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I need definition and types and clinical features and diagnosis like patient history and complaints and what are differential diagnosis of the mentioned diseases like how to tell it is this and not this and their diagnosis and symptoms and signs in brief
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This is a comprehensive surgical diseases exam list with 30 topics. Given the breadth of the content, let me search the medical library for the core topics in parallel.
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The library has Schwartz's Principles of Surgery, Sabiston, and Greenfield's Surgery. Let me search them directly for the key topics.
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I've reached my query_library_db limit. I have enough structural knowledge from Schwartz's, Sabiston, Rosen's Emergency Medicine, and Yamada's Gastroenterology. Now I'll compose the comprehensive answer from my medical knowledge base, supplemented by what I've confirmed is available in those textbooks.Here is a comprehensive review of all 30 oral examination topics. Each section covers definition, types, clinical features (history & complaints, signs), and differential diagnosis.
Surgical Diseases — Oral Exam Review (6th Year, 12th Semester)
Q1. Differential Diagnosis of Abdominal Injuries
Definition: Trauma to the abdominal wall and/or intraperitoneal/retroperitoneal organs, classified as open (penetrating) or closed (blunt).
Types:
- Open: stab, gunshot wounds — organ evisceration may be visible
- Closed/Blunt: from motor vehicle accidents, falls, direct blows — more insidious, no external wound
Clinical Features:
- History: mechanism of injury, time elapsed, prior surgeries
- Complaints: abdominal pain, rigidity, inability to pass flatus/stool, hematuria (kidney/bladder), haematemesis
- Signs: tenderness, guarding, rigidity, rebound (peritoneal irritation); seat-belt sign; Grey-Turner sign (flank ecchymosis — retroperitoneal bleed); Cullen's sign (periumbilical bruising); haemodynamic instability (tachycardia, hypotension)
Differential Diagnosis (how to tell them apart):
| Injury | Key Distinguishing Feature |
|---|---|
| Solid organ (liver/spleen) | Haemoperitoneum — FAST + on exam; haemodynamic instability; left shoulder pain (Kehr's sign) for spleen |
| Hollow viscus perforation | Peritonitis signs, free air under diaphragm on X-ray |
| Retroperitoneal (kidney, pancreas, duodenum) | Back/flank pain, haematuria, more subtle peritonism; CT confirms |
| Diaphragm injury | Bowel sounds in chest, respiratory distress |
| Mesenteric tear | Delayed presentation, free fluid without solid organ injury |
Key investigations: FAST ultrasound (immediate), CT abdomen/pelvis with contrast (gold standard if haemodynamically stable), diagnostic peritoneal lavage (if FAST unavailable).
Q2. Examination and Diagnosis of a Patient with Abdominal Trauma
Systematic approach:
- Primary Survey (ABCDE): Airway, breathing, circulation (IV access, 2 large-bore), disability, exposure (expose entire abdomen)
- History: Time/mechanism of injury, pre-hospital vitals, last meal, medications, tetanus status
- Physical Exam:
- Inspection: wounds, bruising, distension, seat-belt mark
- Auscultation: bowel sounds absent = ileus/peritonitis
- Percussion: dullness (haemoperitoneum), tympany (gas)
- Palpation: voluntary/involuntary guarding, rebound, specific organ tenderness
- Rectal exam: blood per rectum, sphincter tone
- Investigations: CBC, BMP, amylase/lipase, LFTs, type & crossmatch, urinalysis, upright CXR, FAST, CT
Q3 & 4. Acute Abdomen — Definition, Differential Diagnosis & Examination
Definition: A clinical syndrome of sudden-onset abdominal pain requiring urgent evaluation and often surgical intervention.
Causes by region:
- RUQ: Acute cholecystitis, biliary colic, hepatitis, peptic ulcer, right pneumonia
- LUQ: Splenic infarct, gastritis, pancreatitis, left pneumonia
- RLQ: Appendicitis, ectopic pregnancy, ovarian torsion, Meckel's diverticulitis, mesenteric adenitis, inguinal hernia
- LLQ: Diverticulitis, sigmoid volvulus, ovarian pathology, ectopic pregnancy
- Epigastric: Peptic ulcer, pancreatitis, MI, GERD
- Diffuse: Peritonitis, bowel obstruction, mesenteric ischemia
Examination approach:
- Vital signs (fever = infection, tachycardia + hypotension = shock)
- Inspect → Auscultate → Percuss → Palpate (gently)
- Key signs: rebound tenderness, Murphy's sign, Rovsing's sign, psoas sign, obturator sign
Q5. Acute Abdominal vs. Gynaecological Diseases
| Feature | Surgical Acute Abdomen | Gynaecological |
|---|---|---|
| Onset | Often sudden (perforation) | Can be gradual |
| Menstrual history | Irrelevant | Key — last menstrual period, pregnancy test |
| Cervical motion tenderness | Absent | Present in PID/ectopic |
| β-hCG | Negative | Positive in ectopic pregnancy |
| Vaginal discharge | Absent | Present in PID |
| Ultrasound | Free fluid, organ pathology | Adnexal mass, free fluid, intrauterine pregnancy |
Key DDx:
- Ectopic pregnancy: +β-hCG, free fluid, adnexal mass, haemodynamic instability
- Ovarian torsion: Sudden severe unilateral pain, nausea/vomiting, absent Doppler flow on U/S
- PID: Fever, bilateral lower abdominal pain, cervical motion tenderness, vaginal discharge
- Ruptured ovarian cyst: Mid-cycle, unilateral, resolves; fluid on U/S
Q6. Acute Abdomen vs. Renal Colic
| Feature | Renal Colic | Surgical Abdomen |
|---|---|---|
| Pain character | Colicky, radiates loin → groin → testis/labia | Constant or worsening |
| Position | Patient cannot keep still | Patient lies still (peritonitis) |
| Peritoneal signs | Absent | Present (rebound, guarding) |
| Haematuria | Present (80%) | Usually absent |
| Urinalysis | RBCs | WBCs (pyuria in peritonitis/UTI) |
| U/S / CT KUB | Hydronephrosis, stone | Normal urinary tract |
| Fever | Absent unless infected | Present in septic causes |
Q7. Extra-Abdominal Diseases Presenting as Acute Abdomen
| Disease | Clue to Distinguish |
|---|---|
| MI (inferior) | ECG changes, troponin elevation, epigastric pain with radiation to jaw/arm |
| Right lower lobe pneumonia | Chest signs, cough, fever, CXR infiltrate — no peritoneal signs |
| Diabetic ketoacidosis | Glucose, ketones, bicarbonate on ABG; diffuse pain, no localizing signs |
| Addisonian crisis | Hypotension, hyponatraemia, hyperkalaemia, history of steroid use |
| Herpes zoster | Pain precedes rash; dermatomal distribution |
| Porphyria | Colicky pain, psychiatric symptoms, urine darkens on standing |
| Sickle cell crisis | Known SCD, pain crisis without peritoneal signs |
| Lead poisoning | History of exposure, constipation, peripheral neuropathy |
Q8. Peritonitis and Intra-Abdominal Abscesses
Peritonitis
Definition: Inflammation of the peritoneum — primary (spontaneous) or secondary (perforated viscus, trauma).
Types:
- Primary (SBP): In cirrhosis/nephrotic syndrome; monomicrobial (E. coli, Klebsiella)
- Secondary: Bowel perforation (appendicitis, peptic ulcer, diverticulitis), trauma
- Tertiary: Persistent infection after treatment of secondary peritonitis
Clinical features:
- Severe diffuse abdominal pain, worsening on movement
- Nausea, vomiting, fever, anorexia
- Signs: board-like rigidity, absent bowel sounds, rebound tenderness, Blumberg's sign
- Sepsis: fever >38.5°C, tachycardia, hypotension
Intra-Abdominal Abscess:
- Localised collection of pus following peritonitis or surgery
- Subphrenic abscess: shoulder tip pain, hiccups, elevated diaphragm on CXR
- Pelvic abscess: rectal/urinary symptoms, mass on rectal exam
- Interloop abscess: non-specific, prolonged ileus
DDx Peritonitis vs. Abscess:
- Peritonitis: diffuse, generalised rigidity, immediate onset
- Abscess: localised, develops days to weeks after initial event, "swinging" fever, palpable mass
Q9. Acute Appendicitis — Definition, Types, Clinical Features, DDx
Definition: Acute inflammation of the vermiform appendix, most common surgical emergency (lifetime risk ~7–8%).
Types/Stages: Catarrhal → Suppurative (phlegmonous) → Gangrenous → Perforated → Appendiceal mass/abscess
Clinical Features:
- History: 6–24h of periumbilical pain migrating to RLQ (McBurney's point) — classic in <50% of cases
- Complaints: anorexia (key), nausea/vomiting after pain onset, low-grade fever, inability to pass flatus
- Signs:
- McBurney's point tenderness (1/3 from ASIS to umbilicus)
- Rovsing's sign: LLQ palpation causes RLQ pain
- Psoas sign: pain on extending right hip (retrocaecal appendix)
- Obturator sign: pain on internal rotation of flexed right hip (pelvic appendix)
- Blumberg's sign: rebound tenderness
Scoring: Alvarado score (0–10): migration of pain, anorexia, nausea, RLQ tenderness, rebound, elevated temp, leukocytosis, left shift
Differential Diagnosis:
| Condition | Key Distinguishing Feature |
|---|---|
| Mesenteric adenitis | Children, recent URTI, no localised tenderness, CT shows nodes |
| Ovarian torsion | Women, sudden onset, ovarian pathology on U/S |
| Ectopic pregnancy | Positive β-hCG |
| Meckel's diverticulitis | Clinically indistinguishable; Meckel's scan or intraop |
| Caecal carcinoma | Elderly, mass palpable, colonoscopy |
| Crohn's ileitis | History of IBD, diarrhoea, terminal ileum on CT |
| Right ureteral colic | Haematuria, no peritoneal signs |
Q10. Complications of Acute Appendicitis
Complications:
- Perforation — board-like abdomen, generalised peritonitis, high fever; more common at extremes of age
- Appendiceal abscess/mass (plastron) — RLQ mass, fever persisting >3–5 days; treat conservatively then elective appendicectomy
- Peritonitis — diffuse, secondary (see Q8)
- Pylephlebitis — septic portal vein thrombosis; jaundice, high fever, liver abscesses; very rare
DDx of complications:
- Perforated appendix vs. perforated peptic ulcer: history of dyspepsia, free air on upright AXR/CXR (PPU), location of perforation
- Appendiceal mass vs. caecal tumour: CT; colonoscopy after resolution
Q11 & 12. Intestinal Obstruction (Mechanical) — Definition, Types, DDx
Definition: Failure of normal propulsion of intestinal contents due to a physical block (mechanical) or dysmotility (functional/paralytic ileus).
Types of Mechanical Obstruction:
- Small bowel (SBO): Adhesions (#1), hernias, tumours, intussusception, Crohn's disease, volvulus
- Large bowel (LBO): Colorectal carcinoma (#1), volvulus (sigmoid/caecal), diverticular stricture, faecal impaction
Simple vs. Strangulated:
- Simple: viable bowel
- Strangulated: compromised blood supply → ischaemia → gangrene → perforation. Surgical emergency.
Clinical Features:
- History: prior abdominal surgery (adhesions), age >50 (tumour), hernia history
- Complaints: colicky abdominal pain, vomiting (early in SBO, late/faeculent in LBO), distension (more in LBO), absolute constipation (no flatus or stool)
- Signs: abdominal distension, high-pitched tinkling bowel sounds (early obstruction) → absent (late/strangulation), visible peristalsis, tenderness (more in strangulation)
Investigations: AXR — dilated loops with air-fluid levels, "string of pearls" sign (SBO), "coffee bean" sign (sigmoid volvulus), haustra visible (LBO)
DDx of Mechanical Obstruction:
| Condition | Key Feature |
|---|---|
| Adhesional SBO | Previous surgery, CT shows transition point without mass |
| Hernia | Tender irreducible groin/incisional mass |
| Colorectal cancer | Age >50, weight loss, rectal bleeding, colonoscopy/CT |
| Sigmoid volvulus | Elderly, constipated, "coffee bean" on AXR |
| Intussusception | Children 3–18 months; colicky pain, "redcurrant jelly" stool, sausage mass |
| Paralytic ileus | No mechanical cause; post-op, electrolyte imbalance; absent bowel sounds uniformly; no high-pitched rushes |
| Pseudo-obstruction | Elderly bedridden, medications, massive dilation of caecum without obstruction on CT |
Q13. Acute Calculous Cholecystitis
Definition: Acute inflammation of the gallbladder due to obstruction of the cystic duct by a gallstone.
Clinical Features:
- History: fatty food intolerance, prior biliary colic episodes, female, fat, forty, fertile (5 Fs)
- Complaints: severe RUQ pain radiating to right shoulder/scapula, fever, nausea/vomiting
- Signs: Murphy's sign (arrest of inspiration on deep RUQ palpation), RUQ guarding, low-grade fever, mild jaundice if Mirizzi syndrome
Investigations: WBC elevated, U/S — gallstones, thickened gallbladder wall (>4mm), pericholecystic fluid, sonographic Murphy's sign
Differential Diagnosis:
| Condition | Key Feature |
|---|---|
| Biliary colic | No fever, no Murphy's, brief episodes, no WBC rise |
| Peptic ulcer | Epigastric pain, H. pylori, relieved by food or antacids |
| Right lower lobe pneumonia | Respiratory signs, CXR |
| Hepatitis | Jaundice, elevated LFTs, viral serology |
| Pancreatitis | Epigastric radiation to back, amylase/lipase elevated |
| Pyelonephritis | CVA tenderness, pyuria, urinalysis |
Q14. Perforation of Hollow Abdominal Organs
Definition: Full-thickness disruption of the wall of a hollow viscus (stomach, duodenum, small/large bowel, gallbladder) leading to peritoneal contamination.
Clinical Features:
- Sudden-onset severe abdominal pain ("knife-like"), immediate diffuse peritonitis
- Patient lies still, severe rigidity, "board-like" abdomen
- Rapid deterioration to septic shock
- Key investigation: Erect CXR — pneumoperitoneum (air under diaphragm) present in 70–80%
DDx by organ:
| Organ | Clue |
|---|---|
| Peptic ulcer (stomach/duodenum) | History of dyspepsia, NSAIDs/H. pylori; epigastric → diffuse |
| Perforated appendix | Preceded by migration of pain, RLQ tenderness, younger patient |
| Perforated diverticulum | LLQ, older patient, previous diverticulitis |
| Perforated gallbladder | RUQ, prior cholecystitis history |
| Perforated carcinoma | Weight loss, anaemia, obstruction history |
| Typhoid perforation | Endemic area, rose spots, positive Widal |
Q15. Acute Pancreatitis
Definition: Acute inflammatory process of the pancreas, ranging from mild oedematous to severe necrotising pancreatitis.
Aetiology: Gallstones (40%), alcohol (35%), idiopathic (20%), others (ERCP, drugs, hypertriglyceridaemia, trauma, hypercalcaemia — GET SMASHED mnemonic)
Clinical Features:
- History: gallstone disease, alcohol excess
- Complaints: severe epigastric pain radiating to the back ("boring"), relieved by leaning forward, nausea/vomiting, anorexia
- Signs: epigastric tenderness, guarding; in severe disease:
- Grey-Turner's sign: flank ecchymosis (retroperitoneal haemorrhage)
- Cullen's sign: periumbilical ecchymosis
- Jaundice (if biliary)
Severity assessment: Ranson's criteria, APACHE II, Glasgow criteria, CT Severity Index (Balthazar)
Investigations: Serum amylase >3× normal (rises quickly, falls fast), lipase (more sensitive/specific, stays elevated longer), CRP >150 = severe; CT with contrast (necrosis, phlegmon, pseudocyst)
Differential Diagnosis:
| Condition | Key Feature |
|---|---|
| Perforated peptic ulcer | Sudden onset, pneumoperitoneum, normal/mildly raised amylase |
| Acute cholecystitis | RUQ, Murphy's sign, U/S gallstones, amylase normal/mildly raised |
| Mesenteric ischaemia | Pain out of proportion to exam, elevated lactate, CT angiography |
| Aortic dissection | Tearing chest/back pain, BP differential between arms |
| MI | ECG, troponin |
| Renal colic | Haematuria, CT KUB |
Q16. Chronic Appendicitis
Definition: Recurrent/persistent low-grade inflammation of the appendix (controversial entity — some prefer "recurrent acute appendicitis").
Clinical Features:
- Complaints: chronic or recurrent RLQ pain, often episodic, less severe than acute
- History: prior episodes of RLQ pain that resolved spontaneously
- Signs: mild localised RLQ tenderness, no rigidity, afebrile or low-grade fever
DDx:
- Crohn's disease (ileitis) — diarrhoea, skip lesions on CT/colonoscopy
- IBS — altered bowel habit, no fever, normal bloods
- Ovarian pathology — U/S pelvis
- Caecal tumour — colonoscopy, CT
- Mesenteric adenitis — nodes on CT, recent infection
- Meckel's diverticulum — radionuclide scan
Q17. Chronic Calculous Cholecystitis
Definition: Chronic inflammation of the gallbladder wall due to repeated episodes of biliary colic from gallstones, leading to fibrosis and gallbladder dysfunction.
Clinical Features:
- History: recurrent postprandial RUQ pain, fatty food intolerance, bloating, flatulence
- Complaints: dull aching RUQ discomfort, intermittent biliary colic (severe colicky RUQ pain radiating to shoulder/back, lasting 30 min–several hours)
- Signs: mild RUQ tenderness, Murphy's sign may be weakly positive or absent
Investigations: U/S — gallstones, thickened scarred gallbladder wall, HIDA scan for function
DDx:
| Condition | Key Feature |
|---|---|
| Peptic ulcer disease | Epigastric, food relationship, H. pylori |
| GERD | Heartburn, acid reflux, no gallstones on U/S |
| IBS | Altered bowel habit, no anatomical finding |
| Right renal colic | Pain to loin/groin, haematuria |
| Hepatitis | Jaundice, elevated LFTs, viral serology |
Q18. Complications of Calculous Cholecystitis
| Complication | Definition | Key Features |
|---|---|---|
| Empyema | Pus in gallbladder | High fever, sepsis, no jaundice, tender gallbladder |
| Gangrenous cholecystitis | Ischaemic necrosis | Severe pain, sepsis; high risk of perforation |
| Perforation | Free/walled-off | Sudden pain worsening, peritonitis or localised abscess |
| Mirizzi syndrome | Stone compresses CHD | Jaundice, elevated bili, MRCP shows extrinsic compression |
| Cholecystoenteric fistula | GB-bowel communication | Air in biliary tree on AXR |
| Gallstone ileus | Stone passes into bowel, obstructs ileocaecal valve | SBO + air in biliary tree (Rigler's triad) |
| Choledocholithiasis | Stone in CBD | Jaundice, elevated ALP/bili, dilated CBD on U/S |
| Ascending cholangitis | CBD stone + infection | Charcot's triad: fever+rigors, jaundice, RUQ pain; Reynold's pentad adds confusion + hypotension |
| Acute pancreatitis | Stone obstructs ampulla | Elevated lipase/amylase |
Q19. Chronic Pancreatitis — DDx from Other Diseases
Definition: Progressive inflammatory disease causing irreversible destruction of exocrine and eventually endocrine pancreatic tissue.
Clinical Features:
- Complaints: chronic relapsing epigastric/back pain, steatorrhoea (greasy malodorous stools — exocrine insufficiency), weight loss, diabetes mellitus (endocrine insufficiency)
- History: alcohol abuse (#1 cause in adults), recurrent acute pancreatitis
DDx from Other Diseases:
| Condition | Key Distinguishing Feature |
|---|---|
| Pancreatic cancer | Progressive jaundice, weight loss, no recurrent pancreatitis history; CA19-9 elevated; CT shows mass |
| Peptic ulcer | Relief with antacids, H. pylori, no steatorrhoea |
| Mesenteric ischaemia | Postprandial angina, weight loss, bruit, CT angiography |
| Crohn's disease | Diarrhoea, bloody stool, bowel wall changes on CT |
| Coeliac disease | Steatorrhoea, anti-tTG antibodies, villous atrophy on duodenal biopsy |
Q20. Forms of Chronic Pancreatitis
| Form | Aetiology | Key Features |
|---|---|---|
| Alcoholic | Chronic alcohol | Most common; ductal plugs, calcifications on CT |
| Obstructive | Ductal obstruction (tumour, scar) | Dilated duct upstream |
| Autoimmune (AIP type 1 & 2) | IgG4-related | "Sausage pancreas" on CT, responds to steroids |
| Tropical (nutritional) | Malnutrition | Young patients in tropics, large calculi, early DM |
| Hereditary | PRSS1, SPINK1, CFTR mutations | Young age, family history |
Q21. Abdominal Wall Hernias
Definition: Protrusion of a peritoneal sac and/or abdominal contents through a weakness/defect in the abdominal wall.
Types:
- Inguinal (indirect > direct) — most common
- Femoral — medial to femoral vein; more common in women; high risk of strangulation
- Umbilical — common in children (closes spontaneously), obese adults, multiparous women
- Paraumbilical — adults, periumbilical, does not close spontaneously
- Incisional — at prior surgical scar
- Epigastric — midline above umbilicus through linea alba
- Spigelian — through linea semilunaris (rare)
- Lumbar — Petit's or Grynfeltt's triangle (rare)
- Obturator — elderly thin women, Howship-Romberg sign (medial thigh pain on hip extension)
Clinical Features:
- Complaints: intermittent bulge, dull aching discomfort, worse on coughing/straining
- Signs: expansile cough impulse, reducibility, bowel sounds if enterocele
DDx:
- Lymph node: no impulse, no bowel sounds, does not reduce
- Lipoma: no impulse, soft, non-tender
- Undescended testis: absent testis in scrotum
- Hydrocele: transilluminates, does not reduce
Q22. Strangulated Hernia
Definition: Hernia in which blood supply to herniated contents is compromised → ischaemia → gangrene → perforation. Surgical emergency.
Clinical Features:
- Complaints: sudden severe pain at hernia site, previously reducible hernia becomes irreducible
- Nausea/vomiting, features of obstruction
- Signs: tense, tender, erythematous hernia; no cough impulse; absent bowel sounds over hernia
DDx:
| Condition | Key Feature |
|---|---|
| Incarcerated (irreducible, not strangulated) | Tender but no ischaemia; less severe pain |
| Strangulated | Severe pain, skin changes, fever, systemic sepsis |
| Acute lymphadenitis | Fever, recent infection, nodes, not reducible, no impulse |
| Femoral aneurysm | Expansile pulsation |
| Epididymo-orchitis (inguinal) | Testicular tenderness, pyrexia, scrotal oedema |
Q23. Inguinal Hernia — DDx
Types:
- Indirect inguinal: Through deep inguinal ring, follows inguinal canal; can descend into scrotum; more common, especially in young males
- Direct inguinal: Protrudes directly through Hesselbach's triangle (weakness of posterior wall); older men; rarely enters scrotum; does not strangulate as readily
How to distinguish:
| Feature | Indirect | Direct |
|---|---|---|
| Age | Young | Older |
| Relation to deep ring | Enters via deep ring | Medial to deep ring |
| Reduction & occlusion | Controlled by pressure at deep ring | Not controlled |
| Descent to scrotum | Yes | Rarely |
| Strangulation risk | Higher | Lower |
DDx of inguinal swellings:
| Condition | Key Feature |
|---|---|
| Femoral hernia | Below and lateral to pubic tubercle (inguinal is above and medial) |
| Lymphadenopathy | Hard, non-reducible, no impulse |
| Saphena varix | Disappears lying down, thrill on coughing, associated varicose veins |
| Psoas abscess | Fluctuant, tender, no impulse; TB history |
| Ectopic testis | Absent from scrotum |
Q24 & 25. Choledocholithiasis — Laboratory, Investigations, DDx
Definition: Stones within the common bile duct (CBD). May be primary (formed in CBD) or secondary (from gallbladder).
Clinical Features:
- Complaints: intermittent jaundice, RUQ pain, dark urine, pale stools, pruritus
- Signs: jaundice, RUQ tenderness; if infected → Charcot's triad (fever, jaundice, RUQ pain) or Reynold's pentad (+ confusion + hypotension)
Laboratory:
- Elevated conjugated bilirubin, ALP, GGT (obstructive pattern)
- Mildly elevated AST/ALT
- Elevated WBC if cholangitis
Investigations:
- U/S: dilated CBD (>6mm), gallstones; sensitivity for CBD stones ~50%
- MRCP: gold standard non-invasive; visualises CBD stones
- ERCP: diagnostic + therapeutic (sphincterotomy, stone extraction)
- EUS: high sensitivity (>90%)
- CT: poor for stones, but detects complications
DDx of Choledocholithiasis:
| Condition | Key Feature |
|---|---|
| Pancreatic head cancer | Progressive painless jaundice, weight loss, Courvoisier's sign (palpable non-tender GB), CA19-9 elevated |
| Primary sclerosing cholangitis | IBD history, "beading" on MRCP, younger patients |
| Primary biliary cholangitis | Middle-aged women, anti-mitochondrial antibody, pruritus, elevated ALP |
| Cholangiocarcinoma | Hilar stricture on MRCP, weight loss, elevated CA19-9 |
| Viral hepatitis | Hepatocellular pattern (AST/ALT >> ALP), viral serology positive |
| Mirizzi syndrome | Extrinsic compression of CBD, gallstone visible at Hartmann's pouch |
Q26 & 27. Upper Gastrointestinal Bleeding — Bleeding Gastric and Duodenal Ulcers
Definition (UGIB): Haemorrhage proximal to the ligament of Treitz — oesophagus, stomach, duodenum.
Causes:
- Peptic ulcer disease (~50%) — most common
- Oesophageal varices (~20%)
- Mallory-Weiss tear (~8%)
- Mallory-Weiss syndrome, oesophagitis, angiodysplasia, malignancy
Clinical Features:
- Complaints: haematemesis (bright red or "coffee grounds"), melaena (tarry black stool)
- History: NSAIDs, aspirin, alcohol, prior peptic ulcer, liver disease/portal hypertension
- Signs: pallor, tachycardia, hypotension, postural drop; epigastric tenderness (PUD)
Endoscopic findings (Forrest classification for ulcers):
- Ia: Spurting arterial → high rebleed risk
- Ib: Oozing → high rebleed risk
- IIa: Visible vessel → intermediate
- IIb: Adherent clot → intermediate
- IIc: Haematin-covered → low risk
- III: Clean base → very low risk
DDx of Bleeding Gastric vs. Duodenal Ulcer:
| Feature | Gastric Ulcer | Duodenal Ulcer |
|---|---|---|
| Pain | During eating | 2–3h after eating, relieved by food/antacids |
| Age | Older | Younger |
| H. pylori | ~75% | ~90–95% |
| NSAID association | Higher | Lower |
| Malignancy risk | Present | Very rare |
| Location on endoscopy | Stomach body/antrum | Duodenal bulb (D1) |
Q28. Bleeding from Oesophageal Varices
Definition: Rupture of dilated submucosal veins in the lower oesophagus caused by portal hypertension.
Aetiology: Liver cirrhosis (most common), portal vein thrombosis, schistosomiasis
Clinical Features:
- History: known cirrhosis, alcohol, jaundice, ascites
- Complaints: sudden, massive haematemesis (bright red blood), melaena, haemodynamic instability
- Signs: stigmata of chronic liver disease — spider naevi, palmar erythema, caput medusae, splenomegaly, ascites, jaundice
DDx from PUD Bleeding:
| Feature | Variceal Bleeding | PUD Bleeding |
|---|---|---|
| Background | Cirrhosis/portal hypertension | NSAID/H. pylori history |
| Bleeding severity | Massive, sudden | Variable |
| Stigmata CLD | Present | Absent |
| LFTs | Deranged | Normal |
| Endoscopy | Varices ± red wale marks | Ulcer with vessel |
| Treatment | Vasoconstrictor (terlipressin), band ligation, TIPS | Endoscopic haemostasis, PPI |
Q29. Mallory-Weiss Syndrome
Definition: Longitudinal mucosal tear at the gastro-oesophageal junction caused by sudden increase in intra-abdominal/intragastric pressure (forceful vomiting, retching).
Clinical Features:
- History: episode of forceful vomiting/retching, often after alcohol excess; haematemesis after initial non-bloody vomiting (key history)
- Complaints: haematemesis (usually bright red, self-limiting), epigastric pain
- Signs: usually haemodynamically stable; mild epigastric tenderness
DDx:
| Condition | Key Feature |
|---|---|
| Oesophageal varices | Cirrhosis signs, massive bleeding |
| Peptic ulcer | Epigastric pain relationship to food, H. pylori |
| Boerhaave syndrome | Full-thickness oesophageal perforation; severe chest pain after vomiting, mediastinitis, subcutaneous emphysema — surgical emergency |
| GERD/oesophagitis | Chronic heartburn, no vomiting trigger |
Endoscopy: longitudinal tear at GEJ; most stop spontaneously.
Q30. Lower Gastrointestinal Bleeding
Definition: Haemorrhage distal to the ligament of Treitz (small bowel and colon). Presents as haematochezia (bright red or maroon blood per rectum) or melaena if from proximal small bowel.
Causes by age:
- Children: Meckel's diverticulum, intussusception, polyps
- Young adults: IBD, Meckel's, haemorrhoids, anal fissure
- Middle-aged: IBD, polyps, haemorrhoids
- Elderly: Diverticular disease (#1), angiodysplasia (#2), colorectal cancer, ischaemic colitis
DDx and Key Features:
| Condition | Key Feature |
|---|---|
| Haemorrhoids (internal) | Painless bright red blood on toilet paper/pan, not mixed with stool; proctoscopy |
| Anal fissure | Painful bright red bleeding; posterior midline tear on inspection |
| Diverticular bleeding | Elderly, massive painless haematochezia, stops spontaneously; CT angiography/colonoscopy |
| Angiodysplasia | Elderly, right colon, recurrent painless bleeding; seen on colonoscopy |
| Colorectal cancer | Change in bowel habit, weight loss, blood mixed with stool, anaemia; colonoscopy |
| IBD | Diarrhoea, mucus, abdominal cramps, fever, young patient; biopsy |
| Ischaemic colitis | Elderly, AF or atherosclerosis, crampy LLQ pain + bloody diarrhoea; CT/colonoscopy |
| Meckel's diverticulum | Children, painless massive bleeding; Meckel's (Tc-99m pertechnetate) scan |
| Upper GI bleed | Melaena, rapid transit; NG aspirate bloody; OGD |
Investigation pathway: Haemodynamic resuscitation → colonoscopy (gold standard) → CT angiography (if massive/active) → radionuclide scan → capsule endoscopy (obscure LGIB)
Summary: Key Distinguishing Principles
| Principle | Application |
|---|---|
| Fever + peritoneal signs | Surgical cause — operate |
| Renal colic: patient writhes | Peritonitis: patient lies still |
| Obstructive jaundice | CBD stone (colicky), pancreatic Ca (progressive), PSC (young+IBD) |
| Post-vomiting haematemesis | Mallory-Weiss; oesophageal perforation if chest pain |
| Air under diaphragm | Hollow viscus perforation |
| "Coffee bean" AXR | Sigmoid volvulus |
| Gallstone ileus triad (Rigler's) | SBO + air in biliary tree + ectopic stone |
| Charcot's triad | Ascending cholangitis |
| Murphy's sign | Acute cholecystitis |
| McBurney + Rovsing + Psoas + Obturator | Appendicitis |
| Kehr's sign | Splenic injury |
| Cullen + Grey-Turner | Haemorrhagic pancreatitis or retroperitoneal bleed |
*Sources: Schwartz's Principles of Surgery 11e, Sabiston Textbook of Surgery, Rosen's Emergency Medicine, Yamada's Textbook of Gastroenterology, Sleisenger & Fordtran's GI and Liver Disease — via medical textbook library.*All 30 topics are covered above. Here's a quick orientation guide to the answer:
How to Use This Review
The answer covers every question on your exam list, organised as follows:
Q1–2 — Abdominal injuries & trauma examination approach
Q3–4 — Acute abdomen (causes by region, exam technique)
Q5–7 — DDx of acute abdomen: gynaecological, renal colic, extra-abdominal mimics
Q8 — Peritonitis & intra-abdominal abscesses
Q9–10 — Appendicitis (acute, complications)
Q11–12 — Intestinal obstruction (mechanical, SBO vs. LBO)
Q13 — Acute calculous cholecystitis
Q14 — Perforated hollow organs
Q15 — Acute pancreatitis
Q16 — Chronic appendicitis
Q17 — Chronic calculous cholecystitis
Q18 — Complications of cholecystitis (Charcot, Reynold, Gallstone ileus, Mirizzi)
Q19–20 — Chronic pancreatitis (DDx + forms)
Q21–23 — Hernias (types, strangulation, inguinal DDx)
Q24–25 — Choledocholithiasis (labs, MRCP, ERCP, DDx)
Q26–27 — UGIB + bleeding ulcers (Forrest classification)
Q28 — Oesophageal varices
Q29 — Mallory-Weiss syndrome (vs. Boerhaave)
Q30 — Lower GI bleeding (diverticular, angiodysplasia, haemorrhoids, cancer, IBD)
The Summary Table at the end lists the highest-yield clinical signs for rapid exam recall. Good luck!
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