8.

Hernias
a. What is meant by the term "hernia‟?

Protrusion of a viscus or part of a viscus outside the cavity which normally

contains it

b. What are the common hernial orifices of the peritoneal cavity?

Inguinal, femoral, obturator, umbilical, Para umbilical, loin and epigastric

c. What is the difference between a direct and an indirect inguinal hernia?

Direct hernia protrude from the post. Inguinal wall (defect in fascia
transversalis) in old age pt.

Indirect hernia protrude from the deep inguinal ring in young age pt.

Enumerate the common causes of massive splenomegaly

A. B-thalassaemia major
B. chronic myeloid leukamia
C. hairy cell leukaemia
D. visceral leishmaniasis
E malaria

1. Mr Firas, a 61 years old, has attended his GP surgery, complaining of

difficulty in swallowing.
A. What questions would you want to ask to fully explore this?

Do they have any difficulty in swallowing (dysphagia)? If so, ask about the type of food
that causes difficulty, for example solids, liquids or both, and the level at which they feel
the food sticking.

Also ask about the duration and progression of these symptoms, and whether swallowing
is painful.

B. How can you classify dysphagia according to the factors of intermittency and
pain?

INTERMITTENT DYSPHAGIA

1- solid and liquid (neuromuscular) like diffuse esophageal spasm

2- solid only (mechanical obst.) like lower esophageal ring

According to pain : a patient may have dysphagia without odynophagia
(dysfunction without pain ), odynophagia without dysphagia(pain without
dysfunction ) , or both

PAINFUL DYSPHAGIA

1- infectious 2- malignant 3- peptic stricture

PAINLESS DYSPHAGIA : NEUROMUSCULAR DYSORDER, CVA

C. List the possible causes of dysphagia

1- INFECTION

2- TUMORS

3- ULCER

4- STRICTURE

5- NEUROMUSCULAR DISORDER

6- RESPIRATORY (COPD)

D. What questions could you ask to narrow down the list of differentials?

1- PAIN

2- TYPE OF FOOD(solid or liquid)

3- DURATION

E. On further questioning him, he said he had lost weight in the last few months.
What questions would you ask to verify the significance of his weight loss?

Amount and duration, appetite , changes in size of clothes, Dietary changes, Any
intentional weight loss, Systemic symptoms – night sweats

F. What are the signs of weight loss on physical examination?

Fever, tachycardia, night sweats, orthostatic hypotension, generalized

lymphadenopathy, muscle wasting , skin striae

2. Miss Saja, an 18 years old female, has been vomiting for 24 hours and has had
watery diarrhoea for 12 hours.
A. What questions would you want to ask to fully explore these symptoms?

Vomiting:

If patients do vomit, how often do they do so? Is the vomiting preceded by nausea? What
is the nature and volume of the vomit? Is it recognizable food from previous meals,
digested food, clear acidic (burning) fluid or bile-stained fluid (bitter-tasting)? Is the
vomiting preceded by another symptom

Diarrhea :

How often does the patient defaecate per day? Are the actions regular or irregular?
Preceded by colicky pain or not? What are the physical characteristics of the stool?:

●●Colour: brown, black, pale yellow, white, silver, bloody?

●●Consistency: hard, soft, frothy or watery?

●●Size: bulky, pellets, string- or tape-like?

●●Specific gravity: does it float or sink?

●●Smell?: is it particularly foul?

such as indigestion, pain, headache or giddiness? Does it follow eating, and what is its
relationship to food? Is it effortless?

B. What do you expect her pulse and blood pressure to be?

Tachycardia with normal or hypotension

C. What about her JVP (jugular venous pressure)?

Low

D. What are other signs of dehydration that you would look for in such patient
apart from pulse?

BP,BAD BREATH, DRY MOUTH, DRY SKIN, LOW URINE OUTPUT.

E. If the patient was a 6 months infant, what other signs of dehydration that you
would check for?

Fontanelle , sunken eyes, fewer tear , wrinkled skin, drowsiness

F. What do you expect the urine output in this patient to be?

Low

3. Basim, a 42 years old known alcoholic, has come into the surgery for his
regular Thiamine injection. While here, he has mentioned that he feels generally
unwell, complaining of vague abdominal symptoms such as nausea, vomiting and
diarrhoea, symptoms he has had 'on and off' for several years. You examine his
abdomen and think that you can palpate the lower liver edge, but are unsure if it
feels normal.

A- When examining the liver edge, what are the features you need to describe?

Tenderness, regular, firm, lobulated, mass, gallbladder distension

B- What other symptoms might you expect to find in a patient with chronic liver
disease?

Jaundice(itching) , abd. Distension (ascites) , dilated abd.wall veins, spider nevi,

hematemesis, fatigue ( muscle wasting ), poor appetite, bleeding tendency, oedema

C- What do you expect to find on examining his face?

Yellowish discoloration of sclera , muscle wasting( prominent bones), pallor, hair

loss

D- What findings would you seek on examining his nipples and genitalia?

Gynecomastia , testicular atrophy

E- What other abdominal signs you expect in this patient?

Ascites, dilated abd.wall veins, spider nevi, striae, skin scratching, umbilical
swelling(hernia)

F- Why patient with chronic liver disease have splenomegaly?

Chronic liver dis. can cause blockage of blood flow through the liver, thus causing blood to
back up in the portal vein resulting in portal hypertension. As a result, the spleen becomes
engorged with blood, leading to splenomegaly
G- Is auscultation of the abdomen beneficial in such patients?

The finding : Abdominal Venous Hum, Hepatic Arterial Bruit, Hepatic Friction
Rub

H- 6 months later, he was rushed into the A & E department with recurrent bloody
throw ups and tarry stool. What questions would you want to ask to fully
explore these symptoms?

Old, altered blood looks like coffee grounds. Some patients have difficulty in
differentiating between vomited or regurgitated blood and coughed-up blood –
haemoptysis. Haemoptysis is usually pale pink

and frothy. When patients have had a haematemesis, always ask whether they have had a
recent nose bleed. They may be vomiting swallowed blood. Associated collapse and/or
faintness suggests major blood loss.

No. of stool passage, offensive or not , Hx of peptic ulcer.

I- What do these symptoms signify?

Esophageal varices

J- What are the other sites where blood can be shunted from portal vein to
systemic circulation?

- Paraumbilical veins

- upper end of anal canal

- retroperitoneal.

- bare area of liver

K- Which one of them is clinical seen on inspection the abdomen?

Paraumbilical veins

L- What is the definition of portal hypertension?

portal hypertension refers to elevated pressures in the portal venous system

M- What is the term coffee-ground vomitus means? Can it tell you about the
anatomical site of bleeding?

Old, altered blood

Upper GI bleeding ( proximal to ligament of Trietz)
4.Jasim, a 49 year old, has visited his GP complaining of lower abdominal pain.
It began about six months ago and has been intermittent, although during the
last month Tom has had pain every day. The pain is colicky and comes and goes
through the day, with each episode lasting between 10 minutes and 2 hours, and
it varies from mild discomfort (2/10) to severe (8/10). Paracetamol has no effect
on the pain, but it is often relieved by a bowel movement. Tom has noticed a
change in his bowel habits, as when he has the pain, he has more frequent and
looser bowel movements; he also has urgency during or after meals - particularly
breakfast.
There is no weight loss, vomiting or bleeding. The GP saw Tom two weeks ago
for this
problem and diagnosed Irritable Bowel Syndrome (IBS). Today Tom has
confided in you
that he thinks it might actually be bowel cancer, as his father died 9 years ago
from this disease.
A. How would you explain the diagnosis of IBS to Tom, remembering to ensure
that you also address his concerns about bowel cancer?

There's no test to definitively diagnose IBS . but we depend on 2 diagnostic criteria for IBS:

1- Rome criteria. These criteria include abdominal pain and discomfort lasting on
average at least one day a week in the last three months, associated with at least
two of these factors: Pain and discomfort are related to defecation, the frequency
of defecation is altered, or stool consistency is altered.
2- Type of IBS. For the purpose of treatment, IBS can be divided into three types,
based on your symptoms: constipation-predominant, diarrhea-predominant or
mixed.

Also the diagnosis not confirmed unless ruling out other serious condition and red flag
symptoms like anemia in old age group, bleeding per rectum , wt. loss and others.

B. What tests would you advise to exclude colon cancer?

Colonoscopy

C. What is meant by Hematochezia? What does it signify about the anatomical

site of bleeding?
Hematochezia is the passage of fresh blood per anus, usually in or with stools

Hematochezia usually comes from a colonic site, although blood rapidly transported from
the upper gastrointestinal tract can be red when passed in large amount

D. How is this different from maroon- coloured stool and from melena?

Maroon stools, which is caused by partial digestion of the blood in

the intestine often arises from the small intestine (jejunum, ileum)
and proximal colon

Melena is a black tarry stool that’s comes from upper GI tract ( proximal to
Trietz ligament )

E. Can upper GI bleeding present with fresh bleeding per rectum?

Yes, if large enough

5- Ali, a 15 years old student, comes to emergency department complaining of

right lower
abdominal pain with nausea and vomiting. He is diagnosed with acute
appendicitis (AA).
A- What characteristics of abdominal pain that suggest AA?

Migratory (shifting ) pain

B- What other important symptoms would you ask about?

Anorexia, fever , dysuria

C- Why do you think early intervention with AA is important?

To avoid the consequences of perforation

D- What do you expect to find on examining his mouth?

Feature of tonsillitis, Fetor oris, dehydration

E- List Seven abdominal signs seen in patient with AA.

1. Mcburney sign ( RIF tenderness)
2. Rovsing sign ( pain in RIF WHEN PRESSING THE LIF )
3.Psoas sign (PAIN ON EXTENSION OF RT. THIGH)
4. Obturator sign( pain on internal rotation of rt. Thigh)
5. Dunphy sign( pain on coughing)
6. Flank tenderness (in retroperitoneal appendix)
7. Rebound tenderness ( pain when lifting the hand suddenly)

8- Aaron’s sign : (Epigastric tenderness due to palpation at McBurney’s point)

9- pelvic tenderness with PR

10- abdominal guarding

11- hip flexion or bending forward

F- What blood test would you send to confirm the diagnosis?

CBC