GI & Surgery 9

oelomar's version from 2016-02-27 15:29


Question Answer
What does carcinoma of the body or tail of the pancreas present with?Carcinoma localised to the body or tail of the pancreas is much more likely to present with abdominal pain as well as non-specific symptoms such as anorexia and weight loss. The pain is often dull in character with radiation through into the back. A characteristic feature is partial relief of pain by sitting forward. Bile duct obstruction and jaundice may infrequently be late phenomena.
What is Courvoisier’s law?Courvoisier's law states that in the presence of an enlarged gallbladder which is non-tender and accompanied with mild jaundice, the cause is unlikely to be gallstones. This sign implicates possible malignancy of the gall bladder or pancreas and the swelling is unlikely due to gallstones.
What investigations can be carried out in someone with carcinoma of the pancreas?Transabdominal ultrasound is the initial investigation but is less reliable in body/tail cancer. Contrast-enhanced spiral CT scan should confirm the presence of a mass lesion, lymph node involvement, and distant metastases. Laparoscopy is also used for pre-operative assessment. CA19-9 tumour marker has a high sensitivity but a high false positive rate.
What is the 5-year survival rate for carcinoma of the pancreas?2-5%.
What is the Whipple procedure and what is it used for?Also known as a pancreaticoduodenectomy. This operation is performed to treat cancerous tumours on the head of the pancreas and malignant tumours involving the common bile duct, duodenal papilla, and duodenum near the pancreas.
What are the different types of neuroendocrine tumour of the pancreas?Insulinoma (50%), gastrinoma (20%), other rare functioning tumours (5%), and non-functioning tumours (25%).
How are neuroendocrine tumours of the pancreas treated?Surgical resection of the pancreatic lesion is the only potential curative approach. Octreotide and lanreotide can be used specifically for the control of symptoms secondary to the hormonal secretion.
What is Zollinger-Ellison syndrome?A condition in which a gastrin-secreting tumour of the pancreas or duodenum causes overproduction of gastric acid resulting in recurrent peptic ulcers.


Question Answer
Perforation within the abdomen gives rise to pain of what character?Sudden onset of diffuse, severe pain.
Obstruction within the abdomen gives rise to pain of what character?Acute onset of severe, radiating, colicky pain.
Inflammation within the abdomen gives rise to pain of what character?Gradual onset (over 10–12 hours) of constant, ill-defined pain.
A family history of abdominal pain should make one suspect what?Familial Mediterranean fever or acute intermittent porphyria (both are hereditary conditions in which there is abdominal pain).
Name some causes of small bowel obstruction.Adhesions from a prior abdominal surgery (60% of cases), hernias (10–20%), neoplasms (10–20%), intussusception (in children), stricture due to IBD, cystic fibrosis, gallstone ileus.
What is intussusception?A medical emergency most often diagnosed in infancy and early childhood in which part of the intestine invaginates into another section of the intestine, often resulting in an obstruction.
How will a patient with small bowel obstruction present?Patients typically experience cramping abdominal pain with a recurrent increase and decrease in intensity at 5- to 10-minute intervals. Vomiting typically follows the pain. In partial obstruction there is continued passage of flatus but no stool, whereas in complete obstruction no flatus or stool is passed (obstipation). Abdominal exam often reveals distention, tenderness, prior surgical scars, or hernias. Bowel sounds are characterised by high-pitched tinkles (later, bowel sounds are absent).
Name some causes of large bowel obstruction.Colon cancer, diverticulitis, volvulus (obstruction caused by twisting of the intestine), faecal impaction (immobile bulk of faeces), benign tumours. Assume colon cancer until proven otherwise.
How will a patient with large bowel obstruction present?Constipation/obstipation, deep and cramping abdominal pain, nausea/vomiting (less than a small bowel obstruction but more commonly faeculent). Abdominal exam reveals significant distention, tympany (swelling of the abdomen with air or gas), and tenderness. Fever or signs of shock suggest perforation/peritonitis. Bowel sounds are characterised by high-pitched “tinkly” sounds (later, bowel sounds are absent).
What may happen if acute appendicitis is left untreated?Gangrene occurs with perforation, leading to a localised abscess or to generalised peritonitis.


Question Answer
What are the clinical features of appendicitis?Most patients present with abdominal pain; in many it starts vaguely in the centre of the abdomen, becoming localised to the right iliac fossa in the first few hours. Nausea, vomiting, anorexia, and occasional diarrhoea can occur. Examination of the abdomen usually reveals tenderness in the right iliac fossa, with guarding due to the localised peritonitis. There may be a tender mass in the right iliac fossa.
Name differential diagnoses for causes of acute pain in the epigastrium.MI, peptic ulcer, acute cholecystitis, perforated oesophagus.
Name differential diagnoses for causes of acute pain in the right upper quadrant.Acute cholecystitis, duodenal ulcer, pyelonephritis, viral hepatitis, congestive hepatomegaly, gallstone ileus.
Name differential diagnoses for causes of acute pain in the left upper quadrant.Ruptured spleen, gastric ulcer, perforated colon, pyelonephritis.
Name differential diagnoses for causes of acute pain in the umbilicus region.Intestinal obstruction, acute pancreatitis, early appendicitis, abdominal aortic aneurysm.
Name differential diagnoses for causes of acute pain in the right lower quadrant.Appendicitis, salpingitis (inflammation of the fallopian tubes), ruptured ectopic pregnancy, renal stone, Meckel’s diverticulum, Crohn’s disease.
Name differential diagnoses for causes of acute pain in the left lower quadrant.Diverticulitis, salpingitis, ruptured ectopic pregnancy.
What is gallstone ileus?Gallstone ileus is a rare form of small bowel obstruction caused by an impaction of a gallstone within the lumen of the small intestine. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum.


Question Answer
What is the most common malignancy in men aged 20-30?Testicular cancer.
What are the classifications of testicular cancer and how are they diagnosed?The two classifications are seminomas and teratomas. Ultrasound is first-line for diagnosis. Otherwise, α-fetoprotein and β-hCG are produced in a seminoma, whereas in a teratoma there is no α-fetoprotein production.
What are the clinical features of testicular cancer?The most common feature is a painless lump. Other features include hydrocele (accumulation of fluids around a testicle) and gynaecomastia.
What is the prognosis like in testicular cancer?Prognosis is excellent. Testicular cancer has one of the highest cure rates of all cancers with an average five-year survival rate of 95%. If the cancer has not spread outside the testicle, the 5-year survival is 99% while if it has grown into nearby structures or has spread to nearby lymph nodes, the rate is 96%.
What are epididymal cysts and how are they diagnosed?An epididymal cyst is a fluid-filled sac which grows at the top end of the testicle. It is benign. It is diagnosed by ultrasound.
What is testicular torsion, what causes it, and what are the symptoms?Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle’s blood supply (ischaemia). The most common underlying cause is a congenital malformation known as a “bell-clapper deformity” (testes inadequately fixed to scrotum). It usually presents with sudden, severe, testicular pain and tenderness. There is often associated nausea and vomiting.
What is the cremasteric reflex and what relevance does it have with testicular torsion?This is a reflex observed in males. This reflex is elicited by lightly stroking or poking the superior and medial part of the thigh - regardless of the direction of stroke. The normal response is an immediate contraction of the cremaster muscle that pulls up the ipsilateral testis. This reflex is lost in an individual with testicular torsion.
What are the features of hydrocele?The swelling is soft and non-tender. The testis may be difficult to palpate if the hydrocele is large. The presence of fluid is demonstrated by trans-illumination with a torch.
How are hydroceles managed?Most hydroceles appearing in the first year of life do not require treatment as they resolve on their own. Hydroceles that persist after the first year or occur later in life require treatment through open operation for removing surgically.
Name some causes of a hydrocele.Hydroceles may develop secondary to epididymo-orchitis, testicular torsion, and testicular tumours.
What is a varicocele and what are its symptoms?A varicocele is an abnormal enlargement of the pampiniform venous plexus in the scrotum, i.e. an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
The majority of varicoceles are on the left side. True or false?True (>80% on left side).
How is a varicocele diagnosed?Palpating a varicocele can be likened to feeling a bag of worms. Doppler ultrasound can also be used or diagnosis. Note that a varicocele does not trans-illuminate like a hydrocele would.
What relevance does the Valsalva manoeuvre have with a varicocele?It can be done to help diagnose a varicocele. Doing the Valsalva manoeuvre will increase intra-abdominal venous pressure, therefore making the veins dilate.
What is a spermatocele?These are small cystic masses separate from the testicles and so can be “got above” and they transluminate. They are harmless.
What is Prehn’s sign?Prehn's sign is a medical diagnostic indicator that helps to determine whether presenting testicular pain is caused by acute epididymitis or from testicular torsion. According to Prehn's sign, the physical lifting of the testicles relieves the pain of epididymitis but not pain caused by testicular torsion. Prehn's sign has been shown to be inferior to Doppler ultrasound to rule out testicular torsion. Negative Prehn’s sign = no pain relief with lifting the affected testicle = more likely to be torsion. Positive Prehn’s sign = pain relief with lifting the affected testicle – more likely to be epididymitis.


Question Answer
What is a hernia and what are its features?The protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Features include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), strangulation (may compromise the bowel blood supply leading to infarction).
Regarding hernias, what is the cough impulse?The cough impulse is a clinical sign that is elicited when examining a hernia. If the swelling expands upon coughing, it is said to have a “cough impulse”. Movement of the swelling without expansion or an increase in tension is not a cough impulse. The presence of an expansile cough impulse is almost diagnostic of a hernia.
What are the features of an inguinal hernia?A groin lump which disappears on pressure or when the patient lies down, discomfort and ache (often worse with activity), severe pain is uncommon, strangulation is rare.
What are haemorrhoids?Haemorrhoids are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become pathological, or piles, also known as haemorrhoidal disease, when swollen or inflamed.
What are the clinical features of haemorrhoidal disease?Painless rectal bleeding (most common symptom), pruritus, pain (usually not significant unless piles are thrombosed).
Internal haemorrhoids are not painful whereas external haemorrhoids are. True or false? Explain your answer.True. Internal haemorrhoids receive visceral innervation and are therefore not painful. External haemorrhoids on the other hand receive somatic innervation (pudendal nerve) and are therefore painful.
How are internal haemorrhoids graded?Grades 1-4. Grade 1: do not prolapse out of the anal canal. Grade 2: Prolapse on defecation but reduce spontaneously. Grade 3: Can be manually reduced. Grade 4: Cannot be manually reduced.
How is haemorrhoidal disease managed?Soften stools: increase dietary fibre and fluid intake. Topical local anaesthetics and steroids may be used to help symptoms. Outpatient treatments: rubber band ligation is superior to injection sclerotherapy. Surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments.
How would a patient with acutely thrombosed external haemorrhoids present?Typically with significant pain. Examination reveals a purplish, oedematous, tender subcutaneous perianal mass.
What are anal fissures?Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal.
How are anal fissures classified into acute or chronic?If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
How are acute anal fissures managed?Dietary advice: high-fibre diet with high fluid intake. Bulk-forming laxatives are first line – if not tolerated then lactulose should be tried. Lubricants such as petroleum jelly may be tried before defecation. Topical anaesthetics can also be used.
How are chronic anal fissures managed?Management for acute anal fissures should be continued. After that, topical GTN is first line treatment for chronic anal fissures. If topical GTN is not effective after 8 weeks then secondary referral should be considered for surgery or botulinum toxin.


Question Answer
What is “elective surgery/procedure”?Elective surgery or elective procedure is surgery that is scheduled in advance because it does not involve a medical emergency.
What is Behcet's disease and what are its cardinal features?Behcet's disease is an inflammatory disorder of unknown cause. The cardinal clinical feature is recurrent oral ulceration.
How is Behcet's disease diagnosed?The international criteria for diagnosis require oral ulceration and any two of either genital ulcers, defined eye lesions, defined skin lesions, or a positive skin pathergy test.