Test yourself on a range of questions on abdominal distention, some are easier than others!
Reviewed by Jonathan Loomes-Vrdoljak
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Stem 1. Question 1 of 4
Susan, an 64 year old female, presents to A&E with abdominal distension.
Which of the following is NOT a non-obstructive cause of generalised abdominal distension?
Question 1 Explanation:
A classic example of "read the question" as it would be easy to miss the key word of "NOT". Neoplasm is classed as a mechanical bowel obstruction , whereas all of the others are non-obstructive. A large neoplasm can cause a blockage of the bowel and thus is an obstructive cause of abdominal distension
Stem 1. Question 2 of 4On inspection of the abdomen, Susan's abdominal distension is localised to the suprapubic region only. Which of the following differentials is most likely?
Polycystic kidney disease
Question 2 Explanation:
In this question you need to apply the question stem and generate the most likely diagnosis using your knowledge of anatomy to assist. Polycystic kidney disease causes distension in the left or right upper or lower quadrants, aortic aneurysms cause distension in the umbilical region. You would be correct in thinking both pregnancy and urinary retention cause distension in the suprapubic region, however in a women in her sixties, it is *more likely* to be urinary retention than pregnancy.
Stem 1. Question 3 of 4.Susan is diagnosed with urinary retention and immediately catheterised. Which of the following urinary tract structures do females lack?
Internal urethral sphincter
External urethral sphincter
Question 3 Explanation:
Another anatomy based question! Females lack an internal urethral sphincter, whereas males have both an internal and external urethral sphincter.
Stem 1. Question 4 of 4.Prior to catheterisation, Susan was complaining of severe pain, despite being given paracetamol and codeine. What would be the next appropriate analgesic to give according to the WHO pain ladder?
Question 4 Explanation:
This question relies on both your knowledge of the pain control ladder and pharmacology. Susan has been given a non-opioid analgesic of paracetamol and a weak opiod analgesic of codeine. This puts her on the third rung of the ladder. The next rung is a strong opioid +/- non-opioid +/- adjuvant, lets work through the choices and see which fits this definition. Naproxen and diclofenac are an NSAIDs so are a lower rung on the ladder. Co-codamol is another way of saying paracetamol and codeine. Ketamine is an anaesthetic so can be used for pain, but wouldn't be appropriate in this case. That leaves morphine, which is a strong opioid analgesic!
Stem 2. Question 1 of 4
54 year old Steven is admitted with progressively worsening abdominal distension and discomfort over 6/52. He drinks 10 units a week and has never smoked. He has been trying to lose weight as his BMI is 40.2.
Which of the following is the most common cause of ascites?
Question 5 Explanation:
All of the above are causes of ascites, but liver failure is the most common cause. The causes of liver failure are numerous and do not always require excessive alcohol intake.
Stem 2. Question 2 of 4.On examination, Steven has shifting dulness, how much fluid needs to be present for shifting dullness to be detected?
Question 6 Explanation:
Shifting dullness is generable detectable with about 1.5L of fluid in the abdomen, but can be seen on USS if there is less than that.
Stem 2. Question 3 of 4It is explained to Steven that his liver is failing due to non-alcoholic fatty liver disease. What type of fluid is causing the ascites in Steven's case?
Exudate as serum albumin- ascites albumin concentration is <11g/L
Exudate as serum albumin- ascites albumin concentration is >11 g/L
Transudate as serum albumin- ascites albumin concentration is <11 g/L
Transudate as serum albumin- ascites albumin concentration is >11 g/L
Interudate as serum albumin- ascites albumin concentration is equal
Question 7 Explanation:
This is a bit more of a tricky one, so don't worry if you didn't get it, hopefully this explanation will help. Firstly if you thought "I've never heard of interudate", correct, that was entirely made up! Transudate is most likely caused by cirrhosis and cardiac failure leading to portal hypertension, therefore fluid is pushed out due to higher intravascular pressure. The SAAG (or serum-ascites albumin gradient) is used to determine whether ascitic fluid is transudative or exudative in nature. It is found by subtracting the albumin concentration in the ascites from the albumin concentration in the serum. Serum albumin concentration is greater than ascites albumin concentration. Exudate is caused by nephrotic syndrome, malignancy and pancreatitis among others. This results in a low albumin states and leads to a lack of oncotic pressure and fluid exits the vasculature and accumulates in the abdominal cavity. Exudate = EXIT. Serum albumin concentration is lower than ascites albumin concentration.
Stem 2. Question 4 of 4One of the nurses asks you to review Steven as he has a temperature of 38.5C, HR of 114 and a BP of 110/90. Which is the most appropriate blood test to perform first?
Full blood count
Urea and electrolytes
Question 8 Explanation:
Steven is now presenting with spontaneous bacterial peritonitis and so the first bloods is to take blood cultures. CA125 is an ovarian cancer tumour marker. FBC and U&E will be performed but the key is blood cultures first so empirical antibiotics can be started
Matt is a 26 year old male who presents with with severe abdominal distension and pain. He has not opened his bowels in 3 days and today has been unable to pass flatus. Today Matt is vomiting which he describes as having a green tinge. PMH includes appendectomy at 18 and Crohn's disease
What is the most likely diagnosis?
Small bowel pseudo-obstruction
Small bowel obstruction
Large bowel obstruction
Large bowel pseudo-obstruction
Question 9 Explanation:
A number of cues in the question help here. Matt is unable to pass faeces or flatus (farts) so this is an obstruction or pseudo-obstruction. Matt has two risk factors for a small bowel obstruction: Crohn's disease and previous abdominal surgery. Risk factors for large bowel obstruction include malignancy and faecal impaction. Thus small bowel obstruction is most likely.
Priya a 44 year old woman presents to GP with a 10/12 history of abdominal distension, bloating and discomfort. Her abdominal pain and bloating is relieved by defecation and she sometimes notices mucus in her stool. She has had numerous investigations to no avail. No PMHx or medications. LMP was 3 days ago.
What is the most likely diagnosis?
Irritable bowel syndrome
Question 10 Explanation:
Irritable bowel syndrome is the correct diagnosis here. Pregnancy is unlikely has symptoms have persisted and she has just had a period. Priya has had numerous investigations, which have shown nothing abnormal, thus making irritable bowel syndrome most likely. IBS has been said to be a "diagnosis of exclusion" but does now have diagnostic criteria which is available on NICE Clinical Knowledge Summaries. IBS is a chronic condition characterised by abdominal pain associated with bowel dysfunction.
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