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SU28.{1-4,18} | Abdominal Wall and Peritoneal Conditions — Graded Quiz
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You are examining a 55-year-old man with a groin swelling. To distinguish an indirect from a direct inguinal hernia at the bedside, you reduce the hernia and apply firm pressure over the deep inguinal ring while he coughs. The swelling is controlled and does NOT reappear. Where is the deep ring located for this manoeuvre?
Correct. The deep (internal) inguinal ring lies about 1.25 cm above the mid-inguinal point; controlling the hernia by pressure here identifies an indirect hernia.
Deep ring = 1.25 cm above the mid-inguinal point. Controlled by deep-ring occlusion → indirect; reappears medially → direct.
The deep ring lies roughly 1.25 cm above the mid-inguinal point; a hernia controlled by pressure there is indirect, while a direct hernia reappears medially despite deep-ring pressure.
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When examining a patient with a groin lump, which single anatomical landmark MUST you establish the swelling's relationship to first, because it separates an inguinal from a femoral hernia?
Correct. An inguinal hernia emerges above and medial to the pubic tubercle, whereas a femoral hernia emerges below and lateral to it; settling the pubic-tubercle relationship first prevents missing a femoral hernia.
Pubic tubercle is the pivotal landmark — inguinal above-and-medial, femoral below-and-lateral. Settle it before anything else.
The pubic tubercle is the key landmark: inguinal = above and medial; femoral = below and lateral. Always settle this first.
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Three weeks after appendicectomy a young man has a swinging (spiking) fever, malaise and deep pelvic ache with mucus-coated stools and tenesmus, but a soft abdomen. CT shows a walled-off fluid collection in the pelvis. What is the principle of management?
Correct. A swinging fever with a walled-off pelvic collection after appendicectomy is an intra-abdominal (pelvic) abscess; pus walled off from the circulation must be drained, with antibiotics as adjunct.
Swinging fever + walled-off collection = abscess → drain it (image-guided/surgical) + antibiotics. Antibiotics alone do not clear pus.
An intra-abdominal abscess must be drained — pus walled off from the bloodstream will not clear on antibiotics alone; image-guided or surgical drainage is the principle.
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A 40-year-old presents with a smooth, mobile central abdominal mass that moves freely in a plane at right angles to the line of the mesentery but is restricted along it. CT confirms a thin-walled cystic lesion in the small-bowel mesentery. Which lesion does this mobility pattern (Tillaux's sign) describe?
Correct. A mesenteric cyst is mobile in the direction perpendicular to the mesenteric attachment but restricted along it (Tillaux's sign) and is treated by enucleation or resection.
Mesenteric cyst: mobile perpendicular to, restricted along, the mesentery (Tillaux's sign); managed by enucleation/resection. Retroperitoneal tumours are fixed and do not move with respiration.
Mobility at right angles to but restricted along the mesentery (Tillaux's sign) is characteristic of a mesenteric cyst, not a fixed retroperitoneal tumour.
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In a patient with generalised peritonitis, which single bedside or imaging finding most directly answers the question 'Is there a surgical source requiring source control?'
Correct. Free gas under the diaphragm indicates a perforated viscus — a surgical source mandating source control — which the other non-specific markers cannot establish.
Free gas under the diaphragm = perforated viscus = surgical source needing source control. It answers 'is there a surgical source?' directly.
Free gas under the diaphragm specifically indicates a perforated viscus and the need for source control; leucocytosis, tachycardia and positive cultures show sepsis but not its surgical source.
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You are differentiating an enlarged spleen from an enlarged left kidney on abdominal examination. Which set of findings supports a SPLEEN rather than a kidney?
Correct. A spleen cannot be 'got above', has a notch, is dull to percussion, moves with respiration toward the right iliac fossa and is not ballotable — distinguishing it from a resonant, ballotable kidney.
Spleen vs kidney: spleen has a notch, is dull, you cannot get above it, enlarges toward the RIF, not ballotable; kidney is resonant and ballotable.
A spleen: no getting above it, has a notch, dull, moves with respiration, not ballotable. A kidney: you can get above it, is resonant (overlying colon) and is bimanually ballotable.
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A patient with strangulated bowel within a hernia is taken for emergency surgery. Once the constricting neck is released and the bowel inspected, which finding mandates resection rather than returning the loop to the abdomen?
Correct. Non-viable bowel — dusky/black, no peristalsis, no return of colour and no mesenteric pulsation after release and warming — must be resected to prevent perforation and sepsis.
After releasing a strangulated loop, assess viability (colour, sheen, peristalsis, mesenteric pulsation after warming). Non-viable bowel must be resected.
Viable bowel regains pink colour, sheen, peristalsis and mesenteric pulsation after release/warming and is returned; bowel that remains dusky and pulseless is non-viable and must be resected.
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