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Questions and Answers
What is the most common cause of fissure-in-ano?
What is the earliest complication of hemorrhoidectomy that one might encounter?
Which degree of hemorrhoids refers to those that prolapse but return back spontaneously or by digital reposition?
What is the primary symptom associated with fistula-in-ano?
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In the context of appendicitis, what does a score greater than 7 on the Alvarado score indicate?
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What is the classic site of tenderness in appendicitis known as?
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Which organism is most commonly associated with appendicitis?
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What is indicated by positive Rovsing's sign during an abdominal examination?
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Which type of hyperparathyroidism is associated with chronic renal failure and malabsorption syndrome?
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What is the most common cause of hypoparathyroidism?
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Which condition is characterized by tetany and abnormal contractions of facial muscles?
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What is a common clinical presentation seen in primary hyperparathyroidism?
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How is Trousseau's sign elicited?
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In which type of hyperparathyroidism is hyperphosphatemia commonly seen?
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What tumor types are associated with Multiple Endocrine Neoplasia type 2?
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What is an indicator of poor prognosis in thyroid cancer?
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Which type of hernia is associated with Meckel's diverticulum?
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What condition is characterized by a 'W' loop of bowel?
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In which patients are complete prolapses more commonly observed?
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Which type of hemorrhoid is found above the dentate line and typically does not cause pain?
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Which of the following represents a condition of intestinal obstruction that does not produce local signs and symptoms?
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What is the most common site for internal hemorrhoids?
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Which type of hernia is described as having local tenderness that is not marked?
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What is the indication for surgery in hemorrhoids?
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What is the most common cause of generalized peritonitis in a 40-year-old male?
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Which type of peritonitis is characterized by localized tenderness and guarding of the abdominal wall?
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What characteristic distinguishes tuberculous peritonitis from acute appendicitis?
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In which compartment is the most common site of subphrenic abscess found?
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What type of hernia occurs when abdominal contents protrude through weak areas of the abdominal wall?
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What is the key anatomical landmark used to differentiate between femoral and inguinal hernias?
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Which hernia is the most commonly overlooked in surgical procedures?
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Which type of hernia has the maximum chance of strangulation?
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What is the most common site for volvulus in the colon?
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Which imaging finding is associated with sigmoid volvulus?
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Which test is used to distinguish between primary and secondary hypothyroidism?
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What characterizes a simple goitre?
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What symptom is commonly observed in patients with diffuse hyperplastic goitre?
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What is true regarding a functioning nodule in the thyroid?
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What condition can complicate Pendred syndrome?
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What laboratory finding is typically elevated in hypothyroidism?
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Study Notes
Peritonitis
- Peritoneal irritants include bile, gastric juice, and pancreatic juice. Blood is the least irritant.
- Diffuse peritonitis is caused by perforation of a hollow viscus, increased virulence of organisms, AIDS, or steroids.
- The most common cause of generalized peritonitis in a 40-year-old male is duodenal ulcer perforation.
- Localized peritonitis presents with localized tenderness, guarding, rigidity of the abdominal wall, and rebound tenderness (Blumberg sign).
- Radiology shows a ground-glass appearance.
- Complications of peritonitis include paralytic ileus, intestinal obstruction, and residual abscesses, particularly pelvic abscesses and subphrenic abscesses.
- Pelvic abscesses are the most common intra-abdominal abscesses, with the Pouch of Douglas being the most common site.
- The Morrison/hepatorenal pouch is the most common site of a subphrenic abscess.
- Tuberculous peritonitis is usually a secondary involvement with a primary focus elsewhere in the body.
- Features include straw-colored fluid with tubercles scattered throughout the peritoneum, fever, anorexia, weakness, weight loss, and a "doughy abdomen".
- Mesenteric lymphadenitis presents with shifting tenderness, differentiating it from acute appendicitis where tenderness remains in the same spot.
Hernia
- A hernia is a protrusion of abdominal contents through weak areas in the abdominal wall caused by increased abdominal pressure.
- Pathology consists of a sac, contents of the sac, and coverings of the sac. The sac has a mouth, neck, body, fundus.
- Pubic tubercle is a landmark differentiating between femoral and inguinal hernias. In inguinal hernias, the neck of the sac lies above and medial to the tubercle. In femoral hernias, the neck lies below and lateral to the tubercle.
- Inferior epigastric vessels differentiate between direct and indirect inguinal hernias. The neck of an indirect hernia lies lateral, while the neck of a direct hernia lies medial to these vessels.
- The most common type of hernia is inguinal, while obturator hernia is extremely rare.
- Epigastric hernia (Fatty hernia of the Linea alba) mimics peptic ulcers.
- Pantaloon hernia is the most common overlooked hernia in surgery.
- The most common hernia in both males and females is indirect inguinal hernia.
- The most common hernia in the elderly is direct hernia.
- Strangulation is most likely to occur in a femoral hernia and least likely in a direct inguinal hernia.
- Femoral hernias are more common on the right side and in females.
- Richter's hernia involves a circumferential part of the intestine and usually complicates femoral hernias, often associated with gangrene or perforation.
- Littre's hernia involves Meckel's diverticulum. It is a hernia-en-glissade, exclusively seen in elderly males. It has a peculiarity where the posterior wall of the hernia sac is not formed solely by the peritoneum but by a viscus behind the peritoneum.
- Little's hernia involves the appendix. Local tenderness is not pronounced because the strangulated loop lies within the abdomen.
- Sliding hernia involves the urinary bladder, sigmoid colon (left side), and cecum (right side).
- Maydl's hernia is a 'W' loop of bowel.
- All hernias reaching vascular compromise produce local signs and symptoms of intestinal obstruction, EXCEPT Richter's hernia, Littre's hernia, and omentocele.
- Inguinal hernias are also more common on the right side and in males.
- Strangulated hernias are most commonly found in the femoral region in infants, with the ovary being the most common content. Gangrene develops within 6 hours of strangulation.
- Gibbon's hernia is a hernia with a hydrocele.
- Berger's hernia is a hernia in the Pouch of Douglas.
- Ogilvie hernia is a hernia through a defect in the conjoint tendon.
- Pantaloon hernia is a double hernia, both direct and indirect.
Clinical Features of Prolapse
| FEATURE | PARTIAL | COMPLETE |
|---|---|---|
| Prolapse of | Mucosa+submucosa | All 3 layers |
| Prolapsed length | 1-4cm | >4cm |
| Common in | extremes of age | Elderly, females after |
| hysterectomy | ||
| Associated with | Tertiary piles | Fecal incontinence in |
| >50% |
Hemorrhoids
- External/false piles occur below the pectinate line and are painful. They do not bleed on straining at stool.
- Internal/true/primary piles occur above the dentate line and are painless.
- Primary haemorrhoids are located at rectal positions 3, 7, and 11 o'clock, which are the most common sites for internal piles.
- Secondary haemorrhoids usually occur between the primary sites, at positions 8, 9, 10, 1, and 4 o'clock.
- Bleeding is the first symptom (splash in the pan). However, in fissures-in-ano, a streak of blood may be seen on the stool.
- Surgery is indicated for 3rd and 4th-degree piles.
- A 'Sentinel pile' is not associated with haemorrhoids but with fissure-in-ano.
Complications of Hemorrhoids
- Bleeding (particularly in the first degree and early stage of the second degree), thrombosis, strangulation (especially seen in the second degree), gangrene, fibrosis, suppuration, and pylephlebitis.
Complications of Hemorrhoidectomy
- Early complications include pain, acute urinary retention, and reactionary haemorrhage.
Degrees of Hemorrhoids
- 1st degree: Bleed but do not prolapse.
- 2nd degree: Prolapse but return back spontaneously or by digital reposition.
- 3rd degree: Prolapse but is reducible manually.
- 4th degree: Permanently prolapsed.
Fissure-in-Ano
- Most commonly occurs in the midline posteriorly at the 6 o'clock position.
- The most common cause is constipation.
- A sentinel pile is a skin tag at the lower end of the ulcer.
- Passage of bright streaks of blood along with stool. Pruritus ani may also occur.
- Best diagnosed clinically by history and visual inspection.
Fistula-in-Ano
- Has an external opening (secondary opening) in the perianal skin and an internal opening (primary opening) in the anal canal or rectum.
- Usually originates from a perianal abscess.
- Rectal continence depends solely on the anorectal ring (Puborectalis).
- The most common symptom is persistent seropurulent discharge.
- The most common cause of multiple fistulas in India is tuberculosis.
Goodall's Rule
- Fistulas with an external opening in relation to the anterior half of the anus (within 1.5 inches) are of direct type.
- Fistulas with an external opening in relation to the posterior half of the anus have a curved track (more common variety).
- An exception is the long anterior fistula.
Appendicitis
- Most commonly seen in the second and third decades of life.
- The most common organism is E. coli.
- Organisms causing appendicitis-like syndrome include Pasteurella, Strongyloides, and Yersinia pseudotuberculosis.
- The Alvarado score is used for diagnosis, where a score of >7 is strongly suggestive.
Clinical Features of Appendicitis
- Pain: Initial pain is typically diffuse and dull, situated in the umbilical or lower epigastric region. Gradually, the pain localizes to the right lower quadrant.
- Anorexia, nausea.
- Murphy triad: Pain, vomiting, and temperature.
- Sequence of symptom appearance: Anorexia-abdominal pain-nausea and vomiting.
- Rovsing's sign: Pain in the right lower quadrant when palpation pressure is exerted in the left lower quadrant (referred rebound tenderness).
- McBurney's point is the classical site of tenderness in appendicitis, located at the junction of the lateral 1/3rd and medial 2/3rd of the line joining the Anterior superior iliac spine and umbilicus.
- Ba enema: Shows a 'reverse 3' on the cecum and mucosal irregularities of the terminal ileum.
Alvarado Score
- Symptoms: Anorexia; nausea and vomiting; migratory right iliac fossa pain.
- Signs: Raised temperature; tenderness in right iliac fossa; rebound tenderness.
- Tests: Leucocytosis; shift to left (segmented neutrophils).
Volvulus
- Volvulus is a rotation of a segment of bowel around its mesenteric axis.
- The most common site in the colon is the sigmoid colon.
- Sigmoid volvulus is caused by severe chronic constipation. It is uncommon in individuals leading an active life without serious mental or physical illness.
- A straight X-ray of the abdomen shows a 'bent inner tube' or 'omega loop sign'.
- A Ba enema shows a "twisted bird's beak", with the sigmoid colon turning in an anticlockwise direction (unlike volvulus of the cecum which occurs in a clockwise direction).
Thyroid and Parathyroid Glands
Assessment of Thyroid Function
- In vitro tests: Serum T3 and T4, TSH.
-
In vivo tests:
- TSH stimulation test differentiates between primary and secondary hypothyroidism.
- Thyroid scan distinguishes between functioning (hot) and non-functioning (cold) thyroid nodules. A functioning nodule is unlikely to be a carcinoma.
- Thyroid autoantibodies.
Miscellaneous Other Tests
- Serum cholesterol: Elevated in hypothyroidism.
- Tendon reflexes: Particularly ankle jerk and knee jerk - relaxation is quite slow in hypothyroidism.
Goitre
- Goitre denotes enlargement of the thyroid gland irrespective of its cause.
- Types include simple and toxic goitre.
Simple Goitre
- Formed due to stimulation with increased TSH along with low levels of circulating thyroid hormones.
- Causes: Iodine deficiency, enzyme deficiency, puberty, pregnancy, familial, goitrogens (antithyroid drugs, cauliflower, cabbage, turnips, etc.).
-
Types:
- Diffuse Hyperplastic goitre: Most patients are asymptomatic. The most common symptom is swelling of the neck which moves on swallowing. Dysphagia due to pressure effect.
- Nodular goitre: Usually, multiple nodules are present.
- Colloid goitre: The patient is euthyroid, and the gland is soft and smooth on palpation.
Pendred Syndrome
- Deaf and goitrous patient since infancy.
Complications of Goitre
- Secondary thyrotoxicosis, tracheal obstruction, carcinoma. Hematogenous spread is common. Common in regions with iodine deficiency, associated with endemic goitre.
Thyroid Cancer
| TYPE | CHARACTERISTICS |
|---|---|
| PAPILLARY | Most common. Good prognosis. |
| FOLLICULAR | Usually well-differentiated. Occurs mostly in young women. |
| MEDULLARY | Most malignant. Resembles normal thyroid. |
| ANAPLASTIC | Worst prognosis. Undifferentiated. |
| UNCOMMON | Associated with MEN 2a and 2b. Hyaline amyloid stroma. |
- Orphan annie eyed Nuclei, Psammoma bodies. Multiple cold nodules, multicentric. External radiation.
Hyperparathyroidism
-
Primary hyperparathyroidism: Etiology unknown.
- Familial hyperparathyroidism - usually occurs with Multiple Endocrine Neoplasia (MEN).
- MEN type 1 (Wermer syndrome): Hyperparathyroidism + Pancreatic tumor + Pituitary adenoma.
- MEN type 2 (Sipple syndrome): Medullary thyroid cancer + pheochromocytoma + hyperparathyroidism.
Clinical Features of Hyperparathyroidism
- Hypercalcemia, calcification of soft tissues, bone disease.
- Bizarre presentations: Gastroduodenal ulcers, pancreatitis, hypertension; Increased levels of serum alkaline phosphatase.
Secondary and Tertiary Hyperparathyroidism
- Secondary hyperparathyroidism develops in chronic renal failure and malabsorption syndrome.
- Chronic Phosphate Retention-Hyperphosphatemia-Hypocalcemia-Parathyroid hyperplasia.
- Tertiary hyperparathyroidism is due to adenomata.
Hypoparathyroidism
- The most common cause is damage to the parathyroid gland during thyroid surgery.
Clinical Features of Hypoparathyroidism
-
Hypocalcemia is manifested by:
- Numbness and tingling in the fingers, toes, and circumoral region.
- Anxiety, depression.
- Tetany: Characterized by carpopedal spasms, convulsions, laryngeal stridor.
Physical Examinations for Hypoparathyroidism
- Chvostek's sign: Abnormal contraction of facial muscles elicited by tapping on the facial nerve anterior to the ear.
- Trousseau's sign: Elicited by occluding blood flow to the forearm for 3 minutes with a sphygmomanometer cuff applied to the arm and raising the pressure above systolic level. It will induce carpopedal spasm, i.e., MCP joints are flexed with extension of IP joints and adduction of the thumb.
- ECG changes: Include prolonged QT intervals.
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Description
Test your knowledge on the causes, symptoms, and complications of peritonitis. This quiz covers both diffuse and localized peritonitis, including key radiological findings and common sites of abscesses. Prepare to assess your understanding of this critical abdominal condition.
