Hernia and Acute Abdomen MCQ

1. The most common hernia in females is:

A. Femoral hernia.
B. Direct inguinal hernia.
C. Indirect inguinal hernia.
D. Obturator hernia.
E. Umbilical hernia.
Answer: C
DISCUSSION: Indirect inguinal hernias are the most common hernia in both
females and males. Femoral hernias are more common in females than in
males.

2. Which of the following statements regarding unusual hernias is incorrect?

A. An obturator hernia may produce nerve compression diagnosed by a
positive Howship-Romberg sign.
B. Grynfeltt's hernia appears through the superior lumbar triangle, whereas
Petit's hernia occurs through the inferior lumbar triangle.
C. Sciatic hernias usually present with a painful groin mass below the
inguinal ligament.
D. Littre's hernia is defined by a Meckel's diverticulum presenting as the sole
component of the hernia sac.
E. Richter's hernia involves the antimesenteric surface of the intestine within
the hernia sac and may present with partial intestinal obstruction.
Answer: C
DISCUSSION: Sciatic hernias usually present with intestinal obstruction or a
mass in the gluteal or infragluteal region.

3. Staples may safely be placed during laparoscopic hernia repair in each of

the following structures except:
A. Cooper's ligament.
B. Tissues superior to the lateral iliopubic tract.
C. The transversus abdominis aponeurotic arch.
D. Tissues inferior to the lateral iliopubic tract.
E. The iliopubic tract at its insertion onto Cooper's ligament.
Answer: D
DISCUSSION: Placement of staples inferior to (below) the lateral iliopubic
tract may result in injury to the lateral femoral cutaneous nerve or the
genitofemoral nerve. Staples should also not be placed within the triangle of
doom, owing to the risk of major vascular injury.

4. The following Nyhus classification of hernias is correct except for:

A. Recurrent direct inguinal herniaType IVa.
B. Indirect inguinal hernia with a normal internal inguinal ringType I.
C. Femoral herniaType IIIc.
D. Direct inguinal herniaType IIIa.
E. Indirect inguinal hernia with destruction of the transversalis fascia of
Hesselbach's triangleType II.
Answer: E
DISCUSSION: An indirect inguinal hernia with destruction of the
transversalis fascia of Hesselbach's triangle is classified as a Type IIIb hernia.
Also classified as Type IIIb hernias are sliding, pantaloon, and massive
scrotal hernias. Type II hernia is an indirect inguinal hernia with a dilated
internal ring but without displacement of the inferior deep epigastric vessels
or destruction of the transversalis fascia of Hesselbach's triangle.

5. Which of the following statements about the causes of inguinal hernia is

correct?
A. Excessive hydroxyproline has been demonstrated in the aponeuroses of
hernia patients.
B. Obliteration of the processus vaginalis is a contributing factor for the
development of an indirect inguinal hernia.
C. Physical activity and athletics have been shown to have a protective effect
toward the development of inguinal hernias.
D. Elevated levels of circulating serum elastalytic activity have been
demonstrated in patients with direct herniation who smoke.
E. The majority of inguinal hernias are acquired.
Answer: D
DISCUSSION: A correlation between cigarette smoking and an inguinal
hernia formation has been demonstrated. Elevated circulating serum
elastalytic activity and free active unbound neutrophil elastase has been
detected in smokers.

6. The following statements about the repair of inguinal hernias are true
except:
A. The conjoined tendon is sutured to Cooper's ligament in the Bassini hernia
repair.
B. The McVay repair is a suitable option for the repair of femoral hernias.
C. The Shouldice repair involves a multilayer, imbricated repair of the floor
of the inguinal canal.
D. The Lichtenstein repair is accomplished by prosthetic mesh repair of the
inguinal canal floor in a tension-free manner.
E. The laparoscopic transabdominal preperitoneal (TAPP) and totally
extraperitoneal approach (TEPA) repairs are based on the preperitoneal
repairs of Cheattle, Henry, Nyhus, and Stoppa.

Answer: A
DISCUSSION: The Bassini repair is accomplished by high ligation of the
hernia sac followed by suturing the conjoined tendon and the internal oblique
muscle to the inguinal ligament.
7. Which of the following statements concerning the abdominal wall layers
are correct?
A. Scarpa's fascia affords little strength in wound closure.
B. The internal abdominal oblique muscles have fibers that continue into the
scrotum as cremasteric muscles.
C. The transversalis fascia is the most important layer of the abdominal wall
in preventing hernias.
D. The lymphatics of the abdominal wall drain into the ipsilateral axillary
lymph nodes above the umbilicus and into the ipsilateral superficial inguinal
lymph nodes below the umbilicus.
Answer: ABCD
DISCUSSION: The integrity of the abdominal wall is maintained principally
by the transversalis fascia. Scarpia's fascia affords little strength in wound
closure, but its approximation contributes considerably to the creation of an
aesthetically acceptable scar. The cremasteric muscles of the spermatic cord
are a continuation of muscle fibers from the internal abdominal oblique
musculature. The lymphatic supply of the abdominal wall follows a simple
pattern. These superficial lymphatics run parallel to the superficial veins,
which above the umbilicus drain into the ipsilateral axillary vein and below it
into the ipsilateral femoral vein.

8. Which of the following congenital abnormalities are correctly defined?

A. Omphalocele represents a defect in the abdominal wall lateral to the
umbilical cord.

B. The herniated viscera associated with omphaloceles are usually covered

with a membranous sac.
C. An umbilical polyp is a small excrescence of omphalomesenteric duct
mucosa that is retained in the umbilicus.
D. Meckel's diverticulum results when the intestinal end of the
omphalomesenteric duct persists and represents a true diverticulum.
Answer: BCD
DISCUSSION: Omphalocele may be seen in newborns and represents a
defect in the closure of the umbilical ring. The herniated viscera are usually
covered with a sac. Gastroschisis, a defect of the abdominal wall lateral to the
umbilical cord, is caused by failure of closure of the body wall. The intestines
protrude through the defect, and no sac is present to cover the herniated
intestine. In the fetus, the omphalomesenteric duct may present as
abnormalities related to the abdominal wall when the duct fails to obliterate.
Meckel's diverticulum is the result of the failure of obliteration of the
intestinal end of the omphalomesenteric duct. This is a true diverticulum with
all layers of the intestinal wall represented. An umbilical polyp is a small
excrescence of omphalomesenteric duct mucosa retained in the umbilicus.
Such polyps resemble umbilical granulomas except that they do not disappear
after silver nitrate cauterization. Appropriate treatment is excision of the
mucosal remnant.

9. The following statement(s) is/are true concerning the indications for

treatment of an inguinal hernia.
a. Most adult hernias will remain stable in size, therefore delay seldom affects
the technical aspects of a surgical repair
b. There is a direct correlation between the length of time that a hernia is
present and the risk of major complications
c. The morbidity and mortality associated with emergent operation due to

hernia complications is significantly greater than for elective repair of the

identical hernia
d. A truss maintains a hernia in the reduced state, therefore, minimizing the
risk of incarceration and strangulation
Answer: b, c
The indications for hernia repair must be individualized for each patient and
the particular situation. In general, the presence of a hernia may be
considered an adequate indication for hernia repair. Certainly the presence of
complications due to hernia necessitates the correction of those complications
and usually the repair of the hernia. As with any treatment, the benefits of
operative repair must be weighed against the natural history of the disease,
the extent to which the treatment can correct the problem, the possibility of
treatment-related injury, and the interference of concomitant disease with the
treatment results. With a few exceptions, the natural history of an abdominal
wall hernia is that the size of the defect and the sac enlarges over time, and
this enlargement increases the difficulty of adequate repair and the chances of
recurrence of the hernia. The risk of major complications is greater in an
individual patient, the longer the exposure to a hernia and the larger the sac
relative to the hernia defect. In addition, major complications necessitate an
emergent operation with attended high mortality and morbidity relative to
that experienced with an elective repair. The use of a truss, an external
support device using a system of straps to exert regional pressure over the
hernia defect, should generally be avoided. Trusses do not consistently
maintain a hernia in the reduced state, and they may put an unreduced hernia
in greater jeopardy of strangulation. The pressure exerted induces edema by
decreasing lymphatic and venous flow out of the herniated bowel. Trusses
may also lead to injury to the skin overlying the hernia.

10. Which of the following statement(s) is/are true concerning the diagnosis
and management of epigastric hernias?

a. A large peritoneal sac containing abdominal viscera is common

b. At the time of surgical repair, a careful search for other defects should be
performed
c. Recurrent epigastric hernias after simple closure is uncommon
d. Patients with symptoms of a painful midline abdominal mass frequently
will contain incarcerated small bowel
Answer: b
Epigastric hernias are usually small but they vary considerably in size. Most
of these defects occur in the midline. The small defects contain only
preperitoneal fat with no sac. With increasing size, fat in the falciform
ligament and eventually a peritoneal sac and abdominal viscera may be
contained within the hernia. The preperitoneal fat in the small defect is
usually incarcerated. Multiple defects may be present in up to 20% of
patients. Surgical treatment is recommended in all adult patients with
symptoms or with a hernia defect greater than 1.5 to 2 cm. in diameter.
Methods of repair depend upon the size of the defect. For small defects,
simple closure with obliquely placed sutures after reduction or removal of the
preperitoneal fat from the defect has been recommended. However recurrent
epigastric hernias in up to 10% of the cases have been reported with this
method, most likely as a result of additional undetected or unrepaired
weaknesses in the epigastric midline.

11. The following statement(s) is/are true concerning neurovascular structures

in the inguinal region.
a. The inferior epigastric artery and vein run upward in the preperitoneal fat
posterior to the transversalis fascia close to the lateral margin of the internal
inguinal ring
b. The iliohypogastric and ilioinguinal are motor and sensory nerves in the

inguinal region which lie beneath the external oblique aponeurosis

c. The ilioinguinal nerve runs anterior to the spermatic cord in the inguinal
canal and at the superficial inguinal ring, branches into the sensory supply to
the pubic region and the upper scrotum or labium majoris
d. The genital branch of the genitofemoral nerve is a sensory nerve only to
the upper thigh and genital area
Answer: b, c
Arising anteriorly from the external iliac artery, the inferior epigastric artery
with its accompanying vein runs obliquely medially and upward in the
preperitoneal fat, posterior to the transversalis fascia and close to the inferior
margin of the internal inguinal ring. Inguinal hernias arising superior to the
inferior epigastric vessels are indirect inguinal hernias, whereas those arising
inferior to the vessels are direct inguinal hernias. The iliohypogastric and
ilioinguinal nerves are motor and sensory nerves to the muscles and skin of
the inguinal region. The nerves penetrate the transversus abdominis muscle at
the point above the middle of the iliac crest, lie below the internal oblique
muscle up to the point just medial and superior to the anterior superior iliac
spine, and then penetrate the internal oblique muscle and lie below the
external oblique aponeurosis. The ilioinguinal nerve runs anterior to the
spermatic cord in the inguinal canal and at the superficial inguinal ligament,
branches into sensory supply to the pubic region and the upper scrotum or
labium majoris. The genital branch of the genitofemoral nerve perforates the
transversalis fascia usually just inferior to the internal ring. It courses along
the posterior surface of the spermatic cord and supplies motor fibers to the
cremaster muscle. At the superficial inguinal ring, it divides to provide
sensory innervation to the scrotum and medial aspect of the upper thigh.

12. In advising a patient preoperatively of potential complications of

operative treatment of an inguinal hernia, which of the following statement(s)
is/are true?

a. Severe symptoms due to sensory nerve entrapment or injury can occur

b. The most common vascular structure injured during the course of a groin
hernia repair is the femoral artery
c. Recurrent hernia after primary groin repair should occur in less than 10%
of cases
d. Wound infection increases the risk of recurrent hernia
Answer: a, c, d
Many complications can occur with operations to repair an inguinal hernia.
Sensory nerve injury may lead to disabling symptoms from neuromas or
nerve entrapment during inguinal hernia repair. Although vascular injuries are
uncommon in inguinal repair, the proximity of the femoral vein to the
structures used in the hernia repair makes injury of this vessel the most
frequent vascular injury observed. Hernia recurrence after primary groin
hernia repairs should be infrequent and varies in several large series from less
than one percent to almost nine percent. The prevalence of recurrent hernia
may be higher after repair of recurrent groin hernia. Factors responsible for
hernia recurrence include closure under excessive tension, failure to identify
and use an adequately strong musculoaponeurotic tissue, and wound
infection.

13. Chylous ascites is the accumulation of chyle within the peritoneal cavity.
Which of the following statement(s) is/are true concerning chylous ascites?
a. The cisterna chyli lies at the anterior surface of the first and second lumbar
vertebrae and receives lymphatic fluid from the mesenteric lymphatics
b. Chylous ascites is most commonly associated with abdominal lymphoma
c. Paracentesis and analysis of chylous fluid typically reveals elevated
triglycerides, protein, and leukocyte levels with cytologic analysis reflecting
the underlying presence of malignancy

d. Treatment of chylous ascites with dietary manipulation will be successful

in most cases
e. The mortality rate in adults with chylous ascites is in excess of 50%
Answer: a, b, e
Chylous ascites is accumulation within the peritoneal cavity of chyle, a
lymphatic fluid with a high lipid content. Access of intestinal lipids to the
circulation is via mesenteric lymphatics that enter the cisterna chyle, which in
turn becomes the thoracic duct which eventually enters the venous system at
the junction of the left subclavian and internal jugular veins. The cisterna
chyli lies at the anterior surface of the first and second lumbar vertebrae
slightly to the right of the aorta. Chylous ascites may result from injury to
major lymphatic duct or the cisterna. However for lymphatic leakage to
persist, widespread occlusion of lymphaticovenous collaterals within the
abdomen must be present. Malignancy is the predominant cause (88%) of
spontaneous chylous ascites in adults, with lymphoma the most common
malignancy. Diagnostic studies must include not only documentation of
lymphatic origin of the abdominal fluid but also an attempt to delineate the
cause of chylous ascites. Paracentesis and analysis of chylous fluid typically
reveals elevated triglycerides, protein, and leukocyte levels, with a
predominance of lymphocytes. Unfortunately, cytology is seldom positive
despite the presence of malignancy. Lymphangiography may define the site
of lymphatic leak for patients in whom the leak is from the cisterna or
retroperitoneal lymphatics but not when from the mesenteric or hepatic
lymphatics. Of noninvasive studies, CT is the test of choice, with a high
diagnostic yield in nontraumatic chylous ascites in adults. Frequently,
laparotomy with node biopsy is required for histology and typing in cases
suspected to be cancer, particularly for lymphoma. Treatments for chylous
ascites have been directed toward decreasing lymph and triglyceride
accumulation. Successful resolution of chylous ascites has been achieved
using a fat-restricted diet with added medium-chain triglycerides in an
attempt to reduce lymphatic transport of triglycerides and perhaps intestinal

lymph flow. Although there have been reports of success using such dietary
manipulation, many failures have been reported. Therefore, in most patients
with chylous ascites, treatment is likely to be successful only when directed
toward the underlying cause. For patients with lymphoma, therapy effective
against lymphoma is likely to eliminate chylous ascites.
The prognosis for patients with chylous ascites is much better in infants and
children than in adults, principally because of the differences in causes of the
condition. A mortality of 21% is reported in infants and children whereas a
mortality of 88% has been noted in adults. Patients with chylous ascites with
associated neoplasms typically have the gravest prognosis.

14. Which of the statement(s) is/are true concerning laparoscopic hernia

repair?
a. General anesthesia is required
b. Either an abdominal or preperitoneal approach is possible
c. The use of prosthetic mesh is required in all variations
d. Long-term results suggest that the laparoscopic approach is equal or better
than traditional repairs
Answer: a, b, c
The laparoscopic approach to the repair of groin hernias has been recently
developed. Either a transabdominal approach, wherein the peritoneum in the
inguinal area is opened, and the repair is performed in the preperitoneum or
an entirely preperitoneal approach can be used. In either technique, which are
both performed under general anesthesia, after reducing the visceral contents
out of the hernia, the repair is performed by placing a sheet of prosthetic
mesh over the internal aspect of the inguinal floor and internal ring. Although
early results and short-term benefits appear promising, long-term follow-up
data is still not available to compare these techniques with traditional repairs.

15. A 28-year-old woman with a history of an appendectomy presents with a

nontender palpable mass in the right lower quadrant abdominal incision. The
following statement(s) is/are true concerning the diagnosis and management
of this patient.
a. The best diagnostic test involves imaging of the abdominal wall by either
CT or MRI
b. Resection of the mass with a 2 cm margin is usually adequate
c. Low dose radiation is a suitable alternative to surgery for primary
treatment
d. Re-resection for recurrence will likely have a higher rate of recurrence than
for primary resection
Answer: a
Desmoid tumors are fibromatous tumors that may resemble low-grade
fibrosarcoma but never metastasize. The tumor often infiltrates adjacent
muscle and has a high incidence of recurrence despite seemingly adequate
gross resection. The highest frequency is in women of childbearing age of
which over 90% of tumors are abdominal in location. For abdominal wall
desmoid tumors, approximately one-third are associated with a previous
operation at the tumor site. The most frequent presenting symptom is a
nontender, palpable abdominal wall mass. Diagnostic imaging is best carried
out by CT or MRI, which delineate the extent of involvement of the layers of
the abdominal wall and potential intraperitoneal extension. Initial treatment
of abdominal wall desmoid tumors is surgical. Because the margins of the
tumor are not easily determined and because the tumor often infiltrates
muscle and periosteum, limited margins around the gross tumor frequently
result in microscopic tumor at the margin. Recurrence rates for abdominal
desmoid tumors vary from 9% to 40%, and recurrence is frequent with
inadequate margins. A 5-cm margin of resection is considered adequate with
mono bloc resection of rib cage, pubic or iliac bone or involved portions of

organs such as bladder to achieve these margins. Reconstruction of the

abdominal wall with polypropylene mesh is necessary in most cases. In
patients in whom adequate margins of resection are achieved, there is no
benefit from adjuvant radiotherapy. Second and third resections after
recurrence have been associated with no higher rate of recurrence than
primary resection. Radiotherapy alone has achieved local control in desmoid
tumor in as many as 100% of tumors treated primarily and 75% of recurrent
tumors. Radiation doses at least 60 Gy are considered necessary for
consistent control. The large radiation dose risks major damage to adjacent
bowel and therefore primary radiation treatment of abdominal wall desmoid
tumors has a limited role.

16. Which of the following statement(s) is/are true concerning repair of

inguinal hernias?
a. The Bassini repair approximates the transversus abdominis aponeurosis
and transversalis fascia and the shelving edge of the inguinal ligament.
b. The Bassini repair is an adequate repair for a femoral hernia
c. A relaxing incision is important for repairs of direct and large indirect
inguinal hernias to prevent excessive tension in the closure
d. An advantage to the use of prosthetic material is the mesh incites formation
of scar tissue to further increase tensile strength provided by the mesh alone
Answer: a, c, d
The Bassini repair is an inguinal hernia repair used world-wide and has been
the standard against which other repairs are judged. The repair involves
approximation of the transversus abdominis aponeurosis and transversalis
fascia and the lateral edge of the rectus sheath to the shelving edge of the
inguinal ligament. A femoral hernia cannot be repaired by the Bassini repair
because the orifice to the femoral canal lies deep to the inguinal ligament. A
Coopers ligament repair does approximate the structures to the transversalis

fascia of the pectineal (Coopers) ligament between the pubic tubercle and
the femoral vein and therefore is appropriate for repair of a femoral hernia. A
relaxing incision for repairs of direct and large indirect inguinal hernias
prevents excessive tension in the closure. There are an increasing number of
proponents for the use of prosthetic material for the routine repair of inguinal
hernias. Prosthetic material, such as polypropylene mesh, have been used for
years for repair of large or recurrent inguinal and femoral hernias. The
prosthetic mesh provides a low-tension repair for such large defects which
otherwise could not be closed without excessive tension. In addition, the
mesh incites the formation of scar tissue to further increase tensile strength
beyond that provided by mesh alone. Results reported for inguinal hernia
repairs using mesh have been excellent, although there is a slight risk of
infection of the prosthetic material which must be considered.

17. The following statement(s) is/are true concerning the epidemiology of

inguinal hernias.
a. Inguinal hernias occur with a male-to-female ratio of about 7:1
b. Femoral and umbilical hernias are more common in women, with a
female-to-male ratio of 4:1
c. The frequency of inguinal hernias increases with age
d. Almost all umbilical hernias occur in the pediatric age group
Answer: a, c
Inguinal hernias are the most frequently occurring hernia by a factor of five
over other individual types. Umbilical hernias constitute about 14% of
hernias, femoral hernias about 5%, and other types are rare. There is a male
prevalence in inguinal hernias of about 7:1 (male-to-female), whereas there is
a female dominance in femoral and umbilical hernias of 8:1 and 7:1 (femaleto-male), respectively. For inguinal hernia, which occurs at all age levels,
frequency increases with age. Umbilical hernias have a bimodal distribution,

peaking in the pediatric population and then in the 40 to 60 year group, in

which the hernias are principally paraumbilical.

18. A 77-year-old multiparous female presents with a bowel obstruction. She

has no previous abdominal operations and no abdominal wall hernias can be
detected. In addition to her abdominal symptoms, she reports pain in her right
medial thigh. The following statement(s) is/are true concerning her diagnosis
and management.
a. Expectant management with nasogastric suction and IV fluid replacement
is indicated
b. A right groin approach is indicated for exploration and repair of the
presumed hernia
c. The use of a polypropylene mesh will likely be necessary for repair
d. A correct diagnosis can usually be made by visualizing an external mass in
the upper, medial thigh
Answer: c
An obturator hernia is a hernia that occurs through the obturator canal,
accompanied by the obturator vessels and the obturator nerve. Although rare,
most obturator hernias occur in older multiparous women and are
predominantly right-sided. Symptoms are frequently intermittent but tend to
be acute and become increasingly severe with incarceration of the hernia.
Intestinal symptoms predominate, but dysesthesia or pain in the medial thigh
with occasional radiation to the hip is often present. Dysesthesia results from
compression of either division of the obturator nerve. Although the hernia is
never externally visible, in a small percentage of patients a mass can be
palpated in the upper, medial thigh. A correct diagnosis of obturator hernia is
made in only about one-third of patients presenting with intestinal
obstruction. Plain radiographs are seldom helpful, however a CT scan will
usually confirm the diagnosis. Treatment is operative. There is no place for

expectant therapy, especially in a patient with pain an parasthesias along the

inner aspect of the thigh or with clinical or radiographic evidence of bowel
obstruction. Many surgical approaches have been promoted, but the
transabdominal approach should be used because it has several advantages. It
best confirms the diagnosis and exposes the obturator canal, orifice, vessels,
and nerve, also permitting bowel resection when required. The sac is dealt
with in a standard fashion. The hernia defect should be repaired, but repair
usually requires a polypropylene mesh patch because the margin of the defect
cannot be approximated primarily.

19. The following statement(s) is/are true concerning umbilical hernias in

adults.
a. Most umbilical hernias in adults are the result of a congenital defect carried
into adulthood
b. A paraumbilical hernia typically occurs in multiparous females
c. The presence of ascites is a contraindication to elective umbilical hernia
repair.
d. Incarceration is uncommon with umbilical hernias
Answer: b
An umbilical hernia in a child is usually considered to be congenital. Only
about 10% of umbilical hernias in adults are thought to be the result of a
congenital defect carried into adulthood. Most adult umbilical hernias are
acquired and are called paraumbilical hernias. The paraumbilical hernia
typically occurs in a multiparous female. Other patients with increased
intraabdominal pressure, particularly with concomitant chronic abdominal
distension as from ascites, are also at increased risk for the development of
paraumbilical hernias. Umbilical and paraumbilical hernias vary from small
to extremely large. Incarceration is frequent in the large hernias, which
typically have a small neck.

Indications for umbilical hernia repair in adults include symptoms,

incarceration, large hernia relative to the neck, and trophic changes in the
overlying skin. Among adults with associated ascites, repair is advocated to
avoid potentially serious complications. The presence of discoloration or
ulceration of overlying skin or a rapid increase in size of the hernia herald
impending rupture. Spontaneous rupture of the hernia in these patients can be
catastrophic and is frequently associated with mortality rates approaching
30%. By comparison, elective umbilical hernia repair can be performed
safely in patients with ascites with acceptable morbidity and mortality.

20. Retroperitoneal fibrosis is a fibrosing condition of retroperitoneum, which

is of significance as it generally encompasses the ureters and eventually
causes hydronephrosis and kidney damage. Which of the following
statement(s) is/are true concerning this condition?
a. The majority of cases are idiopathic in nature
b. A history of use of methysergide for treatment of migraine headaches
would be significant
c. There is no known association of malignancy with retroperitoneal fibrosis
d. The disease occurs more commonly in women than in men
Answer: a, b
Retroperitoneal fibrosis is a rare condition in which fibrosis develops in the
retroperitoneal space. The ureters frequently will become encompassed by the
process eventually causing hydronephrosis and kidney damage.
Retroperitoneal fibrosis occurs most commonly in the fifth and sixth decades
with a 2:1 male-female predominance. The pathophysiology of
retroperitoneal fibrosis remains to be delineated. In fully two-thirds of cases,
retroperitoneal fibrosis is idiopathic, however, an autoimmune process has
been suggested as a potential cause. About 12% of cases of retroperitoneal
fibrosis have been associated with the use of methysergide, a serotonin

agonist used for vascular and migraine headache, and in this subgroup
females outnumber males 2:1. Primary or metastatic malignancy in the
retroperitoneum is found in 8% of patients with retroperitoneal fibrosis.
Sarcomas are the most common primary tumors, but non-Hodgkin and
Hodgkin lymphomas and ureteral cancer have also been found. Metastases
have originated from cancer of the stomach, breast, colon, carcinoid,
pancreas, prostate, ovary, and cervix. The focus of tumor may be small but
may induce desmoplasia that is grossly indistinguishable from benign
variance of retroperitoneal fibrosis.

21. The following statement(s) is/are true concerning the anterior abdominal
wall musculature.
a. The lateral musculature of the abdominal wall consists of three muscle
layers. These are, from external to internal, the external oblique, the
transversus abdominis, and the internal oblique muscles
b. The transversalis fascia lies on the deep side of the transversus muscle and
extends to form an essentially complete fascial envelope of the abdominal
cavity
c. Above the semicircular line, the internal oblique aponeurosis splits into
posterior and anterior laminae
d. The rectus abdominis muscles originate on the ribs superiorly and on the
pubis inferiorly and are clearly distinct throughout their entire length
Answer: b, c
The anterior abdominal wall consists of a group of lateral sheet-like muscles
and paired, longitudinally-oriented flat muscles on either side of the midline.
The lateral musculature of the abdominal wall consists of three layers, each
of which has its fascicles running in an oblique angle to the others. The most
superficial of these lateral muscles is the external oblique muscle. The
internal oblique muscle lies deep to the external oblique muscle while the

transversus abdominis muscle is the innermost of the lateral abdominal wall

musculature. The transversalis fascia lies on the deep side of the transversus
muscle and extends to form an essentially complete fascial envelope of the
abdominal cavity. The semicircular line is defined by the lower edge of the
posterior sheath about 3 to 6 cm below the level of the umbilicus, and its
convexity is directed superiorly. Above the semicircular line, the internal
oblique aponeurosis splits into posterior and anterior laminae. The posterior
lamina joins with the transversus abdominis aponeurosis to form the posterior
rectus sheath. The anterior lamina fuses with the external oblique aponeurosis
to form the anterior rectus sheath. Below the semicircular line, the internal
oblique end transversus abdominis aponeurosis fuse to form an internal
lamina of the anterior sheath, with the external oblique aponeurosis forming
the external lamina of the anterior sheath. The medial paired rectus abdominis
muscles originate on the ribs superiorly and on the pubis inferiorly. Below the
semicircular line, the rectus muscles are nearly fused in the midline and
indistinct, and their posterior surfaces covered only with the transversalis
fascia.

22. A 48-year-old woman maintained on Warfarin for a history of cardiac

valvular replacement and a history of recent upper respiratory infection
presents with severe abdominal pain exacerbated by movement. Her physical
examination shows tenderness in the right paramedian area with voluntary
guarding but no peritoneal signs. The following statement(s) is/are true
concerning the diagnosis and management of this patient.
a. Urgent laparotomy should be performed because of concern for arterial
mesenteric embolus
b. The correct diagnosis could likely be made by CT scan and operation
avoided
c. The status of her anticoagulation should be checked and if her prothrombin
time is excessively prolonged, correction is necessary

d. If untreated, hemodynamic instability is common

Answer: b, c
Rectus sheath hematoma results from arterial or venous bleeding into the
rectus sheath, most commonly from arterial bleeding. Rectus sheath
hematomas predominate in women by a ratio of about 3:1. The mean age of
incidence is in the late fifth decade. Although spontaneous formation of a
rectus hematoma is rare, it can occur with vasculitis, arterial venous
malformations, a severe coagulopathy, or with the administration of
anticoagulants. The usual cause is trauma. Events as trivial as sneezing,
coughing, or twisting to the side have initiated a rectus hematoma.
Abdominal pain is almost always described at presentation. Pain is often
described as severe and usually is exacerbated by movements that require
muscular contraction of the abdominal wall. On examination, there is
tenderness over the rectus sheath, voluntary guarding, and often a diffuse
mass sensation in the area of tenderness. Contraction of the rectus muscle
exacerbates the pain and tenderness. Peritoneal signs are absent. Ecchymosis
may occur but usually appears several days after the onset of pain. In cases
where the hematoma dissects or originates inferiorly and expands into the
prevessicle and preperitoneal space, the hematocrit may fall significantly;
however, hemodynamic instability is distinctly unusual. When the
intraabdominal source of pain is unknown, ultrasound and particularly
computed tomography can delineate the hematoma and localize it to the
abdominal wall in almost all cases.
Treatment must take into consideration the cause, if known, and whether the
hematoma is stable or progressive. Coagulopathy should be corrected when
possible. For patients in whom the hematoma is stable, pain medication and
avoidance of muscular stress on the abdominal wall are sufficient. For
patients with progressive hematoma, the treatment of choice is evacuation of
the hematoma from within the rectus sheath and hemostasis, sometimes
requiring ligation of the epigastric vessels above and below the hematoma.

23. True statements concerning the diagnosis and management of

retroperitoneal fibrosis include:
a. Most patients present with dull, non-colicky back, flank, or abdominal pain
b. Evidence of impaired renal function with an elevated blood urea nitrogen
is common
c. The diagnosis is most commonly suggested by intravenous pyelography
although contrast studies with CT scan or MRI are useful in further defining
the disease
d. Most patients can be managed nonoperatively
e. The prognosis for nonmalignant retroperitoneal fibrosis is grim with
progression of disease until death occurring in most patients
Answer: a, b, c
Ninety percent of patients with retroperitoneal fibrosis present with dull, noncolicky pain in the back, flank, or abdomen. Other symptoms include weight
loss, non-specific gastrointestinal complaints, and uncommonly, lower
extremity edema, malaise, and dysuria. Laboratory studies may be normal in
25% of patients, but 55% of patients will have an elevated blood urea
nitrogen. Diagnosis is most commonly suggested by intravenous
pyelography. The combination of medial deviation of the ureter,
hydroureteronephrosis, and extrinsic ureteral compression are highly
suggestive of retroperitoneal fibrosis. CT scanning or MRI can both define
the level of ureteral involvement and depict the mass appearance of the
fibrotic process. Exploratory laparotomy with multiple deep biopsies of the
retroperitoneal process is an essential part of diagnosis, since foci of
carcinoma may be sparse within the predominately sclerotic reaction.
Treatment for retroperitoneal fibrosis must identify and deal with potential
causative agents, relieve the ureteral obstruction, and reverse the
inflammatory-fibrotic process. Renal obstruction may need to be relieved
acutely, either by retrograde ureteral stents or by percutaneous nephrostomy

tubes. Long-term resolution of ureteral obstruction most frequently has been

accomplished by operative freeing of the ureters from the fibrosis and
displacing them laterally or within the peritoneal cavity. Although renal
function is improved in more than 90% of cases so treated, in as many as
one-third of patients, ureteral obstruction recurs on the ipsilateral or
contralateral side. Prognosis for patients with nonmalignant retroperitoneal
fibrosis is good. Survivals of 86100% for several years have been reported.

24. The following statement(s) is/are true concerning incarceration of an

inguinal hernia.
a. All incarcerated hernias are surgical emergencies and require prompt
surgical intervention
b. Attempt at reduction of an incarcerated symptomatic hernia is generally
considered safe
c. Vigorous attempts at reduction of an incarcerated hernia may result in
reduction en masse with continued entrapment and possible progression to
obstruction or strangulation
d. Incarcerated hernias frequently cause both small and large bowel
obstruction
Answer: b, c
Hernia incarceration denotes the condition wherein viscera are contained
within a hernia sac and cannot be disgorged from the sac. Patients with an
incarcerated hernia may be asymptomatic except for the presence of a bulge.
Pain associated with an incarcerated hernia should be interpreted as
indicative of strangulation. Many hernias are of such size that they cannot be
reduced either spontaneously or manually. If the patient is asymptomatic,
elective surgery should be planned. In a patient with pain, attempt at
reduction is relatively safe as long as excessive force is not applied. An
incarcerated hernia with discomfort or signs of bowel obstruction is best

treated with urgent hernia repair, although gentle attempts at reduction may
be without consequences. Reduction of a symptomatic hernia may result in
reduction of gangrenous bowel into the peritoneal cavity. Reduction of bowel
with necrotic areas eventuates in bowel perforation and peritonitis with an
associated 10% to 30% mortality and high levels of morbidity. Vigorous
attempts at reduction may result in reduction en masse, in which the viscera
remain within the peritoneal sac after reduction with the entire sac and its
contained viscera forced through the abdominal wall defect into the
preperitoneal layer. Reduction en masse usually occurs when a small fibrous
neck traps enclosed viscera and is associated with a high risk of continued
entrapment and progression to obstruction or strangulation.
World-wide hernias are the leading cause of intestinal obstruction. The
obstruction is almost exclusively small intestinal with only rarely the colon as
the site of obstruction.

25. A careful history is necessary in all patients being considered for inguinal
hernia repair. Symptoms which deserve investigation and appropriate
treatment prior to proceeding with inguinal hernia repair include:
a. Chronic cough
b. Urinary hesitancy and straining
c. Change in bowel habit
d. A specific episode of muscular straining with associated discomfort
Answer: a, b, c
The history and physical examination are almost exclusively the diagnostic
modalities used for diagnosis and delineation of hernias. Chronic trauma in
the form of overstretching of musculoaponeurotic structures is likely to be the
significant factor in spontaneously occurring hernias. Failure to recognize
underlying pathology contributing to symptoms of abdominal straining may
both increase the risk of recurrent hernia as well as miss significant existing

pathology. A chronic cough from chronic obstructive pulmonary disease

should be investigated and attempts made to control symptoms. Significant
obstructive uropathy may warrant urologic consultation and treatment prior to
hernia repair. Such treatment is important both to prevent postoperative
urinary retention, as well as persistent straining on the newly-completed
repair. Change in bowel habits with constipation or the presence of blood
associated with bowel movements may suggest a rectal or left-sided colon
cancer. Patients frequently relate a specific episode of muscular straining
during which a sudden discomfort occurs followed by hernia symptoms of
discomfort or a bulge. There is little evidence to suggest that such a specific
acute event can precipitate a hernia. A history of heavy lifting is important,
however, in both planning of postoperative disability as well as consideration
for long-term recurrence rates.

26. The following statement(s) is/are true concerning abdominal incisional

hernias.
a. Large incisional hernias are associated with a high recurrence rate when
closed primarily
b. A large potential space remains anterior to the abdominal wall closure in
most patients indicating a need for postoperative wound drainage
c. The use of prosthetic mesh can often be avoided by employing relaxing
incisions in the anterior fascia parallel to the midline
d. Incisional hernias are frequently associated with a tissue deficit either due
to chronic retraction and scarring or the result of tissue necrosis from either
infection or tension at the initial closure
Answer: a, b, c, d
Repair of an incisional hernia can be difficult with several factors making
these hernias particularly challenging. First, incisional hernias are often
related to a postoperative wound infection, in which case associated fascitis

or muscle necrosis may result in loss of tissue. Second, a previous abdominal

wall closure under tension or with a technique that resulted in tension on
particular sutures may lead to a multifenestrated region of the
musculoaponeurotic abdominal wall near or slightly back from its margin.
Third, chronic retraction of the abdominal wall muscles result in a larger
defect. Fourth, a large potential space remains anterior to the abdominal wall
closure in the subcutaneous area; postoperative fluid accumulation in this
space contributes to the wound infection rate of 5%. Any such potential space
should have operatively placed drains.
The key to successful repair involves sufficient dissection and exposure of
the true musculoaponeurotic edge and exclusion of adjacent
musculoaponeurotic defects and avoidance of closing the wound under
tension. Large defects greater than 3 to 4 cm in diameter are seldom able to
be closed without excessive tension. The use of relaxing incisions decreases
tension and may be particularly useful in midline hernias and therefore may
avoid the need for prosthetic mesh.

27. Which of the following structures are derived from the external oblique
muscle and its aponeurosis?
a. The inguinal or Pouparts ligament
b. The lacunar ligament
c. The superficial inguinal ring
d. The conjoined tendon
Answer: a, b, c
The external oblique muscle and its aponeurosis, with its inferiorly and
medially-directed fascicles and the overlying innominate fascia lie deep to
the subcutaneous tissue. The inguinal ligament (Pouparts ligament) is the
inferior edge of the external oblique aponeurosis and extends from the
anterior superior iliac spine to the pubic tubercle, turning under itself

posteriorly and then superiorly to form a shelving edge. Medially, the

inguinal ligament turns under even further to form the lacunar ligament, as
part of its insertion on the pubis. The superficial inguinal ring is a triangular
opening in the external aponeurosis, with its apex superiorly in position
slightly above and lateral to the pubic tubercle, through which the cord exits
the inguinal canal. The conjoined tendon is commonly alluded to in
descriptions of inguinal hernia repairs. The conjoined tendon is the fusion of
the aponeurosis of the internal oblique and transversus abdominis muscles.

28. A number of special circumstances exist in the repair of inguinal hernias.

The following statement(s) is/are correct.
a. Simultaneous repair of bilateral direct inguinal hernias can be performed
with no significant increased risk of recurrence
b. The preperitoneal approach may be appropriate for repair of a multiple
recurrent hernia
c. A femoral hernia repair can best be accomplished using a Bassini or
Shouldice repair
d. Management of an incarcerated inguinal hernia with obstruction is best
approached via laparotomy incision
Answer: b
The approach to bilateral groin hernias is based on the extent of the hernia
defect. For hernias for which inguinal floor reconstruction is required (all
direct and moderate to large indirect inguinal hernias, all femoral hernias),
simultaneous repair of bilateral hernia results in recurrence of one or both of
the hernias twice as frequently as if the hernias were repaired sequentially.
Repair of recurrent inguinal or much less commonly femoral hernias can be
repaired via an anterior approach particularly at the time of first recurrence in
most cases. If a deficit of aponeurotic tissue exists, methods such as
polypropylene mesh as an overlay or preferably as an underlay, and tailored

around the spermatic cord have proved highly successful. The preperitoneal
approach also has potential benefits especially in cases of multiple recurrence
where the technique allows avoidance of the inevitable scar encountered with
the anterior approach, excellent assessment of the defect, and the ease for
placement of synthetic mesh. The Bassini and Shouldice repairs involve
approximation of the medial tissues of the transversus abdominis aponeurosis
and transversalis fascia to the inguinal ligament. These techniques cannot be
used to repair a femoral hernia because the femoral canal lies deep to the
inguinal ligament. Either the anterior approach of McVay (Coopers ligament
repair) or a preperitoneal approach is preferred for femoral hernias. In
patients with bowel obstruction attributed to a hernia, the primary operative
approach is on the hernia. Assessment of bowel viability is possible without
laparotomy in most cases, and release of adhesions holding the bowel within
the sac is more easily accomplished through direct entry into the hernia sac.
Reduction of the herniated and incarcerated bowel may be difficult from the
intraabdominal approach necessitating a counter incision over the external
presentation of the hernia.

29. Which of the following statements concerning intraperitoneal fluid

collections are correct?
A. Ascites occurs when either the peritoneal fluid secretion rate increases or
the absorption rate decreases.
B. Accumulation of lymph within the peritoneal cavity usually results from
trauma as tumor involving the intra-abdominal lymphatic structures.
C. Choleperitoneum (intraperitoneal bile) generally occurs following biliary
surgery, but spontaneous perforation of the bile duct has been reported.
D. The most common cause of hemoperitoneum is trauma to the liver or
spleen.
Answer: ABCD
DISCUSSION: Normally, there is a balance between fluid secretion and

absorption in the peritoneal cavity. Ascites occurs when either the secretion
rate increases or the absorption rate decreases disproportionately.
Accumulation of lymph in the peritoneal cavity usually results from trauma
or tumor involving lymphatic structures. Proposed treatment regimens range
from salt restriction and diuretics to surgical ligation and peritoneovenous
shunting. Uninfected bile is a mild irritant to the peritoneal cavity and causes
increased production of peritoneal fluid, resulting in bile ascities or
choleperitoneum. Most cases of choleperitoneum follow biliary tract surgery,
but cases of spontaneous bile duct perforation have been reported in infants
and some adults. The most common cause of hemoperitoneum is trauma to
the liver or spleen. Less common causes include ruptured ectopic pregnancy,
ruptured aortic aneurysms, and other intra-abdominal injuries.

30. The following statement about peritonitis are all true except:
A. Peritonitis is defined as inflammation of the peritoneum.
B. Most surgical peritonitis is secondary to bacterial contamination.
C. Primary peritonitis has no documented source of contamination and is
more common in adults than in children and in men than in women.
D. Tuberculous peritonitis can present with or without ascites.
Answer: C
DISCUSSION: Peritonitis is inflammation of the peritoneum and can be
septic or aseptic, bacterial or viral, primary or secondary, acute or chronic.
Most surgical peritonitis is secondary to bacterial contamination from the
gastrointestinal tract. Primary peritonitis refers to inflammation of the
peritoneal cavity without a documented source of contamination. It is more
common in children than in adults and in women than in men. The female
predominance is felt to be explained by entry of organism into the peritoneal
cavity through the fallopian tubes. The clinical manifestations of tuberculous
peritonitis are of two types. The moist form consists of fever, ascites,
abdominal pain, and weakness. The dry form presents in a similar manner but

without ascites.

31. True or false?

A. Mesenteric cysts are most often due to congenital lymphatic spaces that
gradually fill with lymph.
B. Mesenteric cysts usually present as abdominal masses accompanied by
pain, nausea, or vomiting.
C. Mesenteric cysts are best treated by marsupialization.
D. Omental cysts are frequently asymptomatic unless they undergo torsion.
Answer: A-TRUE, B-TRUE, C-FALSE, D-TRUE
DISCUSSION: Mesenteric cysts are most often due to congenital lymphatic
spaces that gradually enlarge as they fill with lymph. They generally present
as abdominal masses accompanied by pain, nausea, and vomiting. They
usually can be diagnosed by physical examination and have characteristic
lateral mobility. They are best treated by surgical excision, and intestinal
resection may be necessary for complete removal. Omental cysts are
frequently asymptomatic but may present with vague discomfort or as a
mobile abdominal mass that can cause torsion of the omentum. Torsion
generally presents with signs and symptoms compatible with acute
cholecystitis, appendicitis, or a twisted ovarian cyst. Treatment entails local
resection.

32. Which of the following statements about acute salpingitis are true?
A. The disease rarely occurs after menopause.
B. Gonococcal infection is most common.
C. There is minimal cervical tenderness to palpation.
D. Vaginal discharge occurs rarely.
Answer: AB

33. Acute appendicitis is most commonly associated with which of the

following signs?
A. Temperature above 104 F.
B. Frequent loose stools.
C. Anorexia, abdominal pain, and right lower quadrant tenderness.
D. White blood cell count greater than 20,000 per cu. mm.
Answer: C
34. Which of the following most often initiates the development of acute
appendicitis?
A. A viral infection.
B. Acute gastroenteritis.
C. Obstruction of the appendiceal lumen.
D. A primary clostridial infection.
Answer: C
DISCUSSION: The majority of patients with acute appendicitis have an
obstructed lumen that is due to either hyperplasia of the lymph follicles in the
wall of the appendix or a fecalith. The obstruction creates a site where the
bacteria in the lumen multiply rapidly, producing exotoxins and endotoxins
that then ulcerate the mucosa, allowing pathogenic organisms to enter the
wall of the appendix. An inflammatory process follows that can extend to the
serosa, and penetration through the serosal layer causes generalized
peritonitis.

35. The diagnosis of acute appendicitis is most difficult to establish in:

A. Persons aged 60 and older.
B. Women aged 18 to 35.
C. Infants younger than 1 year.
D. Pregnant women.
Answer: C

DISCUSSION: It is very difficult to establish a firm diagnosis of acute

appendicitis in an infant of 1 year or younger since the patient cannot provide
a history or be helpful during the physical examination. It is rare to make a
definitive diagnosis preoperatively in such infants, and in such cases the
appendix is usually perforated at the time of operation. While appendicitis is
somewhat more difficult to diagnose in the elderly because of the reduced
response to inflammation; nevertheless, it is usually possible to make the
diagnosis. With pregnant women it is wise to remember that the enlarging
uterus in the last trimester dislocates the appendix higher in the abdomen and
that the signs and symptoms follow this anatomic shift accordingly.

36. Once a diagnosis of acute appendicitis has been made and appendectomy
decided upon, which of the following is/are true?
A. Prophylactic antibiotics should be administered.
B. Prophylactic antibitics are not necessary unless there is evidence of
perforation.
C. If the appendix is not ruptured and not gangrenous, antibiotics may be
discontinued after 24 hours.
D. Multiple antibiotics are in all cases preferable to a single agent.
Answer: AC
DISCUSSION: It is generally held that patients with a diagnosis of acute
appendicitis should receive antibiotics such as cefoxitin or cefotetan.
Administration can be discontinued after 24 hours if the appendix is not
gangrenous or ruptured. Multiple antibiotics are unnecessary in
straightforward cases.

37. The best type of x-ray to locate free abdominal air is:
A. A posteroanterior view of the chest.

B. A flat and upright view of the abdomen.

C. Computed tomograph (CT) of the abdomen.
D. A lateral decubitus x-ray, right side up.
Answer: D
38. The most helpful diagnostic radiographic procedure in small bowel
obstruction is:
A. CT of the abdomen.
B. Contrast study of the intestine.
C. Supine and erect x-rays of the abdomen.
D. Ultrasonography of the abdomen.
Answer: C
39. The most commonly used imaging method for diagnosis of acute
cholecystitis is:
A. CT of the abdomen.
B. Ultrasonography of the gallbladder.
C. Oral cholecystogram.
D. Radionuclide (HIDA) scan of the gallbladder.
Answer: B
40. Acute salpingitis occurs most often:
A. After menopause.
B. In patients with unilateral lower abdominal pain.
C. During the menstrual cycle.
D. In patients with cervical tenderness and vaginal discharge.
Answer: D
41. Meckel's diverticulitis most often occurs in the:
A. Proximal jejunum.
B. Distal jejunum.
C. Proximal ileum.

D. Distal ileum.
Answer:D
42. A patient is seen in the emergency room with reproducible right lower
quadrant tenderness. The approximate incidence of finding a normal
appendix on right lower quadrant exploration in similar nonselected patients
is which of the following:
a. 5%
b. 10%
c. 20%
d. 40%
Answer: c
Appendectomy is the most common surgical procedure performed on an
emergency basis in Western medicine. Appendicitis has a negative
appendectomy rate of approximately 22% to 26% in broad based reviews.
The perforation rate is as low as 3.6% in a subset of young males, although
this rises substantially when the children or the elderly are included.
Likewise, young females represent a group at particularly high risk for other
intraabdominal pathology.

43. Of adult patients presenting to the emergency room for evaluation of

acute abdominal pain, which one of the following answers includes the most
common diagnoses?
a. Urologic problems, cholelithiasis, pelvic inflammatory disease
b. Mittelschmerz, appendicitis, ureterolithiasis
c. Nonspecific abdominal pain, appendicitis, intestinal obstruction
d. Appendicitis, pelvic inflammatory disease, perforated ulcer
Answer: c

Numerous surgical causes exist for the patient presenting with acute
abdominal pain. A recent review of nearly 1200 patients presenting for
emergency evaluation of abdominal pain affords some interesting findings.
The most common diagnosis was nonspecific abdominal pain, occurring in
35% of patients. Appendicitis (17%), intestinal obstruction (15%), urologic
problems (6%), and gallstones (5%) were the leading surgical causes. The
largest number of admissions occurred in the age groups 1029 years old
(31%) and 6079 years old (29%). Surgical procedures were required in 47%
of these patients. Large series of elderly patients presenting with acute
abdominal pain have found the leading diagnoses to be cholelithiasis,
nonspecific pain, malignancy, incarcerated hernia, ileus, and gastroduodenal
ulcer.

44. Nonsurgical causes of acute abdominal pain may include which of the
following?
a. Hyperthyrodism
b. Adrenal insufficiency
c. Pneumonia
d. Diabetic ketoacidosis
Answer: b, c, d
Many nonsurgical problems cause acute abdominal pain. A partial listing is
provided above. Of the choices in question, the only one that is not associated
with acute abdominal pain is hyperthyroidism. The remainder cause
abdominal pain through a variety of mechanisms, both direct and indirect.
NONSURGICAL CAUSES OF THE ACUTE ABDOMEN
METABOLIC
Diabetic ketoacidosis
Porphyria

Adrenal insufficiency
Uremia
Hypercalcemia
TOXIC
Insect bites
Venoms (scorpion, snake)
Lead poisoning
Drugs
MISCELLANEOUS
Hemolytic crises
Rectus sheath hematoma
NEUROGENIC
Herpes zoster
Abdominal epilepsy
Spinal cord tumor, infection
Nerve root compression
CARDIOPULMONARY
Pneumonia
Myocardial infarction
Myocarditis
Empyema
Costochondritis

45. Which of the following cause visceral pain from the abdominal organs?
a. Stretching and contraction
b. Traction, compression, torsion

c. Cutting
d. Certain chemicals
Answer: a, b, d
Abdominal pain can be divided into three categories; visceral, somatic, and
referred. The intramural sensory receptors of the abdominal organs are
responsible for visceral pain. A diverse group of destructive stimuli to the
abdominal viscera are painless. For example, almost all abdominal organs are
insensitive to pinching, burning, stabbing, cutting, and electrical and thermal
stimulation. The same is true for the application of acid and alkali to normal
mucosa.
The general classes of visceral stimulation that result in abdominal pain
include: (1) stretching and contraction; (2) traction, compression, and torsion;
(3) stretch alone; and (4) certain chemicals. Mediating receptors for these
responses are located intramurally in hollow organs, on serosal structures
such as the visceral peritoneum and capsule of solid organs, within the
mesentery and the mucosa. These receptors are polymodal, or responsive to
both mechanical and chemical stimuli. Mucosal receptors respond primarily
to chemical stimulation. Visceral pain almost always heralds intra-abdominal
disease but may not indicate the need for surgical therapy. When visceral pain
is superceded by somatic pain, the need for surgical intervation becomes
likely.

46. Factors which may influence the clinical presentation of intraabdominal

pathology include which of the following?
a. Pregnancy
b. Oral anticoagulants
c. Age
d. HIV infection
Answer: a, b, c, d

A variety of conditions influence the presentation of intraabdominal

pathology. Pregnancy is among these, principally because of displacement of
adjacent normal viscera and therefore a shift in the location of the parietal
pain. Oral anticoagulation is associated with the development of spontaneous
intramural hematomas of the bowel causing pain but not requiring surgical
resection. This pain may be confused with a variety of other intraabdominal
emergencies.
Age is likewise a confounding factor, generally in infancy and in the elderly.
In these age groups, the symptoms may be less pronounced and the
presentations occur later in the course of disease.
Immunocompromised patients are a heterogenous group that includes those
receiving allografts, chemotherapy, immunosuppressive drugs for
autoimmune disorders, and individuals with the acquired immunodeficiency
syndrome (AIDS). This group has a variety of specific abdominal
complications that must be appreciated and suspected by the evaluating
physician.
ACUTE ABDOMINAL PAIN ASSOCIATIONS IN THE
IMMUNOCOMPROMISED PATIENT
CYTOMEGALOVIRUS INFECTION
Interstitial pneumonitis
Mononucleosis
Pancreatitis
Hepatitis
Cholecystitis
Gastrointestinal ulceration
PANCREATITIS
Steroids
Azathioprine
Cytomegalovirus

Pentamidine
HEPATITIS
Hepatitis A, B, and C
Cytomegalovirus
Epstein-Barr virus
CHOLECYSTITIS
Cytomegalovirus
Acalculous cholecystitis
Campylobacter
HEPATOSPLENIC ABSCESS
Fungal
Mycobacterial
Protozoal
Splenic rupture
BOWEL PERFORATION
Lymphoma, leukemia (especially after chemotherapy)
Cytomegalovirus
Colon ulcers
Kaposi sarcoma
Pseudomembranous colitis
Mycobacteria
latrogenic
ACUTE GRAFT-VERSUS-HOST DISEASE
PSEUDOACUTE ABDOMEN
FECAL IMPACTION

STANDARD ABDOMINAL PROCESSES

Appendicitis
Cholecystitis
Diverticulitis
Bowel obstruction
Ulcer disease
Pelvic inflammatory disease
Perirectal abscess
Urinary tract infection
Lymphadenitis
NEUTROPENIC ENTEROCOLITIS

47. Prospective studies have shown incidental appendectomy to be

advantageous in which of the following patient groups?
a. Children undergoing staging laparotomy for malignancy who are then to
enter chemotherapy
b. HIV infected patients
c. Patients over 50 years of age
d. Patients with spinal cord injuries
e. None of the above
Answer: e
Several studies have looked at incidental appendectomies in a variety of
populations. The deficiency in all past studies of this issue is the lack of
prospective long-term trials to assess the true cost and benefit.
Incidental appendectomy is clearly not indicated in the elderly and in patients
undergoing laparatomy for staging of Hodgkins disease. These two specific
groups have been shown to have increased perioperative risks with incidental

appendectomy. No prospective studies have addressed the issue of HIV

infected or spinal cord injured patients. While incidental appendectomies may
be performed safely in general, it is difficult to justify any increase in
operative risk without demonstrable benefit.

48. Visceral pain is typically:

a. Well localized
b. Sharp
c. Mediated via spinal nerves
d. Perceived to be in the midline
Answer: d
Peritoneum is a continuous visceral and parietal layer. The nerve supply to
each layer is separate. The visceral layer, i.e., the layer surrounding all
intraabdominal organs, is supplied by autonomic nerves (sympathetic and
parasympathetic) and the parietal peritoneum is supplied by somatic
innervation (spinal nerves). The pathways relaying the sensation of pain
differ for each layer and differ in quality as well. Visceral pain is
characteristically dull, crampy, deep, aching and may involve sweating and
nausea. Parietal pain is sharp, severe and persistent. Visceral organs have
very little pain sensation, but stretching of the mesentery and stimulation of
the parietal peritoneum cause severe pain.
Normal embryologic development of the abdominal viscera proceeds with
bilateral midline autonomic innervation that results in visceral pain usually
being perceived as arising from the midline. Epigastric pain is typical of
foregut origin. Periumbilical pain signifies pain emanating from the midgut.
Hypogastric or lower abdominal midline pain indicates a hindgut origin.

49. True statements regarding the pathophysiology of acute appendicitis

include which of the following:

a. Fecaliths are responsible for the disease process in approximately 30% of
adult patients
b. Lymphoid hyperplasia is a rare cause of appendicitis in young patients
c. Clostridium difficile is implicated as a pathogenic organism
d. Carcinoid tumors account for approximately 5% of all cases of acute
appendicitis
Answer: a
The most common cause of appendicitis is obstruction of the appendiceal
lumen. In young children and young adults, the most common cause of
lumenal obstruction is lymphoid hyperplasia from the submucosal follicles
which are abundant. Lymphoid hyperplasia accounts for 60% of acute
appendicitis in the young. In adults, fecalith formation accounts for
approximately 30% of acute appendicitis. There is no known causative
relationship of Clostridium difficile or other specific organisms with acute
appendicitis. The normal flora of the appendix is consistent with that of the
adjacent cecum.
Neoplasms of the appendix are rare, occurring in 1% to 1.3% of all appendectomy
specimens. Carcinoid
mors are the most common, followed in frequency by benign and malignant
mucoceles.

50. A 26-year old woman in her first trimester of pregnancy presents with a 2day history of right lower quadrant pain and fever. Physical examination
reveals a tender, palpable, right lower quadrant mass. There is no evidence of
peritonitis or systemic sepsis. Laboratory evaluation is remarkable for mild
leukocytosis, and abdominal ultrasound demonstrates an inflammatory mass but no
evidence of abscess. As the surgeon on call, your recommendation would be:

a.

b. Intravenous hydration, antibiotic prophylasis, and urgent appendectomy

c. Intravenous hydration, antibiotics, bowel rest, and interval appendectomy
in 4 to 6 weeks
d. Intravenous hydration, antibiotics, and appendectomy if no improvement
in 12 to 24 hours
e. Intravenous hydration, antibiotics, and interval appendectomy when fever
has subsided, leukocyte count has returned to normal, and the patient is pain
free
f. Emergent obstetrical consultation for evaluation and treatment of possible
ectopic pregnancy
Answer: a
The patient presented has a perforated appendix with a phlegmon, but no
abscess. One must routinely provide resuscitation and broad spectrum
antiobiotic coverage in this circumstance. As she is not systemically toxic, it
would be rational in a nonpregnant patient to treat this patient nonoperatively
initially and follow this with interval appendectomy. However, in this
circumstance, the risk of preterm labor associated with anesthesia and pelvic
inflammation increases with more advanced gestation, so the best decision is
to proceed with intravenous hydration, broad spectrum antibiotic coverage
and urgent appendectomy.

51. True statements regarding appendiceal neoplasms include which of the

following?
a. Carcinoid tumors of the appendix less than 1.5 cm are adequately treated
by simple appendectomy
b. Appendiceal carcinoma is associated with secondary tumors of the GI tract
in up to 60% of patients

c. Survival following right colectomy for a Dukes stage C appendiceal

carcinoma is markedly better than that for a similarly staged colon cancer at 5
years
d. Mucinous cystadenocarcinoma of the appendix is adequately treated by
simple appendectomy, even in patients with rupture and mucinous ascites
e. Up to 50% of patients with appendiceal carcinoma have metastatic disease,
with the liver as the most common site of spread
Answer: a
Carcinoids represent two-thirds of all appendiceal neoplasms. Nearly half of
all GI carcinoids arise in the appendix at a mean age of 41 years. Two-thirds
of the time the carcinoid is only incidentally detected, only 0.5% have
evidence of distant metastatic spread at resection. In one experience,
carcinoids between 1.5 and 2.0 cm have had minimal metastatic potential and
those smaller than 1.5 cm never metastasized. In the 1% that are larger than 2
cm however, metastases are frequent and 80% recur even after resection at
this size.
Adenocarcinoma of the appendix is exceedingly rare. These tumors occur in
elderly patients at the base of the appendix. Appendicitis often follows and
the diagnosis is not made preoperatively and is rarely considered during
surgery since the appearance of the tumor may mimic perforated appendicitis.
Up to half the patients have metastatic disease at diagnosis and the
peritoneum is the most common site of spread. Survival is proportional to
tumor stage. Dukes Stage A disease may be treated simply with
appendectomy if all disease can be removed with reasonable margins. Dukes
B and C lesions require formal right hemicolectomy for disease control.
Survival is, stage for stage, similar to colon cancer after 5 years. Appendiceal
adenocarcinomas also appear to have an association with secondary tumors,
often of the GI tract, in up to 35% of patients.
Patients with mucinous cystadenocarcinoma of the appendix typically are

symptomatic, and wide resection of the primary disease, together with

debulking of peritoneal implants, is indicated. Indolent progression of
metastases commonly results in prolonged survival rates (50% at 5 years)
during which patients may require repeated laparatomies for complications of
the disease.