B. Biliary colic

C. Acute appendicitis

D. Ureteric colic

E. Pancreatitis

Non specific abdominal pain is a commonly recorded diagnosis for patients presenting with acute abdominal
pain. Following careful diagnostic work up a proportion of patients may be identified with disorders such as
coeliac disease and the diagnosis of non specific abdominal pain should be used lightly.

Acute abdominal pain

Acute abdominal pain is a common cause of admission to hospital. The relative proportions of conditions
presenting with abdominal pain is given below:

• Non specific abdominal pain (35%)

• Appendicitis (17%)
• Intestinal obstruction (15%)
• Urological disease (6%)
• Gallstone disease (5%)
• Colonic diverticular disease (4%)
• Abdominal trauma (3%)
• Perforated peptic ulcer (3%)
• Pancreatitis (2%)

(Data derived from Irvin T Br. J. Surg 1989 76:1121-1125)

Non specific abdominal pain should really be a diagnosis of exclusion and if care is taken in excluding organic
disease the proportion of cases labeled such should decline. It should also be appreciated that a proportion of
patients may have an underlying medical cause for their symptoms such as pneumonia or diabetic ketoacidosis.

Key points in management

• Early administration of adequate analgesia (including opiates).

• Abdominal ultrasound is safe, non invasive and cheap and yields significantly more information than
plain radiology. However, plain radiology is still the main test for suspected perforated viscus,
especially out of hours.
• In up to 50% cases with perforated peptic ulcer, the plain x-rays may show no evidence of free air. If
clinical signs suggest otherwise, then a CT scan may be a more accurate investigation, if plain films are
normal.
• Plain film radiology usually cannot detect <1mm free air, and is 33% sensitive for detection of 1-13mm
pockets of free air (Stoker et al. Radiology 2009 253: 31-46).
• Think of strangulated intestine when there is fever, raised white cell count, tachycardia and peritonism.
• In suspected large bowel obstruction a key investigation is either a water soluble contrast enema or CT
scan.
• Where need for surgery is difficult to define and imaging is inconclusive the use of laparoscopy as a
definitive diagnostic test is both safe and sensible.

Question 76 of 89
A 72 year old obese man undergoes and emergency repair of a ruptured abdominal aortic aneurysm. The wound
is closed with an onlay prolene mesh to augment the closure. Post operatively he is taken to the intensive care
unit. Over the following twenty four hours his nasogastric aspirates increase, his urine output falls and he has a
metabolic acidosis. What is the most likely underlying cause?

A. Colonic ischaemia

B. Abdominal compartment syndrome

 C. Peritonitis

D. Reactionary haemorrhage

E. Aorto-duodenal fistula

Obese patients with ileus following major abdominal surgery are at increased risk of intra abdominal
compartment syndrome.The risk is increased by the use of prosthetic meshes, which some surgeons favor
following a major vascular case as they may reduce the incidence of incisional hernia. They prevent abdominal
distension and may increase the risk of intra abdominal hypertension in the short term. Although colonic
ischaemia may occur following major aortic surgery it would not typically present in this way.

Abdominal compartment syndrome

Background
Intra-abdominal pressure is the steady state pressure concealed within the abdominal cavity.

• In critically ill adults the normal intra abdominal pressure = 5-7mmHg

• Intra abdominal hypertension has pressures of 12-25mmHg
• Changes >15mmHg are associated with microvascular hypoperfusion
• Abdominal compartment syndrome is defined as sustained intra abdominal pressure >20mmHg
coupled with new organ dysfunction / failure
• It may occur either primarily without previous surgical intervention e.g. Following intestinal ischaemia
or secondarily following a surgical procedure
• Diagnosis is typically made by transvesical pressure measurements coupled with an index of clinical
suspicion.

Management
Once the diagnosis is made non operative measures should be instituted including:

• Gastric decompression
• Improve abdominal wall compliance e.g. muscle relaxants/ sedation
• Drain abdominal fluid collections.
• Consider fluid restriction/ diuretics if clinically indicated.

In those whom non operative treatment is failing; the correct treatment is laparotomy and laparostomy. Options
for laparostomy are many although the Bogota bag or VAC techniques are the most widely practised. Re-look
laparotomy and attempts at delayed closure will follow in due course.

2/3 Question 77-79 of 89

Theme: Surgical drains

A. Redivac suction drain

B. Corrugated drain
C. Wallace Robinson drain
D. Penrose tubing
E. Latex T Tube drain
F. Silastic T Tube drain

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.

77. A 56 year old lady undergoes and open cholecystectomy and exploration of common bile duct. The
bile duct is closed over a drain.

Latex T Tube drain

Latex is used for this indication as it will encourage track formation.

78. A 48 year old lady undergoes a mastectomy and axillary node clearance for an invasive ductal cancer
of the breast with lymph node metastasis.

Redivac suction drain

Suction drains are commonly used following mastectomy and axillary surgery to prevent haematoma
formation. Not all surgeons routinely drain the axilla.

79. A 75 year old man undergoes a hartmans procedure for sigmoid diverticular disease with pericolic
abscess and colovesical fistula.

You answered Penrose tubing

The correct answer is 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.

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 • Consist of small systems such as the lantern style drain that may be used for short
drainage systems 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 trach (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

2/3 Question 80-82 of 89

Theme: Right iliac fossa pathology

A. Appendicitis
B. Mesenteric adenitis
C. Inflammatory bowel disease
D. Irritable bowel syndrome
E. Mesenteric cyst
F. Campylobacter infection
G. Appendix abscess

Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or
not at all.

80. An 8 year old boy is examined by his doctor as part of a routine clinical examination. The doctor
notices a smooth swelling in the right iliac fossa. It is mobile and the patient is otherwise well.

Mesenteric cyst

Theme from April 2012 Exam

Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although
rare, they most often occur in young children (up to 30% present before the age of 15). Many are
asymptomatic and discovered incidentally. Acute presentations are recognised and may occur
following cyst torsion, infarction or rupture. Most cysts will be surgically resected.

81. An 8 year old boy presents with abdominal pain,a twelve hour history of vomiting, a fever of 38.3 oC
and four day history of diarrhoea. His abdominal pain has been present for the past week.

You answered Campylobacter infection

The correct answer is Appendix abscess

The high fever and diarrhoea together with vomiting all point to a pelvic abscess. The presence of
pelvic pus is highly irritant to the rectum, and many patients in this situation will complain of
diarrhoea.

82. A 7 year old boy presents with a three day history of right iliac fossa pain and fever. On examination
he has a temperature of 39.9o C. His abdomen is soft and mildly tender in the right iliac fossa.

Mesenteric adenitis

High fever and mild abdominal signs in a younger child should raise suspicion for mesenteric
adenitis. The condition may mimic appendicitis and many may require surgery.
Right iliac fossa pain

Differential diagnosis

Appendicitis • Pain radiating to right iliac fossa

• Anorexia
• Typically short history
• Diarrhoea and profuse vomiting rare

Crohn's disease • Often long history

• Signs of malnutrition
• Change in bowel habit, especially diarrhoea

Mesenteric adenitis • Mainly affects children

• Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic
Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus
viridans and Yersinia spp.
• Patients have a higher temperature than those with appendicitis
• If laparotomy is performed, enlarged mesenteric lymph nodes will be
present

Diverticulitis • Both left and right sided disease may present with right iliac fossa pain
• Clinical history may be similar, although some change in bowel habit is
usual
• When suspected a CT scan may help in refining the diagnosis

Meckel's diverticulitis • A Meckel's diverticulum is a congenital abnormality that is present in

about 2% of the population
• Typically 2 feet proximal to the ileocaecal valve
• May be lined by ectopic gastric mucosal tissue and produce bleeding

Perforated peptic ulcer • This usually produces upper quadrant pain but pain may be lower
• Perforations typically have a sharp sudden onset of pain in the history

Incarcerated right inguinal • Usually only right iliac fossa pain if right sided or bowel obstruction.
or femoral hernia
Bowel perforation secondary • Seldom localised to right iliac fossa, although complete large bowel
to caecal or colon carcinoma obstruction with caecal distension may cause pain prior to perforation.

Gynaecological causes • Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic

pregnancy/Ovarian torsion/Threatened or complete
abortion/Mittelschmerz

Urological causes • Ureteric colic/UTI/Testicular torsion

Other causes • TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Question 83 of 89
A 56 year old man undergoes a difficult splenectomy and is left with a pancreatic fistula. There are ongoing
problems with very high fistula output. Which of the following agents may be administered to reduce the fistula
output?

A. Metoclopramide

B. Erthyromycin

C. Octreotide

D. Loperamide

E. Omeprazole

Octreotide is a useful agent in reducing the output from pancreatic fistulae. Prokinetic agents will increase
fistula output and should be avoided.

Fistulas

• A fistula is defined as an abnormal connection between two epithelial surfaces.

• There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae
abdominally.
• In general surgical practice the abdominal cavity generates the majority and most of these arise from
diverticular disease and Crohn's.
• As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is
particularly true of intestinal fistulae.

The four types of fistulae are:

Enterocutaneous
These link the intestine to the skin. They may be high (>1L) or low output (<1L) depending upon source.
Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe
excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result
from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or
may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula
following sub total colectomy for colitis.

Suspect if there is excess fluid in the drain.

Enteroenteric or Enterocolic
This is a fistula that involves the large or small intestine. They may originate in a similar manner to
enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate
malabsorption syndromes. This may be particularly serious in inflammatory bowel disease.

Enterovaginal
Aetiology as above.

Enterovesicular
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the
passage of gas from the urethra during urination.

Management
Some rules relating to fistula management:

• They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so
conservative measures may be the best option
• Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin
damage is difficult to treat
• A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to
reduce the volume of pancreatic secretions.
• Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these
may necessitate the use of TPN to provide nutritional support together with the concomitant use of
octreotide to reduce volume and protect skin.
• When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is
present, this almost always worsens outcomes.
• When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain
acute sepsis and maintain that drainage through the judicious use of setons whilst medical management
is implemented.
• Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal
source the use of barium and CT studies should show a track. For perianal fistulae surgeons should
recall Goodsall's rule in relation to internal and external openings.

3/3 Question 84-86 of 89

Theme: Inguinal hernia management

A. Bassini repair
B. Inguinal herniotomy
C. Lichtenstein repair
D. Laparoscopic hernia repair
E. Shouldice repair
F. McVey repair

For the herniae described please select the most appropriate procedure from the list. Each option may be used
once, more than once or not at all.

84. A 11 month old child presents with intermittent groin swelling, it has a cough impulse and is easily
reducible.

Inguinal herniotomy
 Infants usually suffer from a patent processus vaginalis (a congential problem). As a result a simple
herniotomy is all that is required. A mesh is not required as there is not specific muscle weakness.

85. A 25 year old builder presents with a reducible swelling in the right groin, it is becoming larger and
has not been operated on previously.

Lichtenstein repair

An open Lichtenstein repair using mesh is appropriate. There is a 0.77% recurrence rate with this
technique. A Shouldice repair is an acceptable alternative if the surgeon is experienced

86. A 28 year old man presents with a recurrent inguinal hernia on the left side of his abdomen and a
newly diagnosed inguinal hernia on the right side.

Laparoscopic hernia repair

Laparoscopic hernia repairs are specifically indicated where there are bilateral hernias or recurrence
of a previous open repair.

3/3 Question 87-89 of 89

Theme: Surgical access

A. Kocher's
B. Lanz
C. Rooftop
D. Pfannenstiel's
E. Midline
F. Paramedian incision
G. Mcevedy

Please select the most appropriate incision for the procedure described. Each option may be used once, more
than once or not at all.

87. A 19 year old girl who is 39 weeks pregnant goes into labour. The labour is prolonged and she is
found to have an undiagnosed breech baby.

Pfannenstiel's

This patient needs an emergency cesarean section.

88. A 49 year old woman presents with jaundice and abdominal pain. She is haemodynamically unstable.
An USS shows a dilated common bile duct and gallstones in the gallbladder.
 Kocher's

This lady needs a cholecystectomy and bile duct exploration.

89. A 42 year old man with history of alcohol abuse is diagnosed with pancreatic cancer and requires a
Whipples resection.

Rooftop

A pancreatectomy is usually performed through a roof top incision. This provides excellent access to
the upper abdomen.