Regarding appendicitis, which ONE of the following statements is most CORRECT?
Answer: A: In retrocaecal appendicitis the pain may be localised to the flank. Pregnant women with appendicitis may present with right flank or right upper quadrant pain as the gravid uterus may displace the appendix. In males acute appendicitis can present with testicular pain if the appendix lies in a retroileal position. Appendicitis can also cause suprapubic pain and the sensation of the need to defaecate if the appendix lies in the pelvis.
Table below illustrates the MANTRELS scoring system (Alvarado score) for acute appendicitis. Patients with a score of 7 points or higher should be referred to surgery as the probability of acute appendicitis is 50%. If the score is < 7, the probability is 5%.
MANTRELS SCORE:
The perforation rate is high in children under the age of 5 because appendicitis is commonly misdiagnosed. Signs of peritonitis in a young child can be vague and the child may present with lethargy or hypothermia. In elderly patients most cases of appendicitis are perforated at the time of surgery. This is attributed to delayed presentation, atypical presentation and age-related anatomical changes of the appendix.
References:
Which ONE of the following is the MOST LIKELY diagnosis for a 68-year-old male who presents to the emergency department (ED) with a history of left lower quadrant abdominal pain and tenderness, low-grade fever and altered bowel habit?
Answer: D: Diverticulitis is the most common clinical presentation of diverticular disease. It is more common in the older age group. It presents with left lower quadrant abdominal pain and tenderness, low-grade fever and a history of altered bowel habit. Occasionally pain can be right-sided. Diverticulae accounts for 40% of all lower gastrointestinal bleeds.
Pyelonephritis is more likely to present with urinary symptoms such as frequency, dysuria and urgency, fever and rigors. Pain is usually in the flank rather than the lower quadrant.
The diagnosis of irritable bowel syndrome is based on clinical presentation – both history and examination – because there are no diagnostic investigations able to provide the diagnosis. It is characterized by abdominal pain that is usually eased by defaecation, changes in bowel habit, changes in stool consistency and other features such as bloating. It is not usually associated with a fever. Romes II criteria assists with the diagnosis of irritable bowel syndrome and consists of symptoms for 12 weeks or more plus two or more of:
Sigmoid volvulus more frequently occurs in patients who have chronic constipation. The presentation is that of abdominal distension and generalized abdominal tenderness.
An elderly patient with atrial fibrillation presents with acute severe abdominal pain, nausea and vomiting. Which ONE of the following would MOST support the diagnosis of acute mesenteric ischaemia?
Answer: C: Acute mesenteric ischaemia can present in a variety of ways. Nausea and vomiting occurs in about 75% of patients, and diarrhoea in about 50%. The patient can have a low-grade fever and poorly localized abdominal pain that radiates to the back. Classically, the pain is out of keeping with the physical findings on examination and often refractory to analgesia. The WCC may be normal initially; however, it usually rises to >15,000 cells/mm3 . Elevated lactate is a late sign and if it remains within normal limits then another diagnosis should be sought. Metabolic acidosis is a non-specific late sign. Often the abdominal X-ray is normal; however, the following features if present suggest the diagnosis of acute mesenteric ischaemia:
Approximately 50% of cases of acute mesenteric ischaemia are due to arterial embolism, 20% arterial thrombosis, 20% non-occlusive mesenteric ischaemia and 10% venous thrombosis.
Patient A is more likely to have bowel obstruction. Classic features of bowel obstruction are nausea, vomiting, abdominal distention and obstipation. Patient B is more likely to have a perforated appendicitis. Pain initially in the right lower quadrant, now generalized with fever, nausea and vomiting, suggests perforated appendicitis.
Patient D has acute pancreatitis. Lipase may be elevated in acute mesenteric ischaemia, however, at much lower levels than in acute pancreatitis. The presence of umbilical bruising can be seen in pancreatitis and is known as Cullen’s sign.
A 56-year-old male patient presents to the ED with acute abdominal pain. He is a smoker and takes aspirin for a heart condition. He has severe, constant epigastric pain that radiates to the left shoulder. He has associated vomiting but no haematemesis. On examination his vital signs are HR 104, BP 135/89, RR 22, temp 37.2°. He has rebound tenderness on palpation of the abdomen. Erect chest X-ray (CXR) demonstrates a small amount of free air under the diaphragm.
Which ONE of the following describes the MOST appropriate management?
Answer: D: This patient has a perforated peptic ulcer. The peak age for perforated peptic ulcer is between 40–60 years and the incidence of duodenal perforation is 7–10 per 100,000 people per year. The perforation site typically involves the anterior wall of the duodenum (60%). Less commonly the perforation may occur in the antral region of the stomach (20%) or the lesser curvature of the stomach (20%). Duodenal ulcers are more commonly found in the Western population and gastric ulcers more predominantly in the Asian community. Gastric ulcers are associated with higher morbidity and mortality.
The patient in the question has two risk factors identified from the stem – aspirin and smoking. Risk factors for peptic ulcers include:
The pain from a perforated duodenal ulcer is of sudden onset and the sharp pain is first noticed in the epigastric region; however, it can rapidly become generalized. The pain can radiate to the back or to the shoulders (due to sub-phrenic air). About 50% of patients with a perforated peptic ulcer will experience vomiting. A mild tachycardia is common; hypotension and fever are usually late signs. Free air under the diaphragm is visible on erect CXR in 80–85% of cases.
Other complications of peptic ulcers include:
Upper gastrointestinal bleeding (from rupturing into an artery)
Penetration – similar to perforation only the ulcer ruptures into another organ (gastric ulcer may rupture into the liver, a duodenal ulcer may erode into the pancreas)
Gastric outlet obstruction occurs in approximately 2% and is a result of oedema and scarring at the gastroduodenal junction.
Management of this patient in the ED should concentrate on fluid resuscitation and maintaining an adequate blood pressure. The patient should be kept nil by mouth and a nasogastric tube should be inserted. Intravenous broad-spectrum antibiotics and a proton pump inhibitor should be administered. An urgent surgical opinion should be sought.
What ONE of the following is the MOST common cause of small bowel obstruction (SBO) in the adult population?
Answer: B: Postoperative adhesions are responsible for small bowel obstruction (SBO) in more than 50% of cases in the developed world. It has been found that adhesions have a higher incidence following intestinal and gynaecological surgeries. Hernias and neoplasms are each responsible for 15% of cases of SBO.
Gallstone ileus is more common in older patients and accounts for 25% of cases of non-strangulated SBO in those over 65 years of age.
Although intussusception is frequently associated with young infants and children, it can occur in the adult population and contributes to 5% of SBO in adults. The aetiology is more likely to be mechanical (90% cases). Tumours, malignant or benign are responsible for 65% of adult intussusceptions.
Obturator hernia is an uncommon cause of SBO in adults. It is frequently diagnosed when it causes SBO.
Click to expand