A 78 year old man presents with worsening generalised abdominal pain, abdominal distension and absolute constipation over the past 2 days. For the past 6 hours he has been repeatedly vomiting. He is awaiting investigations for suspected bowel cancer. 

On examination he has a distended, tender abdomen, hyper-resonant on percussion. He is actively vomiting.

Blood pressure: 128/84. Heart rate: 110. Respiratory rate: 16. Oxygen saturations: 98%. Temperature: 37.2°C.

An abdominal x-ray reveals dilated loops of bowel.

What is the most likely finding on his ABG?

A 43 year old woman presents to the A&E department. She is known to have gallstones and is overweight but is otherwise fit and well.

She has had pain in the right upper quadrant of her abdomen for the past week. This has been fluctuating and is worse after a heavy meal. It has a crampy nature to it. She denies other symptoms.

Her examination is normal other than some mild right upper quadrant tenderness. There is no guarding.

Her blood tests are normal.

What is the most likely diagnosis?

A 68 year old gentleman presents with rectal bleeding and unexplained weight loss.

He has noticed that he often has a sensation of needing to open his bowels, with discomfort and a cramping feeling in his rectum. Despite feeling as though he needs to, he is unable to open his bowels.

What term is used to describe this sensation?

An 86 year old woman, who is a nursing home resident, presents with abdominal pain, distension and vomiting. She denies passing stools or flatus for the past 24 hours.

An abdominal x-ray shows the “coffee bean sign”.

After being admitted to the surgical team and having a CT scan to confirm the diagnosis, it is decided that she needs surgical management.

What procedure is likely to be recommended?

A 75 year old woman presents with non-specific, acute, severe abdominal pain. She finds it difficult to give a clear past medical history due to the pain. She is brought in by her son, who is not sure about her past medical history. She has a bag of medications, containing boxes of bisoprolol, atorvastatin and amlodipine. Her son says she does not take any other medications.

There are no specific findings on examination of her abdomen. There is mild, generalised tenderness. There is no guarding or rebound tenderness. She is noted to have an irregularly irregular pulse.

Blood pressure: 146/86. Heart rate: 124. Respiratory rate: 28. Temperature: 37°C. Oxygen saturation: 97%.

What is the most likely cause of her abdominal pain?

A 21 year old man is admitted under the surgical team with a 2 day history of worsening abdominal pain, nausea and loss of appetite. The pain started around his umbilicus, then moved and became localised in the right iliac fossa. He has rebound tenderness in the right iliac fossa.

His blood tests show a raised c-reactive protein (CRP) and white blood cells (WBC). 

How is the diagnosis made in this scenario?

A 72 year old woman presents with acute abdominal pain. She is seen by the foundation year 2 doctor who performs a history, examination and blood tests. She is then reviewed by the surgical registrar, who requests a contrast CT scan.

What is the most important investigation to get prior to a contrast CT scan?

A 73 year old man is day 3 post-op after an open left hemicolectomy to treat T2N0M0 bowel cancer.

He has not opened his bowels since the operation. His abdomen has been gradually increasing in size and he has started to vomit this morning.

Given the likely diagnosis, what is the physiological process that has been disrupted?

A 46 year old man describes having worsening epigastric pain and dyspepsia for the past 2 months. He has vomited on several occasions and recently describes the vomit as looking like “ground coffee beans”.

He presents acutely to the A&E department with acute generalised abdominal pain. Examination reveals generalised tenderness, guarding and rigidity.

Initial investigations are arranged and an urgent senior surgical review is requested. What is the most likely finding on an erect chest x-ray?

A 65 year old lady is bought in to the A&E department with severe abdominal pain. She is hunched over, clutching the centre of her abdomen. The paramedic tells you he is concerned about a ruptured abdominal aortic aneurysm.

What is your initial management?

You are the oncall surgical SHO for your hospital. The A&E department bleep you with a referral.

They describe a 23 year old women who has arrived at the A&E department with less than 24 hours of right iliac fossa pain. It started as a mild generalised abdominal pain but has now localised to the right iliac fossa.

The A&E doctor says she has tenderness to the right iliac fossa with guarding and he is worried about appendicitis.

What investigation would you insist that the patient has prior to being accepted under the care of the surgical team?

A 64 year old man presents with abdominal distension, generalised abdominal pain and vomiting. He has not passed stools or flatus for the last 48 hours. His past medical history includes hypertension and bowel cancer, for which he was previously treated with a curative open right hemicolectomy 8 years ago. His bowel cancer follow-up has not identified any cause of concern.

On examination you note a midline laparotomy scar. He has a distended abdomen, hyper-resonant on percussion, with tinkling bowel sounds. You cannot find any hernias. He is actively vomiting.

Blood pressure: 93/65. Heart rate: 104. Respiration rate: 16. Temperature: 36.8°C. Oxygen saturation: 96% on room air.

You perform blood tests and an ABG and are awaiting results from the laboratory.

His chest xray is normal but his abdominal xray reveals dilated loops of small bowel measuring 8cm.

A CT scan is requested to help establish the diagnosis. He is made nil-by-mouth and prescribed IV fluids and analgesia.

What would be the most appropriate additional step in managing this patient whilst awaiting the CT scan?

A 70 year old woman presents to her GP as she has noticed her skin turning yellow. On further questioning she admits she has probably lost weight, but is not sure why. She has no other symptoms. 

Blood tests are taken.

• Hb 126 g/L (normal 120 – 165
• WBC 10.8 10⁹/L (normal 4.0 – 11.0)
• Platelets 454 10⁹/L (normal 150 – 450)

• Bilirubin 285 μmol/L (normal 0 – 21)
• Alanine transaminase 56 U/L (normal 10 – 35)
• Alkaline phosphatase 789 U/L (normal 30 – 130)
• Albumin 32 g/L (normal 35 – 50)

• Sodium 136 mmol/L (normal 133 – 146)
• Potassium 4.6 mmol/L (normal 3.5 – 5.3)
• Urea 3.4 mmol/L (normal 2.5 – 7.0)
• Creatinine 54 μmol/L (normal 45 – 84)
• eGFR >90 ml/min (normal above 90)

Regarding the most likely diagnosis, what tumour marker is most relevant?

A 54 year old woman presents with epigastric pain radiating to her back, worsening over the past 2 days. She is normally fit and well without any health issues. She has never consumed alcohol for religious reasons.

Examination reveals epigastric tenderness without guarding. There are no other notable abnormalities on examination.

Blood tests reveal an amylase of 2340 and a diagnosis of acute pancreatitis is made.

What investigation is most likely to be helpful in establishing the cause for her pancreatitis?

A 34 year old woman presents complaining of tiny spots of fresh PR blood on the toilet tissue when wiping after opening her bowels. She also complains of frequent constipation, straining and itching around her anus.

She has noticed that when she strains, a soft erythematous lump prolapses from her anus. This does not return on its own and requires her to manually re-insert it.

What grade of haemorrhoid is she describing?

A 13 year old girl presents with worsening right iliac fossa pain, fever and anorexia for 3 days. She has no coryza or other symptoms.

Examination revealed right iliac fossa tenderness with guarding.

Blood tests reveal mildly raised inflammatory markers, but are otherwise normal. A urine dipstick and hCG are unremarkable.

The surgical team decide to take the patient to theatre to perform a laparoscopic appendicectomy. During the procedure they note that the appendix looks normal. However, they find a 5cm long, inflamed appendage roughly 60cm proximal to the terminal ileum.

What is the diagnosis?

A 62 year old man presents with acute severe epigastric pain radiating to his back. He has associated nausea and vomiting. He rarely visits his GP and is not known to have any ongoing health problems. He admits to heavy alcohol consumption. 

He has epigastric tenderness. 

Blood pressure: 135/84. Heart rate: 108. Respiratory rate: 20. Oxygen saturations: 98%. Temperature: 37.6°C.

Blood results show:

• Hb 126 g/L (normal 120 – 165)
• WBC 12 x 10⁹/L (normal 4.0 – 11.0)
• Neutrophils 8 x 10⁹/L (normal 1.5 – 8.0)
• Platelets 421 x 10⁹/L (normal 150 – 450)

• Bilirubin 20 μmol/L (normal 0 – 21)
• Alanine transaminase 270 U/L (normal 10 – 35)
• Alkaline phosphatase 125 U/L (normal 30 – 130)
• Albumin 30 g/L (normal 35 – 50)

• Sodium 145 mmol/L (normal 133 – 146)
• Potassium 4.5 mmol/L (normal 3.5 – 5.3)
• Urea 7.6 mmol/L (normal 2.5 – 7.0)
• Creatinine 54 μmol/L (normal 45 – 84)
• eGFR >90 ml/min (normal above 90)

• Amylase 780 U/L (normal 28 – 100)
• Calcium 1.96 mmol/L (normal 2.2 – 2.6)
• Glucose 15.4 mmol/L
• PaO₂ 12.3. kPa (normal 11.0 – 14.4)

What is his Glasgow score?

An 80 year old man presents with acute, generalised, non-specific severe abdominal pain. Acute mesenteric ischaemia is suspected. 

What investigation will be most helpful in demonstrating bowel ischaemia?

A 64 year old presents feeling tired. He has no other symptoms and it otherwise fit and well. On examination, he has conjunctival pallor and appears slightly pale. There are no other clinical findings.

Blood tests are taken:

• Hb 75 g/L (normal 130 -180)
• WBC 6.5 x 10⁹/L (normal 4.0 – 11.0)
• Platelets 400 x 10⁹/L (normal 150 – 450)
• MCV 63 fL (normal 80 – 100)

• Sodium 138 mmol/L (normal 133 – 146)
• Potassium 4.2 mmol/L (normal 3.5 – 5.3)
• Urea 6.4 mmol/L (normal 2.5 – 7.0)
• Creatinine 90 μmol/L (normal 59 – 104)
• eGFR 74 ml/min (normal above 90)

• B12 256 pg/ml (normal 150 – 1000)
• Folate 5.1 ng/mL (normal 2.7 – 17.0)
• Ferritin 4 ng/mL (normal 25 – 350)

• TSH 3.2 mU/L (0.27 – 4.2)

What would be the most appropriate investigation to perform next?

You are asked to see a 16 year old boy with abdominal pain.

He describes a 24 hour history of abdominal pain, starting generally in the middle of his abdomen, now isolated in his right iliac fossa. He also complains of fluctuating fever, nausea and a distinct lack of appetite.

On examination, you find tenderness and guarding over a specific point in his right iliac fossa.

You also notice that palpation of his left iliac fossa causes pain in his right iliac fossa. What is the name of this finding?

A 41 year old man presents with a lump in his groin on the left side. He has noticed that it is possible to make the lump disappear by carefully applying pressure, but then the lump reappears when he removes the pressure and stands up. 

The lump is soft and bowel sounds can be heard when auscultating the area. It is possible to reduce the lump and prevent it from reappearing by applying pressure with two fingertips over the mid-way point from the anterior superior iliac spine (ASIS) to the pubic tubercle.

What structure is the lump passing through to appear in his groin?

A 72 year old woman presents with frequent loose stools (3 times per day most days). She is otherwise well.

She undergoes a colonoscopy, which shows multiple small (less than 1cm) pouches extending out of the large bowel wall due to defects in the bowel wall muscle. The colonoscopy is otherwise normal.

What is the diagnosis?

You are discussing a patient’s case with your consultant. The patient will undergo surgery for cancer of the proximal transverse colon.

The consultant is explaining how they plan to remove the tumour by cutting out the affected section of the large bowel. The two remaining ends of the large bowel will be anastomosed to ensure the large bowel is continuous. This anastomosis will initially be protected with a temporary stoma. The stoma will be formed from the small bowel, taken outside of the skin, folded and opened, leaving the two ends of the small bowel (proximal and distal) open on the abdomen. This stoma would then be reversed in 6-8 weeks when the large bowel anastomosis has sufficiently healed.

With regard to the stoma, what procedure is the consultant describing?

A 48 year old man presents having recently noticed yellow skin, pale stools and dark urine. He has a past medical history of ulcerative colitis, diagnosed aged 20, and primary sclerosing cholangitis, diagnosed aged 39.

On examination, he is visibly jaundiced and has a palpable gallbladder, without any abdominal tenderness.

He has a CT scan, which shows a mass obstructing the biliary system.

What diagnosis are you suspecting?

A 61 year old man requires a liver transplant for chronic liver failure caused by excessive alcohol consumption. He stopped drinking when he started to develop symptoms of liver failure 18 months ago. He plans to never consume alcohol again.

Which of the following would likely prevent him from receiving a liver transplant?

A 70 year old woman undergoes a left hemicolectomy for a T2N0M0 tumour of the descending colon. The surgery goes well, and she makes a full recovery.

What investigation is likely to be included as part of her follow-up monitoring for recurrence?

A 45 year old overweight woman presents with right upper quadrant pain and tenderness for 24 hours. She is otherwise fit and well.

There is tenderness and guarding in her right upper quadrant. She is afebrile.

Blood tests are as follows:

• Hb 127 g/L (normal F 120 – 165)
• WBC x 13.2 10⁹/L (normal 4.0 – 11.0)
• Platelets 390 10⁹/L (normal 150 – 450)

• Bilirubin 36 μmol/L (normal 0 – 21)
• Alanine transaminase 64 U/L (normal F 10 – 35 / M 10 – 50)
• Alkaline phosphatase 270 U/L (normal 30 – 130)
• Albumin 37 g/L (normal 35 – 50)

• CRP 198 mg/L (normal <10)

What would be the most appropriate initial imaging investigation?

A 19 year old man presents to the surgical team with right iliac fossa pain. The pain started 2 days ago and has gotten progressively worse. He also complains of feeling hot and cold and completely losing his appetite.

On examination, he is tender over the right iliac fossa, with guarding and rebound tenderness. Palpation of his left iliac fossa exacerbates the pain in his right iliac fossa. There is no palpable mass.

Blood pressure: 123/79. Heart rate: 86. Respiratory rate: 18. Temperature: 37.8°C. Oxygen saturation: 98%.

His blood tests reveal a CRP of 132 mg/L (normal <10) and a white blood cell count of 13 x 10⁹/L (normal 4.0 – 11.0). Otherwise, they are normal.

Besides an ABCDE assessment and analgesia, what is the most appropriate next step?

A 43 year old man is day 2 post-op after an open appendicectomy for acute appendicitis with perforation of the appendix.

He has not opened his bowels since the operation. His abdomen has been gradually increasing in size and he has started to vomit this morning.

On examination, his abdomen is distended with sluggish bowel sounds. Rectal examination reveals an empty rectum. He is haemodynamically stable.

What is the most likely diagnosis?

An 83 year old man presents to the emergency department with abdominal pain and distention. This has been gradually getting worse for the last 24 hours, and he has not opened his bowels or passed wind in that time. He has vomited twice over the last few hours. He normally lives in a nursing home due to his Alzheimers disease, but is otherwise mobile and only takes statins and antihypertensives. He is prone to constipation and occasionally requires laxatives.

On examination, he has a distended, generally tender abdomen with high pitched bowel sounds.

An abdominal x-ray shows distended bowel that looks like a large coffee bean across the abdomen.

Given the likely diagnosis, what is the pathophysiology?

A 60 year old woman presents with abdominal distention, generalised abdominal pain, vomiting and absolute constipation.

She is made nil-by-mouth, an NG tube is inserted and she is prescribed 3 litres of normal 0.9% saline over the next 24 hours.

What electrolyte disturbance is most likely to result from this fluid prescription?

A 45 year old woman presents with acute right upper quadrant pain and fever, developing over the past 18 hours. She has right upper quadrant tenderness on examination. You notice a yellow discolouration to her sclera.

Blood pressure: 100/58. Heart rate: 122. Respiratory rate: 22. Temperature: 38.8°C. Oxygen saturation: 97%.

The abnormalities on her blood tests include:

• WBC 14.5 x 109/L (normal 4.0 – 11.0)
• CRP 280 mg/L (normal <10)
• Bilirubin 130 μmol/L (normal 0 – 21)
• Alkaline phosphatase 195 U/L (normal 30 – 130)

She is started on treatment for sepsis, given analgesia and reviewed by the surgical registrar and consultant. After fluid resuscitation and IV antibiotics, she becomes haemodynamically stable.

An abdominal ultrasound scan reveals stones blocking her common bile duct.

What is the most appropriate next step?

A 20 year old woman is undergoing a laparoscopic appendicectomy. She is a non-smoker and has a history of motion sickness.

The anaesthetist is considering prescribing ondansetron as prophylaxis for post-operative nausea and vomiting.

What would be a contraindication to this choice of antiemetic?

A 51 year old woman is being prepared to have an elective cholecystectomy for gallstones. Which of her regular medications will need to be stopped prior to the operation?

A 74 year old man presents with yellowing to his sclera. He has also been losing weight despite no change in lifestyle. On further questioning, he admits to having some generalised itching, pale stools and dark urine.

On examination, there is a yellow discolouration to his sclera. There is no abdominal tenderness.

What additional examination finding would complete Courvoisier’s law?

An 81 year old man is diagnosed with bowel cancer, confirmed on a biopsy taken during a colonoscopy procedure. Based on his staging CT scan, it appears the cancer may have spread to several local lymph nodes but no distant metastases are identified. The multidisciplinary team meeting suggests proceeding with a combination of surgery and chemotherapy.

The patient considers the situation over the next week and decides he does not want to proceed with treatment. It is determined that he is able to fully understand the implications of the decision, retain the information, weigh up the options and communicate the decision.

His daughter disagrees with his decision and feels that he should have the treatment. She explains that she has lasting power of attorney (LPA) for health and welfare and is able to provide evidence of this.

What should be done?