- •CONTENTS
- •PREFACE
- •ABBREVIATIONS
- •GENERAL AND COLORECTAL
- •CASE 1:
- •ANSWER 1
- •CASE 2:
- •ANSWER 2
- •CASE 3:
- •ANSWER 3
- •CASE 4:
- •ANSWER 4
- •CASE 5:
- •ANSWER 5
- •CASE 6:
- •ANSWER 6
- •CASE 7:
- •ANSWER 7
- •CASE 8:
- •ANSWER 8
- •CASE 9:
- •ANSWER 9
- •CASE 10:
- •ANSWER 10
- •CASE 11:
- •ANSWER 11
- •CASE 12:
- •ANSWER 12
- •CASE 13:
- •ANSWER 13
- •CASE 14:
- •ANSWER 14
- •CASE 15:
- •ANSWER 15
- •CASE 16:
- •ANSWER 16
- •CASE 17:
- •ANSWER 17
- •CASE 18:
- •ANSWER 18
- •CASE 19:
- •ANSWER 19
- •CASE 20:
- •ANSWER 20
- •UPPER GASTROINTESTINAL
- •CASE 21:
- •ANSWER 21
- •CASE 22:
- •ANSWER 22
- •CASE 23:
- •ANSWER 23
- •CASE 24:
- •ANSWER 24
- •CASE 25:
- •ANSWER 25
- •CASE 26:
- •ANSWER 26
- •CASE 27:
- •ANSWER 27
- •CASE 28:
- •ANSWER 28
- •CASE 29:
- •ANSWER 29
- •CASE 30:
- •ANSWER 30
- •CASE 31:
- •ANSWER 31
- •CASE 32:
- •ANSWER 32
- •CASE 33:
- •ANSWER 33
- •CASE 34:
- •ANSWER 34
- •CASE 35:
- •ANSWER 35
- •CASE 36:
- •ANSWER 36
- •BREAST AND ENDOCRINE
- •CASE 37:
- •ANSWER 37
- •CASE 38:
- •ANSWER 38
- •CASE 39:
- •ANSWER 39
- •CASE 40:
- •ANSWER 40
- •CASE 41:
- •VASCULAR
- •CASE 42:
- •ANSWER 42
- •CASE 43:
- •ANSWER 43
- •CASE 44:
- •ANSWER 44
- •CASE 45:
- •ANSWER 45
- •CASE 46:
- •ANSWER 46
- •CASE 47:
- •ANSWER 47
- •CASE 48:
- •ANSWER 48
- •CASE 49:
- •ANSWER 49
- •CASE 50:
- •ANSWER 50
- •CASE 51:
- •ANSWER 51
- •CASE 52:
- •ANSWER 52
- •CASE 53:
- •ANSWER 53
- •CASE 54:
- •ANSWER 54
- •CASE 55:
- •ANSWER 55
- •CASE 56:
- •ANSWER 56
- •UROLOGY
- •CASE 57:
- •ANSWER 57
- •CASE 58:
- •ANSWER 58
- •CASE 59:
- •ANSWER 59
- •CASE 60:
- •ANSWER 60
- •CASE 61:
- •ANSWER 61
- •CASE 62:
- •ANSWER 62
- •CASE 63:
- •ANSWER 63
- •CASE 64:
- •ANSWER 64
- •ORTHOPAEDIC
- •CASE 65:
- •ANSWER 65
- •CASE 66:
- •ANSWER 66
- •CASE 67:
- •ANSWER 67
- •CASE 68:
- •ANSWER 68
- •CASE 69:
- •Questions
- •ANSWER 69
- •CASE 70:
- •ANSWER 70
- •CASE 71:
- •ANSWER 71
- •CASE 72:
- •ANSWER 72
- •CASE 73:
- •ANSWER 73
- •CASE 74:
- •ANSWER 74
- •CASE 75:
- •ANSWER 75
- •CASE 76:
- •ANSWER 76
- •CASE 77:
- •ANSWER 77
- •CASE 78:
- •ANSWER 78
- •CASE 79:
- •ANSWER 79
- •CASE 80:
- •ANSWER 80
- •CASE 81:
- •ANSWER 81
- •EAR, NOSE AND THROAT
- •CASE 82:
- •ANSWER 82
- •CASE 83:
- •ANSWER 83
- •CASE 84:
- •ANSWER 84
- •CASE 85:
- •ANSWER 85
- •NEUROSuRGERY
- •CASE 86:
- •ANSWER 86
- •CASE 87:
- •ANSWER 87
- •CASE 88:
- •ANSWER 88
- •CASE 89:
- •ANSWER 89
- •ANAESTHESIA
- •CASE 90:
- •ANSWER 90
- •CASE 91:
- •ANSWER 91
- •CASE 92:
- •ANSWER 92
- •CASE 93:
- •ANSWER 93
- •CASE 94:
- •ANSWER 94
- •POSTOPERATIVE COMPLICATIONS
- •CASE 95:
- •ANSWER 95
- •CASE 96:
- •ANSWER 96
- •CASE 97:
- •ANSWER 97
- •CASE 98:
- •ANSWER 98
- •CASE 99:
- •ANSWER 99
- •CASE 100:
- •ANSWER 100
General and Colorectal
CASE 9: DiFFerential DiagnoSiS oF loWer abDominal pain
history
A 22-year-old woman presents to the emergency department complaining of lower abdominal pain. This has steadily increased in severity over the previous 24 h and woke her from her sleep. The pain is constant, and simple analgesia has not helped. She has vomited once in the department. Her menses are regular and she is now on day 12 of her cycle. There is no history of vaginal discharge or urinary symptoms. She has no children. She has not undergone any previous surgery but has a history of sexually transmitted disease 2 years ago, treated with antibiotics. There is no other relevant medical history. She takes no current medication and has no allergies. She is a non-smoker.
examination
Her blood pressure is 110/72 mmHg and pulse rate is 110/min. Her temperature is 38.2°C and there is lower abdominal tenderness, more marked in the right iliac fossa, with some rebound tenderness. There are no palpable masses and the loins are not tender. Digital rectal examination is normal. Bimanual per vaginal examination reveals adnexal tenderness on the right.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
14.7 g/dl |
11.5–16.0 g/dl |
White cell count |
16.6 × 109/l |
4.0–11.0 × 109/l |
platelets |
367 × 109/l |
150–400 × 109/l |
Sodium |
139 mmol/l |
135–145 mmol/l |
potassium |
4.1 mmol/l |
3.5–5.0 mmol/l |
urea |
5.6 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
74 μmol/l |
44–80 μmol/l |
C-reactive protein (Crp) |
145 mg/l |
<5 mg/l |
urine dipstick: naD (nothing abnormal detected) urinary b human chorionic gonadotropin (hCg): negative
Questions
•What is the differential diagnosis?
•How should the patient be managed initially?
•If you are unsure of the diagnosis, how should you proceed?
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100 Cases in Surgery
ANSWER 9
The two main differential diagnoses are pelvic inflammatory disease and acute appendicitis. The young female with right iliac fossa pain is often difficult to diagnose. The other differential diagnoses of right iliac fossa pain mimicking appendicitis are shown below.
!Differential diagnoses
•Gynaecological
•pelvic inflammatory disease (salpingitis, salpingo-oophoritis, tubo-ovarian abscess, endometritis, Fitz-hugh–Curtis syndrome)
•ruptured ovarian cyst
•ovarian torsion
•haemorrhage/rupture of ovarian mass
•Surgical
•Crohn’s disease
•mesenteric adenitis
•gastroenteritis
•Diverticulitis (caecal or left sided with a floppy sigmoid lying centrally or on the right of the midline)
•meckel’s diverticulitis
•acute cholecystitis
•Urological
•acute pyelonephritis
•ureteric colic
The high white cell count, raised CRP and tenderness in the right iliac fossa make appendicitis the most likely diagnosis in this patient. In clear-cut cases of appendicitis, the patient is taken to theatre for appendicectomy. If the diagnosis is most likely gynaecological, the patient should be referred to the gynaecologists for a transvaginal ultrasound scan and high vaginal swabs. Where there is doubt, the patient can be taken for diagnostic laparoscopy. If the appendix is abnormal, it can then be removed laparoscopically.
KEY POINT
• a full gynaecological history should be taken in female patients.
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General and Colorectal
CASE 10: Small-boWel anomaly
history
A 14-year-old boy presented to the emergency department with a 24- h history of increasing abdominal pain. The pain localized to the right iliac fossa and a diagnosis of acute appendicitis was made. At operation, the appendix was found to be normal and the anomaly shown in Figure 10.1 was found in a loop of small bowel.
Figure 10.1 operative picture of the small bowel.
Questions
•What is the diagnosis?
•What are the characteristics of this anomaly?
•How can this present?
•How would you deal with this intraoperative finding?
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100 Cases in Surgery
ANSWER 10
The photograph demonstrates a Meckel’s diverticulum located on the anti-mesenteric border of a segment of ileum. This is a remnant of the omphalomesenteric duct. The ‘rule of twos’ is associated with this condition, i.e. it is present in 2 per cent of the population, it is 2 inches long and located 2 feet from the ileocaecal valve. A Meckel’s diverticulum may be lined by small-intestinal, colonic or gastric mucosa, and it may contain aberrant pancreatic tissue.
The mode of presentation may be:
•Inflammation and perforation of the diverticulum presenting with abdominal pain and peritonitis, mimicking acute appendicitis
•Rectal bleeding from peptic ulceration caused by acid secretion from the ectopic gastric mucosa
•Intestinal obstruction from intussusception or entrapment of the bowel in a mesodiverticular band or a fibrous band that may connect the apex of the diverticulum to the umbilicus or anterior abdominal wall
Tumours may also develop inside a Meckel’s diverticulum.
The diverticulum should be removed by a segmental small-bowel resection. A symptomless diverticulum that is an incidental finding at laparotomy should not be excised, but the patient should be informed of its existence.
KEY POINT
•patients should be made aware if an asymptomatic meckel’s diverticulum is found at the time of surgery.
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