Indirect inguinal hernias have an elliptical shape, unlike direct hernias which are round. They are not easily reducible and do not reduce spontaneously when reclining. Unlike direct hernias that appear immediately, indirect hernias take longer to appear when standing. They are reduced superiorly and then superolaterally, while direct hernias reduce superiorly and posteriorly. Pressure over the deep inguinal ring helps control indirect hernias. However, they are more prone to strangulation due to the narrow neck of the deep inguinal ring.

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, and they are often caused by 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 for 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 approach for 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 cases where the fissure does not heal with conservative measures. It has a success rate of 90%.

The caecum, positioned between the ileum and the ascending colon, serves as the closest segment of the large intestine. It can be found in the right iliac fossa, just below the ileocaecal junction. In case of enlargement, it can be detected through palpation. This structure is situated within the peritoneal cavity.

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

The British Society of Gastroenterology (BSG) has developed guidelines for evaluating cases of acute lower intestinal bleeding in a hospital setting. These guidelines are useful in determining which patients should be referred for further assessment.

When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable is defined as having a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP). For example, if the heart rate is 80 and the systolic blood pressure is 120, the shock index would be 0.66.

For patients with stable bleeds, they should be further classified as either major (requiring hospitalization) or minor (suitable for outpatient management) based on a risk assessment tool. The BSG recommends using 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-terminating 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 outpatient investigation.

Patients with a major bleed should be admitted to the hospital for a colonoscopy, which will be scheduled based on availability.

If a patient is hemodynamically unstable or has a shock index greater than 1 after initial resuscitation, and/or active bleeding is suspected, CT angiography (CTA) should be considered, followed by endoscopic or radiological therapy.

If no bleeding source is identified by initial CTA and the patient is stable, 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 source using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.

Red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/d

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 patient is experiencing a breast abscess that has developed as a result of lactational mastitis. When milk is not properly drained, it can lead to an overgrowth of bacteria and subsequently cause an infection in the breast. If left untreated, this infection can lead to the accumulation of pus in a specific area of the breast. It is estimated that around 5-10% of women with infectious mastitis will develop a breast abscess. The recommended treatment involves a combination of antibiotics, such as flucloxacillin or co-amoxiclav, along with either aspiration or incision and drainage of the abscess.

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.

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

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.

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.

Intussusception occurs when a section of the bowel folds into another section, causing a blockage. This can be due to a specific underlying issue, like a Meckel’s diverticulum, or it can happen without any specific cause. The condition is most commonly seen in boys between the ages of 5 and 10 months. Symptoms include sudden vomiting and episodes of abdominal pain that come and go. The vomit quickly becomes greenish-yellow in color. Dance’s sign, which is the absence of bowel in the lower right part of the abdomen, may be observed. Redcurrant jelly-like stools are a late indication of the condition. It is believed that more than 90% of cases are caused by a non-specific underlying issue, often viral infections like rotavirus, adenovirus, and human herpesvirus 6.

Ascending cholangitis occurs when there is an infection in the common bile duct, often caused by a stone that has led to a blockage of bile flow. This condition is characterized by the presence of Charcot’s triad, which includes jaundice, fever with rigors, and pain in the right upper quadrant of the abdomen. It is a serious medical emergency that can be life-threatening, with some patients also experiencing altered mental status and low blood pressure due to septic shock, known as Reynold’s pentad. Urgent biliary drainage is the recommended treatment for ascending cholangitis.

In acute cholecystitis, Murphy’s sign is typically positive, indicating tenderness in the right upper quadrant when the gallbladder is palpated. However, it is negative in cases of biliary colic and ascending cholangitis. The white cell count and C-reactive protein (CRP) levels are usually elevated in ascending cholangitis, along with the presence of jaundice and significantly increased levels of alkaline phosphatase (ALP) and bilirubin.

To differentiate between biliary colic, acute cholecystitis, and ascending cholangitis, the following can be helpful:

Biliary colic:
– Pain duration: Less than 12 hours
– Fever: Absent
– Murphy’s sign: Negative
– WCC & CRP: Normal
– AST, ALT & ALP: Normal
– Bilirubin: Normal

Acute cholecystitis:
– Pain duration: More than 12 hours
– Fever: Present
– Murphy’s sign: Positive
– WCC & CRP: Elevated
– AST, ALT & ALP: Normal or mildly elevated
– Bilirubin: Normal or mildly elevated

Ascending cholangitis:
– Pain duration: Variable
– Fever: Present
– Murphy’s sign: Negative
– WCC & CRP: Elevated
– AST, ALT & ALP: Elevated
– Bilirubin: Elevated

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

Acute pancreatitis is a common and serious cause of acute abdominal pain. It occurs when the pancreas becomes inflamed, leading to the release of enzymes that cause the organ to digest itself. The symptoms of acute pancreatitis include severe epigastric pain, nausea, vomiting, and pain that may radiate to the T6-T10 dermatomes or shoulder tip due to irritation of the phrenic nerve. Other signs include fever, tenderness in the epigastric area, jaundice, and the presence of Gray-Turner and Cullen signs, which are ecchymosis of the flank and peri-umbilical area, respectively.

To determine the severity of acute pancreatitis, the Ranson criteria are used as a clinical prediction rule. A score greater than three indicates severe pancreatitis with a mortality rate of over 15%. The criteria assessed upon admission include age over 55 years, white cell count above 16 x 109/L, blood glucose level higher than 11 mmol/L, serum AST level exceeding 250 IU/L, and serum LDH level surpassing 350 IU/L.

In this particular case, the patient’s Ranson score is three. This is based on the fact that she is 56 years old, her white cell count is 16.7 x 109/L, and her AST level is 358 IU/L.

A pilonidal sinus is a small cyst found near the crease between the buttocks. It contains a clump of hairs and is most commonly seen in young males with thick, dark hair. This condition is rare in individuals over the age of 40. Several factors increase the risk of developing a pilonidal sinus, including being male, having excessive hair growth, having a job that involves prolonged sitting, being overweight, and having a family history of the condition.

This patient is exhibiting the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this particular case, it is highly likely that the patient has acute appendicitis.

The psoas sign can be observed by extending the patient’s thigh while they are lying on their side with their knees extended, or by asking the patient to actively flex their 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 rub against the inflamed tissues nearby, causing discomfort. This strongly suggests that the appendix is positioned retrocaecal.

The appendix is a slender and curved tube that is attached to the back and middle part of the caecum. It has a small triangular tissue called the mesoappendix that holds it in place from the tissue of the terminal ileum.

Although it contains a significant amount of lymphoid tissue, the appendix does not serve any important function in humans. The position of the free end of the appendix can vary greatly. There are five main locations where it can be found, with the most common being the retrocaecal and subcaecal positions.

The distribution of these positions is as follows:

– Ascending retrocaecal (64%)
– Subcaecal (32%)
– Transverse retrocaecal (2%)
– Ascending preileal (1%)
– Ascending retroileal (0.5%)

Acute cholecystitis occurs when a stone becomes stuck in the outlet of the gallbladder, causing irritation of the wall and resulting in chemical cholecystitis. This leads to the accumulation of pus within the gallbladder, which is typically sterile at first. However, there is a possibility of secondary infection with enteric organisms like Escherichia coli and Klebsiella spp.

The clinical features of acute cholecystitis include severe pain in the right upper quadrant or epigastrium, which can radiate to the back and lasts for more than 12 hours. Fevers and rigors are often present, along with common symptoms like nausea and vomiting. Murphy’s sign is a useful diagnostic tool, as it has a high sensitivity and positive predictive value for acute cholecystitis. However, its specificity is lower, as it can also be positive in biliary colic and ascending cholangitis.

In cases of acute cholecystitis, the white cell count and C-reactive protein (CRP) levels are usually elevated. AST, ALT, and ALP may also show elevation, but they can often be within the normal range. Bilirubin levels may be mildly elevated, but they can also be normal. If there is a significant increase in AST, ALT, ALP, and/or bilirubin, it may indicate the presence of other biliary tract conditions such as ascending cholangitis or choledocholithiasis.

It is important to note that there is some overlap in the presentation of biliary colic, acute cholecystitis, and ascending cholangitis. To differentiate between these diagnoses, the following list can be helpful:

Biliary colic:
– Pain duration: Less than 12 hours
– Fever: Absent
– Murphy’s sign: Negative
– WCC & CRP: Normal
– AST, ALT & ALP: Normal
– Bilirubin: Normal

Acute cholecystitis:
– Pain duration: More than 12 hours
– Fever: Present
– Murphy’s sign: Positive
– WCC & CRP: Elevated
– AST, ALT & ALP: Normal or mildly elevated
– Bilirubin: Normal or mildly elevated

Ascending cholangitis:
– Pain duration: Variable
– Fever: Present
– Murphy’s sign: Negative
– WCC & CRP: Elevated
– AST, ALT & ALP: Elevated

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.