GENERAL ABDOMINAL SURGERY
What is the most likely diagnosis?
a. Inflammatory bowel disease
b. Irritable bowel syndrome (IBS)
c. Intussusception
d. Peptic ulcer disease
e. Biliary colic
Answer b. Irritable bowel syndrome (IBS)
This patient presents with all 3 Rome II diagnostic criteria for IBS, which are pain associated with:
• Improvement with defecation
• Association with change in frequency of stool
• Change in form of stool
The patient is experiencing splenic flexure syndrome. Splenic flexure syndrome is caused by gas collecting in splenic flexure, leading to distension of the capsule, causing pain. Furthermore, young women with a history of depression, anxiety, and other mood disorders are more predisposed to developing IBS. IBS presents with diarrhea, tenesmus, and fistulas in the case of Crohn’s disease. Intussusception is more common in children and presents with “currant jelly” stool, which is grossly bloody stool in clots. Peptic ulcer disease is less likely in the left upper quadrant and is mostly epigastric pain. Biliary colic is postprandial pain that is in the right upper quadrant.
Two major forms of IBS:
• Diarrhea-predominant IBS
• Constipation-predominant IBS
IgA protects mucosal surfaces such as the mouth and gastrointestinal tract.
IBS is a diagnosis of exclusion; patients must have an upper and lower colonoscopy and testing for celiac disease.
What is the best initial management of this patient?
a. Fiber supplementation
b. Antispasmodics (dicyclomine, hyoscyamine)
c. Imipramine
d. Probiotics
e. Lactose avoidance
Answer a. Fiber supplementation
Fiber acts as a bulking agents that aids in improving symptoms. Fiber actually helps all forms of IBS. Fiber bulks stool in diarrhea and makes it softer in constipation and adds bulk to prevent spasms. Antispasmodics such as hyoscyamine or dicyclomine are added if symptoms are not controlled with fiber, diet modification, and stress reduction. Tricyclic antidepressants are used when the patient is not helped by all of these other modalities of therapy. Probiotics have no proven benefit. Lactose avoidance is correct only for someone who presents with gas, bloating, and explosive diarrhea after ingesting dairy products.
Dicyclomine and hyoscyamine
• Block muscarinic receptors, leading to an anticholinergic effects
• Slow the bowel
Acetylcholine receptors:
• Nicotinic Receptor: Neuromuscular junction
• Muscarinic receptor: Saliva, lung, bladder, gut, heart
IBS-C manifests as constipation from days to months with infrequent periods of diarrhea or normal bowel function. Stool is described as hard or pellet-like.
What is the most appropriate therapy if the patient has IBS-C?
a. Polyethylene glycol (PEG)
b. Docusate sodium
c. Yoga
d. Linaclotide
Answer d. Linaclotide
In patients with IBS with constipation who have failed a trial of soluble fiber, the next step is PEG as a laxative. PEG does not help patients with abdominal pain or cramping and is, therefore, incorrect in this patient. Patients with persistent constipation despite treatment with PEG or unable to take PEG because of cramping or abdominal pain should be treated with lubiprostone or linaclotide.
Linaclotide: guanylate cyclase agonist that stimulates intestinal fluid secretion
Lubiprostone: chloride channel activator that stimulates chloride-rich fluid secretion
What is the most likely diagnosis?
a. Appendicitis
b. Diverticulitis
c. Cholecystitis
d. Ectopic pregnancy
e. Ovarian torsion
Answer a. Appendicitis
The presentation of right lower quadrant (RLQ) pain in a man with anorexia, nausea, and vomiting combined with pain to palpation at McBurney’s point or displaying Rovsing’s sign is appendicitis. However in females, who present with RLQ pain, the first step in management is to check a urine pregnancy test. If the result is negative, think appendix. In this case, the pregnancy test has already been done for you. Diverticulitis is more common in older patients and presents with left lower quadrant pain. Cholecystitis is usually in middle-aged obese women with right upper quadrant pain. Ectopic pregnancy and ovarian torsion can both present with fever and right lower quadrant pain. Ectopic pregnancy is why every woman with lower abdominal pain younger than age 50 years should have a pregnancy test ordered on CCS. Do not rely on sexual history. Ovarian torsion is acute, sharp, unilateral pain.
Women + Lower abdominal pain = Pregnancy test
The vermiform appendix is located at the base of the cecum near the ileocecal valve where the taenia coli converge on the cecum
Rovsing’s sign: Pain in RLQ with palpation of the LLQ
Press left + Pain right = Rovsing’s sign
Psoas sign is associated with a retrocecal appendix. This is manifested by right lower quadrant pain with right hip extension.
What is the most accurate diagnostic test for this patient?
a. Ultrasonography
b. Computed tomography (CT) scan of the abdomen and pelvis
c. Magnetic resonance imaging (MRI) of the abdomen
d. Radiography of the abdomen
Answer b. Computed tomography (CT) scan of the abdomen and pelvis
A CT scan of the abdomen is the most accurate diagnostic test for a patient with clinical evidence of appendicitis. Ultrasonography is only useful to rule in a diagnosis of appendicitis but cannot be used to reliably exclude the diagnosis. Furthermore, the sensitivity of ultrasonography diminishes with increasing abdominal girth. MRI of the abdomen is always the wrong answer for any acute abdominal inflammatory process because it takes too long. Radiography of the abdomen lacks the resolution and sensitivity to localize an acute process in the RLQ. Radiography can only be used to aid in excluding free air in the case of perforated appendix. Exploratory laparotomy is far too invasive as a diagnostic test of choice because the negative appendectomy rate can approach to 20% but as a therapeutic option is the next step in management.
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