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A set of questions about the diagnosis and management of patients presenting with acute abdomen.

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Acute abdomen

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Question 1
A 45 year old male with a history of alcohol excess is referred to the surgical assessment unit with central abdominal pain, nausea and vomiting. Their vitals and bloods are given below. Which of the given options is not a first line management option?
HR 98
BP 110/68
O2 sats 96%
RR 18
Temp 36.8

Hb 138 (130-170)
WCC 16.2 (4-11)
Neutrophils 11.6 (2-7.5)
Lymphocytes 1.6 (1.5-4)

Sodium 136 (135-145)
Potassium 3.4 (3.5-5.3)
eGFR 68 (>60)
CRP 44 (<5)
Albumin 36 (32-47)
Bilirubin 15 (<17)
ALT 58 (5-42)
ALP 12 (5-42)
Amylase 565 (28-100)
A
1L Hartmann’s over 2 hours
B
IV amoxicillin, metronidazole and gentamicin
C
Metoclopramide
D
Oramorph
E
Paracetamol
Question 1 Explanation: 
This is a case of pancreatitis diagnosed based on the amylase level being more than three times normal. Pancreatitis management involves IV fluids, analgesia and antiemetics. IV antibiotics are only indicated if there is evidence of infection. Although the WCC and CRP are slightly raised, this might be expected as part of an inflammatory response. The patient is afebrile and haemodynamically stable so they are not septic.
Question 2
A 38 year old female presents to ED with upper abdominal pain, predominantly in the right hypochondrium. She reports a six-month history of intermittent abdominal pain after food for which her GP prescribed omeprazole but this has been ineffective. She has had one episode of vomiting with the pain but does not describe any coffee ground appearance. There is no change in bowel habit but her urine is a little darker. She reports drinking less the last day on account of the nausea. On examination she is overweight and afebrile. She is tender to palpation in the right upper quadrant but Murphy’s negative. There is no rebound tenderness. Standard bloods are shown below. What is the next investigation of choice?
Hb 130 (120-150)
WCC 9.6 (4-11)
Neutrophils 8.1 (2-7.5)
Lymphocytes 2 (1.5-4)

Sodium 139 (135-145)
Potassium 4.2 (3.5-5.3)
eGFR 90 (>60)
CRP 9 (<5)
Albumin 48 (32-47)
Bilirubin 10 (<17)
ALT 39 (5-42)
ALP 83 (5-42)
Amylase 35 (28-100)
A
CT abdomen and pelvis with contrast
B
Erect chest X-ray
C
MRCP
D
OGD
E
USS abdomen
Question 2 Explanation: 
The raised ALP alongside the RUQ pain indicates this is likely to be a case of gallstone disease. NICE Clinical Guideline 188 says that USS is the first line imaging for suspected gallstones. An MRCP can be ordered if the CBD is dilated, but no stones are present, or if the LFTs are abnormal. This is also echoed in the the 2017 British Society of Gastroenterology guidelines.
Question 3
A 58 year old patient presents with colicky left loin-to-groin pain with tenderness in the LIF. They are normally fit and well and have no allergies. A CT abdomen and pelvis with contrast shows a non-obstructing 6mm stone near the vesicoureteric junction. How should the patient’s pain be managed?
A
Diclofenac PR
B
Ibuprofen PO
C
Oramorph
D
Paracetamol PO
E
Tamsulosin PO
Question 3 Explanation: 
Diclofenac PR is the most effective analgesia in ureteric colic. The normal dose is 100mg every 16 hours. Tamsulosin is often prescribed as well to aid the passage of the stone, but it is not used for analgesia. The other analgesics may also provide some pain relief; however, in the case of morphine, we should try and discourage the use of opioids, especially when suitable alternatives are available.
Question 4
Which of the following tests may explain the cause of an episode of pancreatitis?
A
Alanine transaminase
B
Amylase
C
Bilirubin
D
CA 19.9
E
LDH
Question 4 Explanation: 
According to BMJ Best Practice, an ALT of more than 3x the upper limit is a strong indicator of gallstones being the cause of pancreatitis.

Amylase is used as a diagnostic marker of pancreatitis but does not tell you the cause. CA 19.9 is used as a tumour marker for pancreatic cancer, and LDH is used in the Glasgow-Imrie score to calculate the severity of pancreatitis.

Question 5
A 38 year old female presents to SAU with a 2 day history of sharp, left flank and left iliac fossa pain, rated 8/10, that comes and goes. She is afebrile but unable to get comfortable and is complaining of nausea. She is sexually active with a single partner and her last period was two weeks ago. She reports normal bowels and denies any dysuria or PV discharge. Her urine results are given below. What is the investigation of choice to confirm the suspected diagnosis?
pH: 6.5
Leukocytes: +/-
Nitrites: –
Blood: ++
Ketones: –
Bilirubin: –
Glucose: –
bhCG: –
A
CT abdomen and pelvis with contrast
B
CT KUB
C
Renal function tests
D
Urine MC&S
E
USS KUB
Question 5 Explanation: 
This is a suspected case of ureteric colic. In non-pregnant adults, a CT KUB is the preferred investigation. In pregnant people and children, an USS is preferred. Renal function tests will also be ordered to ensure no kidney damage.

Note that due to the lady's age and presentation, a CT KUB is the most preferred option; however, in an older patient where there may be more ambiguity of the cause, you might order a CTAP with contrast instead to rule out alternative differentials like diverticulitis. A CT KUB is also performed with the patient lying prone; this helps to confirm whether a stone is stuck in the VUJ.

Question 6

Stem 1 - Question 1

An 8 year old boy presents to ED with a 2 day history of worsening abdominal pain, starting around the belly button and moving to the right iliac fossa. He was uncomfortable on the journey to the hospital and is off his food. He has nausea but no vomiting and there is no change in bowels. There is no history of recent infections and everyone at home is well. On examination he has a mild fever, tender over McBurney’s point and palpation of the LIF causes pain in the RIF. What is the most likely diagnosis?
A
Appendicitis
B
Diverticulitis
C
Gastroenteritis
D
Mesenteric adenitis
E
Testicular torsion
Question 6 Explanation: 
This is a textbook description of appendicitis. Mesenteric adenitis is the most likely alternative differential but with no reported prodrome it is less likely. At 8 years old, the child is too young for diverticulitis, and the lack of change in bowel habit makes gastroenteritis less likely. In a young boy you have to have strong sense of suspicion for torsion and must always examine the external genitalia; however, as the pain wasn't sudden onset it is less likely as well.
Question 7

Stem 1 - Question 2

What is the investigation of choice for the above patient?
A
Abdominal X-ray
B
CT abdomen and pelvis with contrast
C
FBC
D
Ultrasound abdomen/pelvis
E
Urine dip
Question 7 Explanation: 
In a child, an US scan is the most appropriate investigation for appendicitis. If the appendix cannot be fully visualised, a CT scan may be considered although, if the suspicion is high for appendicitis, a diagnostic laparoscopy +/- appendicectomy might be performed instead. You will want to rule out UTIs as a cause of the symptoms and bloods might give you a sense of the severity. An abdominal X-ray is hardly ever indicated to investigate an acute abdomen in any patient; however, in a young child with abdominal pain and a high fever a CXR is prudent to rule out a chest infection since a high fever is not characteristic of appendicitis.
Question 8
A 60 year old lady on methotrexate for rheumatoid arthritis presents to ED with a two day history of constant left iliac fossa pain. She has a history of constipation although she last opened her bowel this morning and reports a type 5 stool. She has no dysuria or PV discharge and a urine dip taken on admission is normal.  On examination she is tender in the left iliac fossa. No masses are palpable, she has no rebound tenderness and a PR exam is clear. She is afebrile and her bloods are unremarkable. You suspect uncomplicated diverticulitis. You arrange a CT scan. What other management would you want to consider for this patient in the meantime?
A
Antibiotics
B
Ibuprofen
C
IV fluids
D
NG tube
E
Senna
Question 8 Explanation: 
In uncomplicated diverticulitis you do not normally give antibiotics unless the patient is unwell or has raised inflammatory markers; however this patient is on methotrexate so is immunosuppressed. You may also want to contact rheumatology as they might want to hold the methotrexate until the antibiotic course is complete.

Unless the patient is dehydrated or NBM for other reasons, there is no need for IV fluids. They are not vomiting and there is no sign of obstruction so no indication for an NG tube. On discharge you will want to make sure she has adequate laxatives, and you might also want to prescribe some on admission if you're giving an opioid analgesic; however, a stimulant laxative might increase the risk of perforation and so Macrogol might be better. She may need analgesia but NSAIDs can also increase the risk of perforation and are therefore contraindicated. On discharge the patient should be on a low residue diet for two weeks.

Question 9
A 50 year old woman presents with a 5 day history of worsening RUQ pain. Her stools have become grey, and her urine is darker and she has noticed some yellowing to her eyes. She also reports a fever. On examination she is tender in the RUQ but Murphy’s negative. What is the most likely diagnosis?
A
Biliary colic
B
Cholangitis
C
Choledocolithiasis
D
Cholecsytitis
E
Pancreatitis
Question 9 Explanation: 
Charcot's Triad of RUQ pain, fever and jaundice is indicative of ascending cholangitis.
Question 10
A 20 year old female student attends ED with a three day history of worsening right lower quadrant pain, mild fever, nausea and vomiting. Her bowels are normal and she doesn't describe any dysuria. She has irregular periods; her last was six weeks ago but she thinks she might be about to come on to her period as she had some PV bleeding this morning. She is sexually active and uses condoms for protection. On examination she is tender in the right lower quadrant but her obs are stable. What investigation does the patient need next?
A
CT abdomen and pelvis with contrast
B
FBC
C
Pregnancy test
D
US scan
E
Urine dip
Question 10 Explanation: 
It is important to rule out an ectopic pregnancy in a woman presenting with lower abdominal pain. A pregnancy test will also be required before approving a CT scan. If the pregnancy test is positive, an abdominal, pelvic and transvaginal ultrasound would be the imaging modality of choice.
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