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SU28.13-17 | Intestinal, Appendicular and Anorectal Surgery — Practice Quiz
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A 45-year-old man with previous open appendicectomy presents with colicky central abdominal pain, early bilious vomiting, abdominal distension and absolute constipation. A plain abdominal film shows central gas-filled loops with valvulae conniventes crossing the full lumen. What is the most likely cause of his obstruction?
Central loops with valvulae conniventes that cross the whole lumen indicate small-bowel obstruction; with previous abdominal surgery, adhesions are the commonest cause. Early vomiting and modest distension also fit SBO.
SBO: central loops, valvulae conniventes crossing the full lumen, early vomiting; adhesions are the commonest cause (then hernia). LBO: peripheral haustra not crossing the lumen, later vomiting; think cancer/volvulus.
Central loops with full-width valvulae conniventes plus prior surgery point to adhesive small-bowel obstruction.
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A 68-year-old presents with several weeks of altered bowel habit, abdominal distension and absolute constipation. AXR shows a distended colon with haustra that do not cross the full lumen. Until proven otherwise, how should a large-bowel obstruction in an adult be regarded?
A large-bowel obstruction in an adult should be treated as colorectal cancer until proven otherwise; volvulus is the other major cause. Investigation includes CT and lower GI endoscopy.
Treat adult LBO as colorectal cancer until proven otherwise; never be reassured by a 'settling' obstruction with worsening signs — the danger sign is the shift from colicky to constant pain (strangulation).
Adult LBO = colorectal cancer until proven otherwise (volvulus the other key cause).
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A 9-month-old infant presents with episodic screaming and drawing up of the legs, vomiting, and the passage of 'red-currant jelly' stool. A sausage-shaped mass is palpable in the right abdomen; ultrasound shows a 'target' sign. What is the diagnosis?
Red-currant-jelly stool, a sausage-shaped mass and a 'target'/'doughnut' sign on ultrasound in an infant are classic for intussusception; pneumatic/hydrostatic reduction is often the first-line treatment.
Intussusception (commonly ileocolic, infants): colicky pain, red-currant jelly stool, sausage mass, target sign; reduce by air/contrast enema, surgery if it fails or there are signs of peritonitis.
Red-currant jelly stool + sausage mass + target sign in an infant is intussusception.
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A 26-year-old has chronic diarrhoea, weight loss and a perianal fistula. Colonoscopy shows patchy inflammation with normal intervening mucosa ('skip lesions') and biopsy reveals transmural inflammation with granulomas. Which diagnosis do these features best fit?
Transmural, skip-pattern inflammation with granulomas and fistulating perianal disease is characteristic of Crohn's disease; ulcerative colitis is mucosal, continuous and confined to the colon.
Crohn's = transmural, skip lesions, fistulae, anywhere mouth-to-anus; UC = mucosal, continuous, colon only, with risk of toxic megacolon.
Transmural inflammation, skip lesions, granulomas and fistulae define Crohn's; UC is mucosal and continuous.
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A 19-year-old student describes central periumbilical pain that has shifted over a day to the right iliac fossa, with anorexia and nausea. There is maximal tenderness with rebound at the junction of the lateral one-third and medial two-thirds of a line from the umbilicus to the anterior superior iliac spine. What is this point and what does it indicate?
Maximal tenderness at McBurney's point with migratory pain and anorexia is the classic clinical picture of acute appendicitis — a primarily clinical diagnosis.
Acute appendicitis: migratory central-to-RIF pain, anorexia, McBurney's-point tenderness; the Alvarado score aids decision-making; definitive treatment is appendicectomy.
Tenderness at the junction of the lateral third/medial two-thirds (umbilicus-to-ASIS) is McBurney's point — acute appendicitis.
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A clinician uses the Alvarado score when assessing a patient with suspected appendicitis. What is the principal role of this scoring system?
The Alvarado score combines symptoms, signs and laboratory findings to stratify the likelihood of appendicitis and guide whether to observe, image or operate; the definitive treatment remains appendicectomy.
Alvarado score = clinical probability tool for appendicitis (migratory pain, anorexia, nausea, tenderness, rebound, fever, leucocytosis, left shift); appendicectomy is definitive treatment.
The Alvarado score stratifies the probability of appendicitis to guide management — it is a clinical decision aid.
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A 50-year-old reports painless, bright-red rectal bleeding that drips into the toilet pan after defecation, with no pain. On proctoscopy there are enlarged vascular cushions arising above the dentate line. Why is the bleeding painless, and what is the diagnosis?
Internal haemorrhoids arise above the dentate line where the lining has visceral (autonomic) innervation and is insensate, so they bleed painlessly; they are graded I-IV. Always exclude a proximal cancer before labelling bleeding as 'just piles'.
Above the dentate line = visceral, insensate → internal haemorrhoids bleed painlessly (graded I-IV). Below the line = somatic, sensate → painful conditions (fissure, thrombosed external pile). Never call bleeding 'just piles' without excluding colorectal cancer.
Painless bright-red bleeding from cushions above the dentate line = internal haemorrhoids (insensate visceral mucosa).
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A 30-year-old has severe, sharp pain on defecation and a small streak of bright-red blood on the paper. Examination is too painful to complete, but a sentinel skin tag is seen, and the tear lies in the posterior midline of the anal canal. What is the most likely diagnosis?
Severe pain on defecation with a posterior-midline tear and a sentinel tag is a classic anal fissure; the posterior midline is the typical site because of its relatively poor blood supply.
Anal fissure: painful defecation, posterior-midline tear (poorly perfused), sentinel tag; manage with stool softeners, GTN/diltiazem, and lateral internal sphincterotomy for chronic cases. Goodsall's rule governs fistula tracks.
Painful defecation + posterior-midline tear + sentinel tag = anal fissure.
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