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Question 1
Correct
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A 72-year-old woman comes in with a history of passing fresh red blood mixed in with her last three bowel movements. She is experiencing low blood pressure, and her shock index is calculated to be 1.4.
Which initial investigation is recommended for hospitalized patients with lower gastrointestinal bleeding who are in a state of hemodynamic instability?Your Answer: CT angiography
Explanation:The British Society of Gastroenterology (BSG) has developed guidelines for healthcare professionals who are assessing cases of acute lower intestinal bleeding in a hospital setting. These guidelines are particularly useful when determining which patients should be referred for further evaluation.
When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable patients are defined as those with a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP).
For stable patients, the next step is to determine whether their bleed is major (requiring hospitalization) or minor (suitable for outpatient management). This can be determined using a risk assessment tool called the Oakland risk score, which takes into account factors such as age, hemoglobin level, and findings from a digital rectal examination.
Patients with a minor self-limiting bleed (e.g., an Oakland score of less than 8 points) and no other indications for hospital admission can be discharged with urgent follow-up for further investigation as an outpatient.
Patients with a major bleed should be admitted to the hospital and scheduled for a colonoscopy as soon as possible.
If a patient is hemodynamically unstable or has a shock index greater than 1 even after initial resuscitation, and there is suspicion of active bleeding, a CT angiography (CTA) should be considered. This can be followed by endoscopic or radiological therapy.
If no bleeding source is identified by the initial CTA and the patient remains stable after resuscitation, an upper endoscopy should be performed immediately, as LGIB associated with hemodynamic instability may indicate an upper gastrointestinal bleeding source. Gastroscopy may be the first investigation if the patient stabilizes after initial resuscitation.
If indicated, catheter angiography with the possibility of embolization should be performed as soon as possible after a positive CTA to increase the chances of success. In centers with a 24/7 interventional radiology service, this procedure should be available within 60 minutes for hemodynamically unstable patients.
Emergency laparotomy should only be considered if all efforts to locate the bleeding using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.
In some cases, red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/dL and a target of 7-9 g/d
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This question is part of the following fields:
- Surgical Emergencies
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Question 2
Incorrect
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A child with a history of repeated episodes of painless rectal bleeding is found to have a Meckel’s diverticulum during a colonoscopy.
What is the most frequently observed type of ectopic mucosa in Meckel’s diverticulum?Your Answer: Jejunal
Correct Answer: Gastric
Explanation:A Meckel’s diverticulum is a leftover part of the vitellointestinal duct, which is no longer needed in the body. It is the most common abnormality in the gastrointestinal tract, found in about 2% of people. Interestingly, it is twice as likely to occur in men compared to women.
When a Meckel’s diverticulum is present, it is usually located in the lower part of the small intestine, specifically within 60-100 cm (2 feet) of the ileocaecal valve. These diverticula are typically 3-6 cm (approximately 2 inches) long and may have a larger opening than the ileum.
Meckel’s diverticula are often discovered incidentally, especially during an appendectomy. Most of the time, they do not cause any symptoms. However, they can lead to complications such as bleeding (25-50% of cases), intestinal blockage (10-40% of cases), diverticulitis, or perforation.
These diverticula run in the opposite direction of the intestine’s natural folds but receive their blood supply from the ileum mesentery. They can be identified by a specific blood vessel called the vitelline artery. Typically, they are lined with the same type of tissue as the ileum, but they often contain abnormal tissue, with gastric tissue being the most common (50%) and pancreatic tissue being the second most common (5%). In rare cases, colonic or jejunal tissue may be present.
To remember some key facts about Meckel’s diverticulum, the rule of 2s can be helpful:
– It is found in 2% of the population.
– It is more common in men, with a ratio of 2:1 compared to women.
– It is located 2 feet away from the ileocaecal valve.
– It is approximately 2 inches long.
– It often contains two types of abnormal tissue: gastric and pancreatic.
– The most common age for clinical presentation is 2 years old. -
This question is part of the following fields:
- Surgical Emergencies
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Question 3
Incorrect
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A 3-year-old boy is brought to the Emergency Department with lower abdominal pain and fever. On examination, he has tenderness in the right iliac fossa. He refuses to flex the thigh at the hip, and if you passively extend the thigh, his abdominal pain significantly worsens.
Which clinical sign is present in this case?Your Answer: Murphy’s sign
Correct Answer: Psoas sign
Explanation:This patient is showing the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this case, it is most likely due to acute appendicitis.
To elicit the psoas sign, the thigh of a patient lying on their side with extended knees can be passively extended, or the patient can be asked to actively flex the thigh at the hip. If these movements result in abdominal pain or if the patient resists due to pain, then the psoas sign is considered positive.
The pain occurs because the psoas muscle is adjacent to the peritoneal cavity. When the muscles are stretched or contracted, they cause friction against the nearby inflamed tissues. This strongly suggests that the appendix is retrocaecal in position.
There are other clinical signs that support a diagnosis of appendicitis. These include Rovsing’s sign, which is pain in the right lower quadrant when the left lower quadrant is palpated. The obturator sign is pain experienced during internal rotation of the right thigh, indicating a pelvic appendix. Dunphy’s sign is increased pain with coughing, and Markle sign is pain in the right lower quadrant when dropping from standing on the toes to the heels with a jarring landing.
A positive Murphy’s sign is observed in cases of acute cholecystitis.
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This question is part of the following fields:
- Surgical Emergencies
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Question 4
Correct
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A 60-year-old woman presents with a history of passing fresh red blood mixed in with her last three bowel movements. She has had her bowels open four times in the past 24 hours. On examination, she is haemodynamically stable with a pulse of 80 bpm and a BP of 120/77. Her abdomen is soft and nontender, and there is no obvious source of anorectal bleeding on rectal examination.
Which risk assessment tool is recommended by the British Society of Gastroenterology (BSG) guidelines to assess the severity of stable lower gastrointestinal bleeds?Your Answer: Oakland score
Explanation:The British Society of Gastroenterology (BSG) has developed guidelines for healthcare professionals who are assessing cases of acute lower intestinal bleeding in a hospital setting. These guidelines are particularly useful when determining which patients should be referred for further evaluation.
When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable patients are defined as those with a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP).
For stable patients, the next step is to determine whether their bleed is major (requiring hospitalization) or minor (suitable for outpatient management). This can be determined using a risk assessment tool called the Oakland risk score, which takes into account factors such as age, hemoglobin level, and findings from a digital rectal examination.
Patients with a minor self-limiting bleed (e.g., an Oakland score of less than 8 points) and no other indications for hospital admission can be discharged with urgent follow-up for further investigation as an outpatient.
Patients with a major bleed should be admitted to the hospital and scheduled for a colonoscopy as soon as possible.
If a patient is hemodynamically unstable or has a shock index greater than 1 even after initial resuscitation, and there is suspicion of active bleeding, a CT angiography (CTA) should be considered. This can be followed by endoscopic or radiological therapy.
If no bleeding source is identified by the initial CTA and the patient remains stable after resuscitation, an upper endoscopy should be performed immediately, as LGIB associated with hemodynamic instability may indicate an upper gastrointestinal bleeding source. Gastroscopy may be the first investigation if the patient stabilizes after initial resuscitation.
If indicated, catheter angiography with the possibility of embolization should be performed as soon as possible after a positive CTA to increase the chances of success. In centers with a 24/7 interventional radiology service, this procedure should be available within 60 minutes for hemodynamically unstable patients.
Emergency laparotomy should only be considered if all efforts to locate the bleeding using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.
In some cases, red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/dL and a target of 7-9 g/d
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This question is part of the following fields:
- Surgical Emergencies
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Question 5
Incorrect
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A 42-year-old woman comes in with a gradual onset of severe colicky abdominal pain and vomiting. She has not had a bowel movement today. Her only significant medical history is gallstones. During the examination, her abdomen appears distended, and a mass can be felt in the upper right quadrant. Bowel sounds can be heard as 'tinkling' on auscultation.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Small bowel obstruction
Explanation:Gallstone ileus occurs when a gallstone becomes stuck in the small intestine, specifically at the caeco-ileal valve. This condition presents with similar symptoms to other causes of small bowel obstruction. Patients may experience colicky central abdominal pain, which can have a gradual onset. Vomiting is common and tends to occur earlier in the course of the illness compared to large bowel obstruction. Abdominal distension and the absence of flatus are also typical signs. Additionally, there may be a lack of normal bowel sounds or the presence of high-pitched tinkling sounds. A mass in the right upper quadrant of the abdomen may be palpable.
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This question is part of the following fields:
- Surgical Emergencies
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Question 6
Incorrect
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You evaluate a 35-year-old male patient who has been diagnosed with an anal fissure. He has been undergoing treatment for the last two months, which includes lactulose, senna, topical creams with local anesthetics, and topical GTN ointment. However, his symptoms continue to persist, and he describes the pain during bowel movements as intolerable.
What would be the most suitable next step in managing this patient's condition?Your Answer:
Correct Answer: Botulinum toxin injection
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline. The most common cause is the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management of an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for fissures that do not heal and has a success rate of 90%. Anal dilatation, also known as Lord’s procedure, is rarely used nowadays due to the high risk of subsequent fecal incontinence.
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This question is part of the following fields:
- Surgical Emergencies
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Question 7
Incorrect
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A 65-year-old man presents with unintentional weight loss and a noticeable lump in his abdomen. A CT scan reveals a sizable tumor in the sigmoid colon.
Where is the mass most likely to be felt when palpating the surface marking?Your Answer:
Correct Answer: Left iliac fossa
Explanation:The sigmoid colon is the last segment of the colon and is primarily situated in the left iliac fossa.
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This question is part of the following fields:
- Surgical Emergencies
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Question 8
Incorrect
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A 65-year-old woman comes in with lower abdominal discomfort and rectal bleeding. An abdominal CT scan is conducted and reveals a diagnosis of diverticulitis.
Which part of her large intestine is most likely to be impacted?Your Answer:
Correct Answer: Sigmoid colon
Explanation:Diverticulitis primarily affects the sigmoid colon in about 90% of cases. As a result, it is more commonly associated with pain in the left iliac fossa.
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This question is part of the following fields:
- Surgical Emergencies
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Question 9
Incorrect
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A patient with a previous history of painless rectal bleeding episodes is found to have a Meckel's diverticulum during a colonoscopy.
Which ONE statement about Meckel's diverticulum is accurate?Your Answer:
Correct Answer: They receive their blood supply from the mesentery of the ileum
Explanation:A Meckel’s diverticulum is a leftover part of the vitellointestinal duct, which is no longer needed in the body. It is the most common abnormality in the gastrointestinal tract, found in about 2% of people. Interestingly, it is twice as likely to occur in men compared to women.
When a Meckel’s diverticulum is present, it is usually located in the lower part of the small intestine, specifically within 60-100 cm (2 feet) of the ileocaecal valve. These diverticula are typically 3-6 cm (approximately 2 inches) long and may have a larger opening than the ileum.
Meckel’s diverticula are often discovered incidentally, especially during an appendectomy. Most of the time, they do not cause any symptoms. However, they can lead to complications such as bleeding (25-50% of cases), intestinal blockage (10-40% of cases), diverticulitis, or perforation.
These diverticula run in the opposite direction of the intestine’s natural folds but receive their blood supply from the ileum mesentery. They can be identified by a specific blood vessel called the vitelline artery. Typically, they are lined with the same type of tissue as the ileum, but they often contain abnormal tissue, with gastric tissue being the most common (50%) and pancreatic tissue being the second most common (5%). In rare cases, colonic or jejunal tissue may be present.
To remember some key facts about Meckel’s diverticulum, the rule of 2s can be helpful:
– It is found in 2% of the population.
– It is more common in men, with a ratio of 2:1 compared to women.
– It is located 2 feet away from the ileocaecal valve.
– It is approximately 2 inches long.
– It often contains two types of abnormal tissue: gastric and pancreatic.
– The most common age for clinical presentation is 2 years old. -
This question is part of the following fields:
- Surgical Emergencies
-
-
Question 10
Incorrect
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You review a patient with chronic severe back pain with a medical student that has examined the patient. He feels the most likely diagnosis is lumbar disc herniation. He explains that all five features of Reynold’s pentad are present.
Which of the following does NOT form part of Reynold’s pentad?Your Answer:
Correct Answer: Raised white cell count
Explanation:Ascending cholangitis occurs when there is an infection in the common bile duct, usually caused by a stone that has led to a blockage of bile flow. This condition is known as choledocholithiasis. The typical symptoms of ascending cholangitis are jaundice, fever (often accompanied by chills), and pain in the upper right quadrant of the abdomen. It is important to note that ascending cholangitis is a serious medical emergency that can be life-threatening, as patients often develop sepsis. Approximately 10-20% of patients may also experience altered mental status and low blood pressure due to septic shock. When these additional symptoms are present along with the classic triad of symptoms (Charcot’s triad), it is referred to as Reynold’s pentad. Urgent biliary drainage is the recommended treatment for ascending cholangitis. While a high white blood cell count is commonly seen in this condition, it is not considered part of Reynold’s pentad.
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This question is part of the following fields:
- Surgical Emergencies
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