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Hernia and Acute Abdomen MCQ

1. The most common hernia in females is:
A. Femoral hernia.
B. Direct inguinal hernia.
C. Indirect inguinal hernia.
D. Obturator hernia.
E. Umbilical hernia.
Answer: C

DISCUSSION: Indirect inguinal hernias are the most common hernia in both females and males. Femoral hernias are more common in females than in males.




2. Which of the following statements regarding unusual hernias is incorrect?
A. An obturator hernia may produce nerve compression diagnosed by a positive Howship-Romberg sign.
B. Grynfeltt's hernia appears through the superior lumbar triangle, whereas Petit's hernia occurs through the inferior lumbar triangle.
C. Sciatic hernias usually present with a painful groin mass below the inguinal ligament.
D. Littre's hernia is defined by a Meckel's diverticulum presenting as the sole component of the hernia sac.
E. Richter's hernia involves the antimesenteric surface of the intestine within the hernia sac and may present with partial intestinal obstruction.
Answer: C

DISCUSSION: Sciatic hernias usually present with intestinal obstruction or a mass in the gluteal or infragluteal region.


3. Staples may safely be placed during laparoscopic hernia repair in each of the following structures except:
A. Cooper's ligament.
B. Tissues superior to the lateral iliopubic tract.
C. The transversus abdominis aponeurotic arch.
D. Tissues inferior to the lateral iliopubic tract.
E. The iliopubic tract at its insertion onto Cooper's ligament.
Answer: D

DISCUSSION: Placement of staples inferior to (below) the lateral iliopubic tract may result in injury to the lateral femoral cutaneous nerve or the genitofemoral nerve. Staples should also not be placed within the triangle of doom, owing to the risk of major vascular injury.


4. The following Nyhus classification of hernias is correct except for:
A. Recurrent direct inguinal hernia—Type IVa.
B. Indirect inguinal hernia with a normal internal inguinal ring—Type I.
C. Femoral hernia—Type IIIc.
D. Direct inguinal hernia—Type IIIa.
E. Indirect inguinal hernia with destruction of the transversalis fascia of Hesselbach's triangle—Type II.
Answer: E

DISCUSSION: An indirect inguinal hernia with destruction of the transversalis fascia of Hesselbach's triangle is classified as a Type IIIb hernia. Also classified as Type IIIb hernias are sliding, pantaloon, and massive scrotal hernias. Type II hernia is an indirect inguinal hernia with a dilated internal ring but without displacement of the inferior deep epigastric vessels or destruction of the transversalis fascia of Hesselbach's triangle.


5. Which of the following statements about the causes of inguinal hernia is correct?
A. Excessive hydroxyproline has been demonstrated in the aponeuroses of hernia patients.
B. Obliteration of the processus vaginalis is a contributing factor for the development of an indirect inguinal hernia.
C. Physical activity and athletics have been shown to have a protective effect toward the development of inguinal hernias.
D. Elevated levels of circulating serum elastalytic activity have been demonstrated in patients with direct herniation who smoke.
E. The majority of inguinal hernias are acquired.
Answer: D

DISCUSSION: A correlation between cigarette smoking and an inguinal hernia formation has been demonstrated. Elevated circulating serum elastalytic activity and free active unbound neutrophil elastase has been detected in smokers.


6. The following statements about the repair of inguinal hernias are true except:
A. The conjoined tendon is sutured to Cooper's ligament in the Bassini hernia repair.
B. The McVay repair is a suitable option for the repair of femoral hernias.
C. The Shouldice repair involves a multilayer, imbricated repair of the floor of the inguinal canal.
D. The Lichtenstein repair is accomplished by prosthetic mesh repair of the inguinal canal floor in a tension-free manner.
E. The laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal approach (TEPA) repairs are based on the preperitoneal repairs of Cheattle, Henry, Nyhus, and Stoppa.
Answer: A

DISCUSSION: The Bassini repair is accomplished by high ligation of the hernia sac followed by suturing the conjoined tendon and the internal oblique muscle to the inguinal ligament.

7. Which of the following statements concerning the abdominal wall layers are correct?
A. Scarpa's fascia affords little strength in wound closure.
B. The internal abdominal oblique muscles have fibers that continue into the scrotum as cremasteric muscles.
C. The transversalis fascia is the most important layer of the abdominal wall in preventing hernias.
D. The lymphatics of the abdominal wall drain into the ipsilateral axillary lymph nodes above the umbilicus and into the ipsilateral superficial inguinal lymph nodes below the umbilicus.
Answer: ABCD

DISCUSSION: The integrity of the abdominal wall is maintained principally by the transversalis fascia. Scarpia's fascia affords little strength in wound closure, but its approximation contributes considerably to the creation of an aesthetically acceptable scar. The cremasteric muscles of the spermatic cord are a continuation of muscle fibers from the internal abdominal oblique musculature. The lymphatic supply of the abdominal wall follows a simple pattern. These superficial lymphatics run parallel to the superficial veins, which above the umbilicus drain into the ipsilateral axillary vein and below it into the ipsilateral femoral vein.


8. Which of the following congenital abnormalities are correctly defined?
A. Omphalocele represents a defect in the abdominal wall lateral to the umbilical cord.
B. The herniated viscera associated with omphaloceles are usually covered with a membranous sac.
C. An umbilical polyp is a small excrescence of omphalomesenteric duct mucosa that is retained in the umbilicus.
D. Meckel's diverticulum results when the intestinal end of the omphalomesenteric duct persists and represents a true diverticulum.
Answer: BCD

DISCUSSION: Omphalocele may be seen in newborns and represents a defect in the closure of the umbilical ring. The herniated viscera are usually covered with a sac. Gastroschisis, a defect of the abdominal wall lateral to the umbilical cord, is caused by failure of closure of the body wall. The intestines protrude through the defect, and no sac is present to cover the herniated intestine. In the fetus, the omphalomesenteric duct may present as abnormalities related to the abdominal wall when the duct fails to obliterate. Meckel's diverticulum is the result of the failure of obliteration of the intestinal end of the omphalomesenteric duct. This is a true diverticulum with all layers of the intestinal wall represented. An umbilical polyp is a small excrescence of omphalomesenteric duct mucosa retained in the umbilicus. Such polyps resemble umbilical granulomas except that they do not disappear after silver nitrate cauterization. Appropriate treatment is excision of the mucosal remnant.


9. The following statement(s) is/are true concerning the indications for treatment of an inguinal hernia.

a. Most adult hernias will remain stable in size, therefore delay seldom affects the technical aspects of a surgical repair
b. There is a direct correlation between the length of time that a hernia is present and the risk of major complications
c. The morbidity and mortality associated with emergent operation due to hernia complications is significantly greater than for elective repair of the identical hernia
d. A truss maintains a hernia in the reduced state, therefore, minimizing the risk of incarceration and strangulation
Answer: b, c

The indications for hernia repair must be individualized for each patient and the particular situation. In general, the presence of a hernia may be considered an adequate indication for hernia repair. Certainly the presence of complications due to hernia necessitates the correction of those complications and usually the repair of the hernia. As with any treatment, the benefits of operative repair must be weighed against the natural history of the disease, the extent to which the treatment can correct the problem, the possibility of treatment-related injury, and the interference of concomitant disease with the treatment results. With a few exceptions, the natural history of an abdominal wall hernia is that the size of the defect and the sac enlarges over time, and this enlargement increases the difficulty of adequate repair and the chances of recurrence of the hernia. The risk of major complications is greater in an individual patient, the longer the exposure to a hernia and the larger the sac relative to the hernia defect. In addition, major complications necessitate an emergent operation with attended high mortality and morbidity relative to that experienced with an elective repair. The use of a truss, an external support device using a system of straps to exert regional pressure over the hernia defect, should generally be avoided. Trusses do not consistently maintain a hernia in the reduced state, and they may put an unreduced hernia in greater jeopardy of strangulation. The pressure exerted induces edema by decreasing lymphatic and venous flow out of the herniated bowel. Trusses may also lead to injury to the skin overlying the hernia.


10. Which of the following statement(s) is/are true concerning the diagnosis and management of epigastric hernias?

a. A large peritoneal sac containing abdominal viscera is common
b. At the time of surgical repair, a careful search for other defects should be performed
c. Recurrent epigastric hernias after simple closure is uncommon
d. Patients with symptoms of a painful midline abdominal mass frequently will contain incarcerated small bowel
Answer: b

Epigastric hernias are usually small but they vary considerably in size. Most of these defects occur in the midline. The small defects contain only preperitoneal fat with no sac. With increasing size, fat in the falciform ligament and eventually a peritoneal sac and abdominal viscera may be contained within the hernia. The preperitoneal fat in the small defect is usually incarcerated. Multiple defects may be present in up to 20% of patients. Surgical treatment is recommended in all adult patients with symptoms or with a hernia defect greater than 1.5 to 2 cm. in diameter. Methods of repair depend upon the size of the defect. For small defects, simple closure with obliquely placed sutures after reduction or removal of the preperitoneal fat from the defect has been recommended. However recurrent epigastric hernias in up to 10% of the cases have been reported with this method, most likely as a result of additional undetected or unrepaired weaknesses in the epigastric midline.


11. The following statement(s) is/are true concerning neurovascular structures in the inguinal region.

a. The inferior epigastric artery and vein run upward in the preperitoneal fat posterior to the transversalis fascia close to the lateral margin of the internal inguinal ring
b. The iliohypogastric and ilioinguinal are motor and sensory nerves in the inguinal region which lie beneath the external oblique aponeurosis
c. The ilioinguinal nerve runs anterior to the spermatic cord in the inguinal canal and at the superficial inguinal ring, branches into the sensory supply to the pubic region and the upper scrotum or labium majoris
d. The genital branch of the genitofemoral nerve is a sensory nerve only to the upper thigh and genital area
Answer: b, c

Arising anteriorly from the external iliac artery, the inferior epigastric artery with its accompanying vein runs obliquely medially and upward in the preperitoneal fat, posterior to the transversalis fascia and close to the inferior margin of the internal inguinal ring. Inguinal hernias arising superior to the inferior epigastric vessels are indirect inguinal hernias, whereas those arising inferior to the vessels are direct inguinal hernias. The iliohypogastric and ilioinguinal nerves are motor and sensory nerves to the muscles and skin of the inguinal region. The nerves penetrate the transversus abdominis muscle at the point above the middle of the iliac crest, lie below the internal oblique muscle up to the point just medial and superior to the anterior superior iliac spine, and then penetrate the internal oblique muscle and lie below the external oblique aponeurosis. The ilioinguinal nerve runs anterior to the spermatic cord in the inguinal canal and at the superficial inguinal ligament, branches into sensory supply to the pubic region and the upper scrotum or labium majoris. The genital branch of the genitofemoral nerve perforates the transversalis fascia usually just inferior to the internal ring. It courses along the posterior surface of the spermatic cord and supplies motor fibers to the cremaster muscle. At the superficial inguinal ring, it divides to provide sensory innervation to the scrotum and medial aspect of the upper thigh.


12. In advising a patient preoperatively of potential complications of operative treatment of an inguinal hernia, which of the following statement(s) is/are true?

a. Severe symptoms due to sensory nerve entrapment or injury can occur
b. The most common vascular structure injured during the course of a groin hernia repair is the femoral artery
c. Recurrent hernia after primary groin repair should occur in less than 10% of cases
d. Wound infection increases the risk of recurrent hernia
Answer: a, c, d

Many complications can occur with operations to repair an inguinal hernia. Sensory nerve injury may lead to disabling symptoms from neuromas or nerve entrapment during inguinal hernia repair. Although vascular injuries are uncommon in inguinal repair, the proximity of the femoral vein to the structures used in the hernia repair makes injury of this vessel the most frequent vascular injury observed. Hernia recurrence after primary groin hernia repairs should be infrequent and varies in several large series from less than one percent to almost nine percent. The prevalence of recurrent hernia may be higher after repair of recurrent groin hernia. Factors responsible for hernia recurrence include closure under excessive tension, failure to identify and use an adequately strong musculoaponeurotic tissue, and wound infection.


13. Chylous ascites is the accumulation of chyle within the peritoneal cavity. Which of the following statement(s) is/are true concerning chylous ascites?

a. The cisterna chyli lies at the anterior surface of the first and second lumbar vertebrae and receives lymphatic fluid from the mesenteric lymphatics
b. Chylous ascites is most commonly associated with abdominal lymphoma
c. Paracentesis and analysis of chylous fluid typically reveals elevated triglycerides, protein, and leukocyte levels with cytologic analysis reflecting the underlying presence of malignancy
d. Treatment of chylous ascites with dietary manipulation will be successful in most cases
e. The mortality rate in adults with chylous ascites is in excess of 50%
Answer: a, b, e

Chylous ascites is accumulation within the peritoneal cavity of chyle, a lymphatic fluid with a high lipid content. Access of intestinal lipids to the circulation is via mesenteric lymphatics that enter the cisterna chyle, which in turn becomes the thoracic duct which eventually enters the venous system at the junction of the left subclavian and internal jugular veins. The cisterna chyli lies at the anterior surface of the first and second lumbar vertebrae slightly to the right of the aorta. Chylous ascites may result from injury to major lymphatic duct or the cisterna. However for lymphatic leakage to persist, widespread occlusion of lymphaticovenous collaterals within the abdomen must be present. Malignancy is the predominant cause (88%) of spontaneous chylous ascites in adults, with lymphoma the most common malignancy. Diagnostic studies must include not only documentation of lymphatic origin of the abdominal fluid but also an attempt to delineate the cause of chylous ascites. Paracentesis and analysis of chylous fluid typically reveals elevated triglycerides, protein, and leukocyte levels, with a predominance of lymphocytes. Unfortunately, cytology is seldom positive despite the presence of malignancy. Lymphangiography may define the site of lymphatic leak for patients in whom the leak is from the cisterna or retroperitoneal lymphatics but not when from the mesenteric or hepatic lymphatics. Of noninvasive studies, CT is the test of choice, with a high diagnostic yield in nontraumatic chylous ascites in adults. Frequently, laparotomy with node biopsy is required for histology and typing in cases suspected to be cancer, particularly for lymphoma. Treatments for chylous ascites have been directed toward decreasing lymph and triglyceride accumulation. Successful resolution of chylous ascites has been achieved using a fat-restricted diet with added medium-chain triglycerides in an attempt to reduce lymphatic transport of triglycerides and perhaps intestinal lymph flow. Although there have been reports of success using such dietary manipulation, many failures have been reported. Therefore, in most patients with chylous ascites, treatment is likely to be successful only when directed toward the underlying cause. For patients with lymphoma, therapy effective against lymphoma is likely to eliminate chylous ascites.
The prognosis for patients with chylous ascites is much better in infants and children than in adults, principally because of the differences in causes of the condition. A mortality of 21% is reported in infants and children whereas a mortality of 88% has been noted in adults. Patients with chylous ascites with associated neoplasms typically have the gravest prognosis.


14. Which of the statement(s) is/are true concerning laparoscopic hernia repair?

a. General anesthesia is required
b. Either an abdominal or preperitoneal approach is possible
c. The use of prosthetic mesh is required in all variations
d. Long-term results suggest that the laparoscopic approach is equal or better than traditional repairs
Answer: a, b, c

The laparoscopic approach to the repair of groin hernias has been recently developed. Either a transabdominal approach, wherein the peritoneum in the inguinal area is opened, and the repair is performed in the preperitoneum or an entirely preperitoneal approach can be used. In either technique, which are both performed under general anesthesia, after reducing the visceral contents out of the hernia, the repair is performed by placing a sheet of prosthetic mesh over the internal aspect of the inguinal floor and internal ring. Although early results and short-term benefits appear promising, long-term follow-up data is still not available to compare these techniques with traditional repairs.


15. A 28-year-old woman with a history of an appendectomy presents with a nontender palpable mass in the right lower quadrant abdominal incision. The following statement(s) is/are true concerning the diagnosis and management of this patient.

a. The best diagnostic test involves imaging of the abdominal wall by either CT or MRI
b. Resection of the mass with a 2 cm margin is usually adequate
c. Low dose radiation is a suitable alternative to surgery for primary treatment
d. Re-resection for recurrence will likely have a higher rate of recurrence than for primary resection
Answer: a

Desmoid tumors are fibromatous tumors that may resemble low-grade fibrosarcoma but never metastasize. The tumor often infiltrates adjacent muscle and has a high incidence of recurrence despite seemingly adequate gross resection. The highest frequency is in women of childbearing age of which over 90% of tumors are abdominal in location. For abdominal wall desmoid tumors, approximately one-third are associated with a previous operation at the tumor site. The most frequent presenting symptom is a nontender, palpable abdominal wall mass. Diagnostic imaging is best carried out by CT or MRI, which delineate the extent of involvement of the layers of the abdominal wall and potential intraperitoneal extension. Initial treatment of abdominal wall desmoid tumors is surgical. Because the margins of the tumor are not easily determined and because the tumor often infiltrates muscle and periosteum, limited margins around the gross tumor frequently result in microscopic tumor at the margin. Recurrence rates for abdominal desmoid tumors vary from 9% to 40%, and recurrence is frequent with inadequate margins. A 5-cm margin of resection is considered adequate with mono bloc resection of rib cage, pubic or iliac bone or involved portions of organs such as bladder to achieve these margins. Reconstruction of the abdominal wall with polypropylene mesh is necessary in most cases. In patients in whom adequate margins of resection are achieved, there is no benefit from adjuvant radiotherapy. Second and third resections after recurrence have been associated with no higher rate of recurrence than primary resection. Radiotherapy alone has achieved local control in desmoid tumor in as many as 100% of tumors treated primarily and 75% of recurrent tumors. Radiation doses at least 60 Gy are considered necessary for consistent control. The large radiation dose risks major damage to adjacent bowel and therefore primary radiation treatment of abdominal wall desmoid tumors has a limited role.


16. Which of the following statement(s) is/are true concerning repair of inguinal hernias?

a. The Bassini repair approximates the transversus abdominis aponeurosis and transversalis fascia and the shelving edge of the inguinal ligament.
b. The Bassini repair is an adequate repair for a femoral hernia
c. A relaxing incision is important for repairs of direct and large indirect inguinal hernias to prevent excessive tension in the closure
d. An advantage to the use of prosthetic material is the mesh incites formation of scar tissue to further increase tensile strength provided by the mesh alone
Answer: a, c, d

The Bassini repair is an inguinal hernia repair used world-wide and has been the standard against which other repairs are judged. The repair involves approximation of the transversus abdominis aponeurosis and transversalis fascia and the lateral edge of the rectus sheath to the shelving edge of the inguinal ligament. A femoral hernia cannot be repaired by the Bassini repair because the orifice to the femoral canal lies deep to the inguinal ligament. A Cooper’s ligament repair does approximate the structures to the transversalis fascia of the pectineal (Cooper’s) ligament between the pubic tubercle and the femoral vein and therefore is appropriate for repair of a femoral hernia. A relaxing incision for repairs of direct and large indirect inguinal hernias prevents excessive tension in the closure. There are an increasing number of proponents for the use of prosthetic material for the routine repair of inguinal hernias. Prosthetic material, such as polypropylene mesh, have been used for years for repair of large or recurrent inguinal and femoral hernias. The prosthetic mesh provides a low-tension repair for such large defects which otherwise could not be closed without excessive tension. In addition, the mesh incites the formation of scar tissue to further increase tensile strength beyond that provided by mesh alone. Results reported for inguinal hernia repairs using mesh have been excellent, although there is a slight risk of infection of the prosthetic material which must be considered.


17. The following statement(s) is/are true concerning the epidemiology of inguinal hernias.

a. Inguinal hernias occur with a male-to-female ratio of about 7:1
b. Femoral and umbilical hernias are more common in women, with a female-to-male ratio of 4:1
c. The frequency of inguinal hernias increases with age
d. Almost all umbilical hernias occur in the pediatric age group
Answer: a, c

Inguinal hernias are the most frequently occurring hernia by a factor of five over other individual types. Umbilical hernias constitute about 14% of hernias, femoral hernias about 5%, and other types are rare. There is a male prevalence in inguinal hernias of about 7:1 (male-to-female), whereas there is a female dominance in femoral and umbilical hernias of 8:1 and 7:1 (female-to-male), respectively. For inguinal hernia, which occurs at all age levels, frequency increases with age. Umbilical hernias have a bimodal distribution, peaking in the pediatric population and then in the 40 to 60 year group, in which the hernias are principally paraumbilical.


18. A 77-year-old multiparous female presents with a bowel obstruction. She has no previous abdominal operations and no abdominal wall hernias can be detected. In addition to her abdominal symptoms, she reports pain in her right medial thigh. The following statement(s) is/are true concerning her diagnosis and management.

a. Expectant management with nasogastric suction and IV fluid replacement is indicated
b. A right groin approach is indicated for exploration and repair of the presumed hernia
c. The use of a polypropylene mesh will likely be necessary for repair
d. A correct diagnosis can usually be made by visualizing an external mass in the upper, medial thigh
Answer: c

An obturator hernia is a hernia that occurs through the obturator canal, accompanied by the obturator vessels and the obturator nerve. Although rare, most obturator hernias occur in older multiparous women and are predominantly right-sided. Symptoms are frequently intermittent but tend to be acute and become increasingly severe with incarceration of the hernia. Intestinal symptoms predominate, but dysesthesia or pain in the medial thigh with occasional radiation to the hip is often present. Dysesthesia results from compression of either division of the obturator nerve. Although the hernia is never externally visible, in a small percentage of patients a mass can be palpated in the upper, medial thigh. A correct diagnosis of obturator hernia is made in only about one-third of patients presenting with intestinal obstruction. Plain radiographs are seldom helpful, however a CT scan will usually confirm the diagnosis. Treatment is operative. There is no place for expectant therapy, especially in a patient with pain an parasthesias along the inner aspect of the thigh or with clinical or radiographic evidence of bowel obstruction. Many surgical approaches have been promoted, but the transabdominal approach should be used because it has several advantages. It best confirms the diagnosis and exposes the obturator canal, orifice, vessels, and nerve, also permitting bowel resection when required. The sac is dealt with in a standard fashion. The hernia defect should be repaired, but repair usually requires a polypropylene mesh patch because the margin of the defect cannot be approximated primarily.


19. The following statement(s) is/are true concerning umbilical hernias in adults.

a. Most umbilical hernias in adults are the result of a congenital defect carried into adulthood
b. A paraumbilical hernia typically occurs in multiparous females
c. The presence of ascites is a contraindication to elective umbilical hernia repair.
d. Incarceration is uncommon with umbilical hernias
Answer: b

An umbilical hernia in a child is usually considered to be congenital. Only about 10% of umbilical hernias in adults are thought to be the result of a congenital defect carried into adulthood. Most adult umbilical hernias are acquired and are called paraumbilical hernias. The paraumbilical hernia typically occurs in a multiparous female. Other patients with increased intraabdominal pressure, particularly with concomitant chronic abdominal distension as from ascites, are also at increased risk for the development of paraumbilical hernias. Umbilical and paraumbilical hernias vary from small to extremely large. Incarceration is frequent in the large hernias, which typically have a small neck.
Indications for umbilical hernia repair in adults include symptoms, incarceration, large hernia relative to the neck, and trophic changes in the overlying skin. Among adults with associated ascites, repair is advocated to avoid potentially serious complications. The presence of discoloration or ulceration of overlying skin or a rapid increase in size of the hernia herald impending rupture. Spontaneous rupture of the hernia in these patients can be catastrophic and is frequently associated with mortality rates approaching 30%. By comparison, elective umbilical hernia repair can be performed safely in patients with ascites with acceptable morbidity and mortality.


20. Retroperitoneal fibrosis is a fibrosing condition of retroperitoneum, which is of significance as it generally encompasses the ureters and eventually causes hydronephrosis and kidney damage. Which of the following statement(s) is/are true concerning this condition?

a. The majority of cases are idiopathic in nature
b. A history of use of methysergide for treatment of migraine headaches would be significant
c. There is no known association of malignancy with retroperitoneal fibrosis
d. The disease occurs more commonly in women than in men
Answer: a, b

Retroperitoneal fibrosis is a rare condition in which fibrosis develops in the retroperitoneal space. The ureters frequently will become encompassed by the process eventually causing hydronephrosis and kidney damage. Retroperitoneal fibrosis occurs most commonly in the fifth and sixth decades with a 2:1 male-female predominance. The pathophysiology of retroperitoneal fibrosis remains to be delineated. In fully two-thirds of cases, retroperitoneal fibrosis is idiopathic, however, an autoimmune process has been suggested as a potential cause. About 12% of cases of retroperitoneal fibrosis have been associated with the use of methysergide, a serotonin agonist used for vascular and migraine headache, and in this subgroup females outnumber males 2:1. Primary or metastatic malignancy in the retroperitoneum is found in 8% of patients with retroperitoneal fibrosis. Sarcomas are the most common primary tumors, but non-Hodgkin and Hodgkin lymphomas and ureteral cancer have also been found. Metastases have originated from cancer of the stomach, breast, colon, carcinoid, pancreas, prostate, ovary, and cervix. The focus of tumor may be small but may induce desmoplasia that is grossly indistinguishable from benign variance of retroperitoneal fibrosis.


21. The following statement(s) is/are true concerning the anterior abdominal wall musculature.

a. The lateral musculature of the abdominal wall consists of three muscle layers. These are, from external to internal, the external oblique, the transversus abdominis, and the internal oblique muscles
b. The transversalis fascia lies on the deep side of the transversus muscle and extends to form an essentially complete fascial envelope of the abdominal cavity
c. Above the semicircular line, the internal oblique aponeurosis splits into posterior and anterior laminae
d. The rectus abdominis muscles originate on the ribs superiorly and on the pubis inferiorly and are clearly distinct throughout their entire length
Answer: b, c

The anterior abdominal wall consists of a group of lateral sheet-like muscles and paired, longitudinally-oriented flat muscles on either side of the midline. The lateral musculature of the abdominal wall consists of three layers, each of which has its fascicles running in an oblique angle to the others. The most superficial of these lateral muscles is the external oblique muscle. The internal oblique muscle lies deep to the external oblique muscle while the transversus abdominis muscle is the innermost of the lateral abdominal wall musculature. The transversalis fascia lies on the deep side of the transversus muscle and extends to form an essentially complete fascial envelope of the abdominal cavity. The semicircular line is defined by the lower edge of the posterior sheath about 3 to 6 cm below the level of the umbilicus, and its convexity is directed superiorly. Above the semicircular line, the internal oblique aponeurosis splits into posterior and anterior laminae. The posterior lamina joins with the transversus abdominis aponeurosis to form the posterior rectus sheath. The anterior lamina fuses with the external oblique aponeurosis to form the anterior rectus sheath. Below the semicircular line, the internal oblique end transversus abdominis aponeurosis fuse to form an internal lamina of the anterior sheath, with the external oblique aponeurosis forming the external lamina of the anterior sheath. The medial paired rectus abdominis muscles originate on the ribs superiorly and on the pubis inferiorly. Below the semicircular line, the rectus muscles are nearly fused in the midline and indistinct, and their posterior surfaces covered only with the transversalis fascia.


22. A 48-year-old woman maintained on Warfarin for a history of cardiac valvular replacement and a history of recent upper respiratory infection presents with severe abdominal pain exacerbated by movement. Her physical examination shows tenderness in the right paramedian area with voluntary guarding but no peritoneal signs. The following statement(s) is/are true concerning the diagnosis and management of this patient.

a. Urgent laparotomy should be performed because of concern for arterial mesenteric embolus
b. The correct diagnosis could likely be made by CT scan and operation avoided
c. The status of her anticoagulation should be checked and if her prothrombin time is excessively prolonged, correction is necessary
d. If untreated, hemodynamic instability is common
Answer: b, c

Rectus sheath hematoma results from arterial or venous bleeding into the rectus sheath, most commonly from arterial bleeding. Rectus sheath hematomas predominate in women by a ratio of about 3:1. The mean age of incidence is in the late fifth decade. Although spontaneous formation of a rectus hematoma is rare, it can occur with vasculitis, arterial venous malformations, a severe coagulopathy, or with the administration of anticoagulants. The usual cause is trauma. Events as trivial as sneezing, coughing, or twisting to the side have initiated a rectus hematoma. Abdominal pain is almost always described at presentation. Pain is often described as severe and usually is exacerbated by movements that require muscular contraction of the abdominal wall. On examination, there is tenderness over the rectus sheath, voluntary guarding, and often a diffuse mass sensation in the area of tenderness. Contraction of the rectus muscle exacerbates the pain and tenderness. Peritoneal signs are absent. Ecchymosis may occur but usually appears several days after the onset of pain. In cases where the hematoma dissects or originates inferiorly and expands into the prevessicle and preperitoneal space, the hematocrit may fall significantly; however, hemodynamic instability is distinctly unusual. When the intraabdominal source of pain is unknown, ultrasound and particularly computed tomography can delineate the hematoma and localize it to the abdominal wall in almost all cases.
Treatment must take into consideration the cause, if known, and whether the hematoma is stable or progressive. Coagulopathy should be corrected when possible. For patients in whom the hematoma is stable, pain medication and avoidance of muscular stress on the abdominal wall are sufficient. For patients with progressive hematoma, the treatment of choice is evacuation of the hematoma from within the rectus sheath and hemostasis, sometimes requiring ligation of the epigastric vessels above and below the hematoma.


23. True statements concerning the diagnosis and management of retroperitoneal fibrosis include:

a. Most patients present with dull, non-colicky back, flank, or abdominal pain
b. Evidence of impaired renal function with an elevated blood urea nitrogen is common
c. The diagnosis is most commonly suggested by intravenous pyelography although contrast studies with CT scan or MRI are useful in further defining the disease
d. Most patients can be managed nonoperatively
e. The prognosis for nonmalignant retroperitoneal fibrosis is grim with progression of disease until death occurring in most patients
Answer: a, b, c

Ninety percent of patients with retroperitoneal fibrosis present with dull, non-colicky pain in the back, flank, or abdomen. Other symptoms include weight loss, non-specific gastrointestinal complaints, and uncommonly, lower extremity edema, malaise, and dysuria. Laboratory studies may be normal in 25% of patients, but 55% of patients will have an elevated blood urea nitrogen. Diagnosis is most commonly suggested by intravenous pyelography. The combination of medial deviation of the ureter, hydroureteronephrosis, and extrinsic ureteral compression are highly suggestive of retroperitoneal fibrosis. CT scanning or MRI can both define the level of ureteral involvement and depict the mass appearance of the fibrotic process. Exploratory laparotomy with multiple deep biopsies of the retroperitoneal process is an essential part of diagnosis, since foci of carcinoma may be sparse within the predominately sclerotic reaction.
Treatment for retroperitoneal fibrosis must identify and deal with potential causative agents, relieve the ureteral obstruction, and reverse the inflammatory-fibrotic process. Renal obstruction may need to be relieved acutely, either by retrograde ureteral stents or by percutaneous nephrostomy tubes. Long-term resolution of ureteral obstruction most frequently has been accomplished by operative freeing of the ureters from the fibrosis and displacing them laterally or within the peritoneal cavity. Although renal function is improved in more than 90% of cases so treated, in as many as one-third of patients, ureteral obstruction recurs on the ipsilateral or contralateral side. Prognosis for patients with nonmalignant retroperitoneal fibrosis is good. Survivals of 86–100% for several years have been reported.


24. The following statement(s) is/are true concerning incarceration of an inguinal hernia.

a. All incarcerated hernias are surgical emergencies and require prompt surgical intervention
b. Attempt at reduction of an incarcerated symptomatic hernia is generally considered safe
c. Vigorous attempts at reduction of an incarcerated hernia may result in reduction en masse with continued entrapment and possible progression to obstruction or strangulation
d. Incarcerated hernias frequently cause both small and large bowel obstruction
Answer: b, c

Hernia incarceration denotes the condition wherein viscera are contained within a hernia sac and cannot be disgorged from the sac. Patients with an incarcerated hernia may be asymptomatic except for the presence of a bulge. Pain associated with an incarcerated hernia should be interpreted as indicative of strangulation. Many hernias are of such size that they cannot be reduced either spontaneously or manually. If the patient is asymptomatic, elective surgery should be planned. In a patient with pain, attempt at reduction is relatively safe as long as excessive force is not applied. An incarcerated hernia with discomfort or signs of bowel obstruction is best treated with urgent hernia repair, although gentle attempts at reduction may be without consequences. Reduction of a symptomatic hernia may result in reduction of gangrenous bowel into the peritoneal cavity. Reduction of bowel with necrotic areas eventuates in bowel perforation and peritonitis with an associated 10% to 30% mortality and high levels of morbidity. Vigorous attempts at reduction may result in reduction en masse, in which the viscera remain within the peritoneal sac after reduction with the entire sac and its contained viscera forced through the abdominal wall defect into the preperitoneal layer. Reduction en masse usually occurs when a small fibrous neck traps enclosed viscera and is associated with a high risk of continued entrapment and progression to obstruction or strangulation.
World-wide hernias are the leading cause of intestinal obstruction. The obstruction is almost exclusively small intestinal with only rarely the colon as the site of obstruction.


25. A careful history is necessary in all patients being considered for inguinal hernia repair. Symptoms which deserve investigation and appropriate treatment prior to proceeding with inguinal hernia repair include:

a. Chronic cough
b. Urinary hesitancy and straining
c. Change in bowel habit
d. A specific episode of muscular straining with associated discomfort
Answer: a, b, c

The history and physical examination are almost exclusively the diagnostic modalities used for diagnosis and delineation of hernias. Chronic trauma in the form of overstretching of musculoaponeurotic structures is likely to be the significant factor in spontaneously occurring hernias. Failure to recognize underlying pathology contributing to symptoms of abdominal straining may both increase the risk of recurrent hernia as well as miss significant existing pathology. A chronic cough from chronic obstructive pulmonary disease should be investigated and attempts made to control symptoms. Significant obstructive uropathy may warrant urologic consultation and treatment prior to hernia repair. Such treatment is important both to prevent postoperative urinary retention, as well as persistent straining on the newly-completed repair. Change in bowel habits with constipation or the presence of blood associated with bowel movements may suggest a rectal or left-sided colon cancer. Patients frequently relate a specific episode of muscular straining during which a sudden discomfort occurs followed by hernia symptoms of discomfort or a bulge. There is little evidence to suggest that such a specific acute event can precipitate a hernia. A history of heavy lifting is important, however, in both planning of postoperative disability as well as consideration for long-term recurrence rates.


26. The following statement(s) is/are true concerning abdominal incisional hernias.

a. Large incisional hernias are associated with a high recurrence rate when closed primarily
b. A large potential space remains anterior to the abdominal wall closure in most patients indicating a need for postoperative wound drainage
c. The use of prosthetic mesh can often be avoided by employing relaxing incisions in the anterior fascia parallel to the midline
d. Incisional hernias are frequently associated with a tissue deficit either due to chronic retraction and scarring or the result of tissue necrosis from either infection or tension at the initial closure
Answer: a, b, c, d

Repair of an incisional hernia can be difficult with several factors making these hernias particularly challenging. First, incisional hernias are often related to a postoperative wound infection, in which case associated fascitis or muscle necrosis may result in loss of tissue. Second, a previous abdominal wall closure under tension or with a technique that resulted in tension on particular sutures may lead to a multifenestrated region of the musculoaponeurotic abdominal wall near or slightly back from its margin. Third, chronic retraction of the abdominal wall muscles result in a larger defect. Fourth, a large potential space remains anterior to the abdominal wall closure in the subcutaneous area; postoperative fluid accumulation in this space contributes to the wound infection rate of 5%. Any such potential space should have operatively placed drains.
The key to successful repair involves sufficient dissection and exposure of the true musculoaponeurotic edge and exclusion of adjacent musculoaponeurotic defects and avoidance of closing the wound under tension. Large defects greater than 3 to 4 cm in diameter are seldom able to be closed without excessive tension. The use of relaxing incisions decreases tension and may be particularly useful in midline hernias and therefore may avoid the need for prosthetic mesh.


27. Which of the following structures are derived from the external oblique muscle and its aponeurosis?

a. The inguinal or Poupart’s ligament
b. The lacunar ligament
c. The superficial inguinal ring
d. The conjoined tendon
Answer: a, b, c

The external oblique muscle and its aponeurosis, with its inferiorly and medially-directed fascicles and the overlying innominate fascia lie deep to the subcutaneous tissue. The inguinal ligament (Poupart’s ligament) is the inferior edge of the external oblique aponeurosis and extends from the anterior superior iliac spine to the pubic tubercle, turning under itself posteriorly and then superiorly to form a shelving edge. Medially, the inguinal ligament turns under even further to form the lacunar ligament, as part of its insertion on the pubis. The superficial inguinal ring is a triangular opening in the external aponeurosis, with its apex superiorly in position slightly above and lateral to the pubic tubercle, through which the cord exits the inguinal canal. The conjoined tendon is commonly alluded to in descriptions of inguinal hernia repairs. The conjoined tendon is the fusion of the aponeurosis of the internal oblique and transversus abdominis muscles.


28. A number of special circumstances exist in the repair of inguinal hernias. The following statement(s) is/are correct.

a. Simultaneous repair of bilateral direct inguinal hernias can be performed with no significant increased risk of recurrence
b. The preperitoneal approach may be appropriate for repair of a multiple recurrent hernia
c. A femoral hernia repair can best be accomplished using a Bassini or Shouldice repair
d. Management of an incarcerated inguinal hernia with obstruction is best approached via laparotomy incision
Answer: b

The approach to bilateral groin hernias is based on the extent of the hernia defect. For hernias for which inguinal floor reconstruction is required (all direct and moderate to large indirect inguinal hernias, all femoral hernias), simultaneous repair of bilateral hernia results in recurrence of one or both of the hernias twice as frequently as if the hernias were repaired sequentially. Repair of recurrent inguinal or much less commonly femoral hernias can be repaired via an anterior approach particularly at the time of first recurrence in most cases. If a deficit of aponeurotic tissue exists, methods such as polypropylene mesh as an overlay or preferably as an underlay, and tailored around the spermatic cord have proved highly successful. The preperitoneal approach also has potential benefits especially in cases of multiple recurrence where the technique allows avoidance of the inevitable scar encountered with the anterior approach, excellent assessment of the defect, and the ease for placement of synthetic mesh. The Bassini and Shouldice repairs involve approximation of the medial tissues of the transversus abdominis aponeurosis and transversalis fascia to the inguinal ligament. These techniques cannot be used to repair a femoral hernia because the femoral canal lies deep to the inguinal ligament. Either the anterior approach of McVay (Cooper’s ligament repair) or a preperitoneal approach is preferred for femoral hernias. In patients with bowel obstruction attributed to a hernia, the primary operative approach is on the hernia. Assessment of bowel viability is possible without laparotomy in most cases, and release of adhesions holding the bowel within the sac is more easily accomplished through direct entry into the hernia sac. Reduction of the herniated and incarcerated bowel may be difficult from the intraabdominal approach necessitating a counter incision over the external presentation of the hernia.


29. Which of the following statements concerning intraperitoneal fluid collections are correct?
A. Ascites occurs when either the peritoneal fluid secretion rate increases or the absorption rate decreases.
B. Accumulation of lymph within the peritoneal cavity usually results from trauma as tumor involving the intra-abdominal lymphatic structures.
C. Choleperitoneum (intraperitoneal bile) generally occurs following biliary surgery, but spontaneous perforation of the bile duct has been reported.
D. The most common cause of hemoperitoneum is trauma to the liver or spleen.
Answer: ABCD

DISCUSSION: Normally, there is a balance between fluid secretion and absorption in the peritoneal cavity. Ascites occurs when either the secretion rate increases or the absorption rate decreases disproportionately. Accumulation of lymph in the peritoneal cavity usually results from trauma or tumor involving lymphatic structures. Proposed treatment regimens range from salt restriction and diuretics to surgical ligation and peritoneovenous shunting. Uninfected bile is a mild irritant to the peritoneal cavity and causes increased production of peritoneal fluid, resulting in bile ascities or choleperitoneum. Most cases of choleperitoneum follow biliary tract surgery, but cases of spontaneous bile duct perforation have been reported in infants and some adults. The most common cause of hemoperitoneum is trauma to the liver or spleen. Less common causes include ruptured ectopic pregnancy, ruptured aortic aneurysms, and other intra-abdominal injuries.


30. The following statement about peritonitis are all true except:
A. Peritonitis is defined as inflammation of the peritoneum.
B. Most surgical peritonitis is secondary to bacterial contamination.
C. Primary peritonitis has no documented source of contamination and is more common in adults than in children and in men than in women.
D. Tuberculous peritonitis can present with or without ascites.
Answer: C

DISCUSSION: Peritonitis is inflammation of the peritoneum and can be septic or aseptic, bacterial or viral, primary or secondary, acute or chronic. Most surgical peritonitis is secondary to bacterial contamination from the gastrointestinal tract. Primary peritonitis refers to inflammation of the peritoneal cavity without a documented source of contamination. It is more common in children than in adults and in women than in men. The female predominance is felt to be explained by entry of organism into the peritoneal cavity through the fallopian tubes. The clinical manifestations of tuberculous peritonitis are of two types. The moist form consists of fever, ascites, abdominal pain, and weakness. The dry form presents in a similar manner but without ascites.


31. True or false?
A. Mesenteric cysts are most often due to congenital lymphatic spaces that gradually fill with lymph.
B. Mesenteric cysts usually present as abdominal masses accompanied by pain, nausea, or vomiting.
C. Mesenteric cysts are best treated by marsupialization.
D. Omental cysts are frequently asymptomatic unless they undergo torsion.
Answer: A-TRUE, B-TRUE, C-FALSE, D-TRUE

DISCUSSION: Mesenteric cysts are most often due to congenital lymphatic spaces that gradually enlarge as they fill with lymph. They generally present as abdominal masses accompanied by pain, nausea, and vomiting. They usually can be diagnosed by physical examination and have characteristic lateral mobility. They are best treated by surgical excision, and intestinal resection may be necessary for complete removal. Omental cysts are frequently asymptomatic but may present with vague discomfort or as a mobile abdominal mass that can cause torsion of the omentum. Torsion generally presents with signs and symptoms compatible with acute cholecystitis, appendicitis, or a twisted ovarian cyst. Treatment entails local resection.


32. Which of the following statements about acute salpingitis are true?
A. The disease rarely occurs after menopause.
B. Gonococcal infection is most common.
C. There is minimal cervical tenderness to palpation.
D. Vaginal discharge occurs rarely.
Answer: AB

33. Acute appendicitis is most commonly associated with which of the following signs?
A. Temperature above 104؛ F.
B. Frequent loose stools.
C. Anorexia, abdominal pain, and right lower quadrant tenderness.
D. White blood cell count greater than 20,000 per cu. mm.
Answer: C

34. Which of the following most often initiates the development of acute appendicitis?
A. A viral infection.
B. Acute gastroenteritis.
C. Obstruction of the appendiceal lumen.
D. A primary clostridial infection.
Answer: C

DISCUSSION: The majority of patients with acute appendicitis have an obstructed lumen that is due to either hyperplasia of the lymph follicles in the wall of the appendix or a fecalith. The obstruction creates a site where the bacteria in the lumen multiply rapidly, producing exotoxins and endotoxins that then ulcerate the mucosa, allowing pathogenic organisms to enter the wall of the appendix. An inflammatory process follows that can extend to the serosa, and penetration through the serosal layer causes generalized peritonitis.


35. The diagnosis of acute appendicitis is most difficult to establish in:
A. Persons aged 60 and older.
B. Women aged 18 to 35.
C. Infants younger than 1 year.
D. Pregnant women.
Answer: C

DISCUSSION: It is very difficult to establish a firm diagnosis of acute appendicitis in an infant of 1 year or younger since the patient cannot provide a history or be helpful during the physical examination. It is rare to make a definitive diagnosis preoperatively in such infants, and in such cases the appendix is usually perforated at the time of operation. While appendicitis is somewhat more difficult to diagnose in the elderly because of the reduced response to inflammation; nevertheless, it is usually possible to make the diagnosis. With pregnant women it is wise to remember that the enlarging uterus in the last trimester dislocates the appendix higher in the abdomen and that the signs and symptoms follow this anatomic shift accordingly.


36. Once a diagnosis of acute appendicitis has been made and appendectomy decided upon, which of the following is/are true?
A. Prophylactic antibiotics should be administered.
B. Prophylactic antibitics are not necessary unless there is evidence of perforation.
C. If the appendix is not ruptured and not gangrenous, antibiotics may be discontinued after 24 hours.
D. Multiple antibiotics are in all cases preferable to a single agent.
Answer: AC

DISCUSSION: It is generally held that patients with a diagnosis of acute appendicitis should receive antibiotics such as cefoxitin or cefotetan. Administration can be discontinued after 24 hours if the appendix is not gangrenous or ruptured. Multiple antibiotics are unnecessary in straightforward cases.


37. The best type of x-ray to locate free abdominal air is:
A. A posteroanterior view of the chest.
B. A flat and upright view of the abdomen.
C. Computed tomograph (CT) of the abdomen.
D. A lateral decubitus x-ray, right side up.
Answer: D

38. The most helpful diagnostic radiographic procedure in small bowel obstruction is:
A. CT of the abdomen.
B. Contrast study of the intestine.
C. Supine and erect x-rays of the abdomen.
D. Ultrasonography of the abdomen.
Answer: C

39. The most commonly used imaging method for diagnosis of acute cholecystitis is:
A. CT of the abdomen.
B. Ultrasonography of the gallbladder.
C. Oral cholecystogram.
D. Radionuclide (HIDA) scan of the gallbladder.
Answer: B

40. Acute salpingitis occurs most often:
A. After menopause.
B. In patients with unilateral lower abdominal pain.
C. During the menstrual cycle.
D. In patients with cervical tenderness and vaginal discharge.
Answer: D

41. Meckel's diverticulitis most often occurs in the:
A. Proximal jejunum.
B. Distal jejunum.
C. Proximal ileum.
D. Distal ileum.
Answer:D

42. A patient is seen in the emergency room with reproducible right lower quadrant tenderness. The approximate incidence of finding a normal appendix on right lower quadrant exploration in similar nonselected patients is which of the following:

a. 5%
b. 10%
c. 20%
d. 40%
Answer: c

Appendectomy is the most common surgical procedure performed on an emergency basis in Western medicine. Appendicitis has a negative appendectomy rate of approximately 22% to 26% in broad based reviews. The perforation rate is as low as 3.6% in a subset of young males, although this rises substantially when the children or the elderly are included. Likewise, young females represent a group at particularly high risk for other intraabdominal pathology.


43. Of adult patients presenting to the emergency room for evaluation of acute abdominal pain, which one of the following answers includes the most common diagnoses?

a. Urologic problems, cholelithiasis, pelvic inflammatory disease
b. Mittelschmerz, appendicitis, ureterolithiasis
c. Nonspecific abdominal pain, appendicitis, intestinal obstruction
d. Appendicitis, pelvic inflammatory disease, perforated ulcer
Answer: c

Numerous surgical causes exist for the patient presenting with acute abdominal pain. A recent review of nearly 1200 patients presenting for emergency evaluation of abdominal pain affords some interesting findings. The most common diagnosis was nonspecific abdominal pain, occurring in 35% of patients. Appendicitis (17%), intestinal obstruction (15%), urologic problems (6%), and gallstones (5%) were the leading surgical causes. The largest number of admissions occurred in the age groups 10–29 years old (31%) and 60–79 years old (29%). Surgical procedures were required in 47% of these patients. Large series of elderly patients presenting with acute abdominal pain have found the leading diagnoses to be cholelithiasis, nonspecific pain, malignancy, incarcerated hernia, ileus, and gastroduodenal ulcer.


44. Nonsurgical causes of acute abdominal pain may include which of the following?

a. Hyperthyrodism
b. Adrenal insufficiency
c. Pneumonia
d. Diabetic ketoacidosis
Answer: b, c, d
Many nonsurgical problems cause acute abdominal pain. A partial listing is provided above. Of the choices in question, the only one that is not associated with acute abdominal pain is hyperthyroidism. The remainder cause abdominal pain through a variety of mechanisms, both direct and indirect.
NONSURGICAL CAUSES OF THE ACUTE ABDOMEN

METABOLIC
Diabetic ketoacidosis
Porphyria
Adrenal insufficiency
Uremia
Hypercalcemia

TOXIC
Insect bites
Venoms (scorpion, snake)
Lead poisoning
Drugs

MISCELLANEOUS
Hemolytic crises
Rectus sheath hematoma

NEUROGENIC
Herpes zoster
Abdominal epilepsy
Spinal cord tumor, infection
Nerve root compression

CARDIOPULMONARY
Pneumonia
Myocardial infarction
Myocarditis
Empyema
Costochondritis


45. Which of the following cause visceral pain from the abdominal organs?

a. Stretching and contraction
b. Traction, compression, torsion
c. Cutting
d. Certain chemicals
Answer: a, b, d

Abdominal pain can be divided into three categories; visceral, somatic, and referred. The intramural sensory receptors of the abdominal organs are responsible for visceral pain. A diverse group of destructive stimuli to the abdominal viscera are painless. For example, almost all abdominal organs are insensitive to pinching, burning, stabbing, cutting, and electrical and thermal stimulation. The same is true for the application of acid and alkali to normal mucosa.
The general classes of visceral stimulation that result in abdominal pain include: (1) stretching and contraction; (2) traction, compression, and torsion; (3) stretch alone; and (4) certain chemicals. Mediating receptors for these responses are located intramurally in hollow organs, on serosal structures such as the visceral peritoneum and capsule of solid organs, within the mesentery and the mucosa. These receptors are polymodal, or responsive to both mechanical and chemical stimuli. Mucosal receptors respond primarily to chemical stimulation. Visceral pain almost always heralds intra-abdominal disease but may not indicate the need for surgical therapy. When visceral pain is superceded by somatic pain, the need for surgical intervation becomes likely.


46. Factors which may influence the clinical presentation of intraabdominal pathology include which of the following?

a. Pregnancy
b. Oral anticoagulants
c. Age
d. HIV infection
Answer: a, b, c, d

A variety of conditions influence the presentation of intraabdominal pathology. Pregnancy is among these, principally because of displacement of adjacent normal viscera and therefore a shift in the location of the parietal pain. Oral anticoagulation is associated with the development of spontaneous intramural hematomas of the bowel causing pain but not requiring surgical resection. This pain may be confused with a variety of other intraabdominal emergencies.
Age is likewise a confounding factor, generally in infancy and in the elderly. In these age groups, the symptoms may be less pronounced and the presentations occur later in the course of disease.
Immunocompromised patients are a heterogenous group that includes those receiving allografts, chemotherapy, immunosuppressive drugs for autoimmune disorders, and individuals with the acquired immunodeficiency syndrome (AIDS). This group has a variety of specific abdominal complications that must be appreciated and suspected by the evaluating physician.
ACUTE ABDOMINAL PAIN ASSOCIATIONS IN THE
IMMUNOCOMPROMISED PATIENT

CYTOMEGALOVIRUS INFECTION
Interstitial pneumonitis
Mononucleosis
Pancreatitis
Hepatitis
Cholecystitis
Gastrointestinal ulceration

PANCREATITIS
Steroids
Azathioprine
Cytomegalovirus
Pentamidine

HEPATITIS
Hepatitis A, B, and C
Cytomegalovirus
Epstein-Barr virus

CHOLECYSTITIS
Cytomegalovirus
Acalculous cholecystitis
Campylobacter

HEPATOSPLENIC ABSCESS
Fungal
Mycobacterial
Protozoal
Splenic rupture

BOWEL PERFORATION
Lymphoma, leukemia (especially after chemotherapy)
Cytomegalovirus
Colon ulcers
Kaposi sarcoma
Pseudomembranous colitis
Mycobacteria
latrogenic

ACUTE GRAFT-VERSUS-HOST DISEASE

PSEUDOACUTE ABDOMEN

FECAL IMPACTION

STANDARD ABDOMINAL PROCESSES
Appendicitis
Cholecystitis
Diverticulitis
Bowel obstruction
Ulcer disease
Pelvic inflammatory disease
Perirectal abscess
Urinary tract infection
Lymphadenitis

NEUTROPENIC ENTEROCOLITIS


47. Prospective studies have shown incidental appendectomy to be advantageous in which of the following patient groups?

a. Children undergoing staging laparotomy for malignancy who are then to enter chemotherapy
b. HIV infected patients
c. Patients over 50 years of age
d. Patients with spinal cord injuries
e. None of the above
Answer: e

Several studies have looked at incidental appendectomies in a variety of populations. The deficiency in all past studies of this issue is the lack of prospective long-term trials to assess the true cost and benefit.
Incidental appendectomy is clearly not indicated in the elderly and in patients undergoing laparatomy for staging of Hodgkin’s disease. These two specific groups have been shown to have increased perioperative risks with incidental appendectomy. No prospective studies have addressed the issue of HIV infected or spinal cord injured patients. While incidental appendectomies may be performed safely in general, it is difficult to justify any increase in operative risk without demonstrable benefit.


48. Visceral pain is typically:

a. Well localized
b. Sharp
c. Mediated via spinal nerves
d. Perceived to be in the midline
Answer: d

Peritoneum is a continuous visceral and parietal layer. The nerve supply to each layer is separate. The visceral layer, i.e., the layer surrounding all intraabdominal organs, is supplied by autonomic nerves (sympathetic and parasympathetic) and the parietal peritoneum is supplied by somatic innervation (spinal nerves). The pathways relaying the sensation of pain differ for each layer and differ in quality as well. Visceral pain is characteristically dull, crampy, deep, aching and may involve sweating and nausea. Parietal pain is sharp, severe and persistent. Visceral organs have very little pain sensation, but stretching of the mesentery and stimulation of the parietal peritoneum cause severe pain.
Normal embryologic development of the abdominal viscera proceeds with bilateral midline autonomic innervation that results in visceral pain usually being perceived as arising from the midline. Epigastric pain is typical of foregut origin. Periumbilical pain signifies pain emanating from the midgut. Hypogastric or lower abdominal midline pain indicates a hindgut origin.


49. True statements regarding the pathophysiology of acute appendicitis include which of the following:

a. Fecaliths are responsible for the disease process in approximately 30% of adult patients
b. Lymphoid hyperplasia is a rare cause of appendicitis in young patients
c. Clostridium difficile is implicated as a pathogenic organism
d. Carcinoid tumors account for approximately 5% of all cases of acute appendicitis
Answer: a

The most common cause of appendicitis is obstruction of the appendiceal lumen. In young children and young adults, the most common cause of lumenal obstruction is lymphoid hyperplasia from the submucosal follicles which are abundant. Lymphoid hyperplasia accounts for 60% of acute appendicitis in the young. In adults, fecalith formation accounts for approximately 30% of acute appendicitis. There is no known causative relationship of Clostridium difficile or other specific organisms with acute appendicitis. The normal flora of the appendix is consistent with that of the adjacent cecum.
Neoplasms of the appendix are rare, occurring in 1% to 1.3% of all appendectomy specimens. Carcinoid tumors are the most common, followed in frequency by benign and malignant mucoceles.


50. A 26-year old woman in her first trimester of pregnancy presents with a 2-day history of right lower quadrant pain and fever. Physical examination reveals a tender, palpable, right lower quadrant mass. There is no evidence of peritonitis or systemic sepsis. Laboratory evaluation is remarkable for mild leukocytosis, and abdominal ultrasound demonstrates an inflammatory mass but no evidence of abscess. As the surgeon on call, your recommendation would be:
a.
b. Intravenous hydration, antibiotic prophylasis, and urgent appendectomy
c. Intravenous hydration, antibiotics, bowel rest, and interval appendectomy in 4 to 6 weeks
d. Intravenous hydration, antibiotics, and appendectomy if no improvement in 12 to 24 hours
e. Intravenous hydration, antibiotics, and interval appendectomy when fever has subsided, leukocyte count has returned to normal, and the patient is pain free
f. Emergent obstetrical consultation for evaluation and treatment of possible ectopic pregnancy
Answer: a

The patient presented has a perforated appendix with a phlegmon, but no abscess. One must routinely provide resuscitation and broad spectrum antiobiotic coverage in this circumstance. As she is not systemically toxic, it would be rational in a nonpregnant patient to treat this patient nonoperatively initially and follow this with interval appendectomy. However, in this circumstance, the risk of preterm labor associated with anesthesia and pelvic inflammation increases with more advanced gestation, so the best decision is to proceed with intravenous hydration, broad spectrum antibiotic coverage and urgent appendectomy.


51. True statements regarding appendiceal neoplasms include which of the following?

a. Carcinoid tumors of the appendix less than 1.5 cm are adequately treated by simple appendectomy
b. Appendiceal carcinoma is associated with secondary tumors of the GI tract in up to 60% of patients
c. Survival following right colectomy for a Dukes’ stage C appendiceal carcinoma is markedly better than that for a similarly staged colon cancer at 5 years
d. Mucinous cystadenocarcinoma of the appendix is adequately treated by simple appendectomy, even in patients with rupture and mucinous ascites
e. Up to 50% of patients with appendiceal carcinoma have metastatic disease, with the liver as the most common site of spread
Answer: a

Carcinoids represent two-thirds of all appendiceal neoplasms. Nearly half of all GI carcinoids arise in the appendix at a mean age of 41 years. Two-thirds of the time the carcinoid is only incidentally detected, only 0.5% have evidence of distant metastatic spread at resection. In one experience, carcinoids between 1.5 and 2.0 cm have had minimal metastatic potential and those smaller than 1.5 cm never metastasized. In the 1% that are larger than 2 cm however, metastases are frequent and 80% recur even after resection at this size.
Adenocarcinoma of the appendix is exceedingly rare. These tumors occur in elderly patients at the base of the appendix. Appendicitis often follows and the diagnosis is not made preoperatively and is rarely considered during surgery since the appearance of the tumor may mimic perforated appendicitis. Up to half the patients have metastatic disease at diagnosis and the peritoneum is the most common site of spread. Survival is proportional to tumor stage. Dukes’ Stage A disease may be treated simply with appendectomy if all disease can be removed with reasonable margins. Dukes’ B and C lesions require formal right hemicolectomy for disease control. Survival is, stage for stage, similar to colon cancer after 5 years. Appendiceal adenocarcinomas also appear to have an association with secondary tumors, often of the GI tract, in up to 35% of patients.
Patients with mucinous cystadenocarcinoma of the appendix typically are symptomatic, and wide resection of the primary disease, together with debulking of peritoneal implants, is indicated. Indolent progression of metastases commonly results in prolonged survival rates (50% at 5 years) during which patients may require repeated laparatomies for complications of the disease.

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