(1) With regard to appendicitis: T F False False False True False (a) McBurney's point lies one third

of the way along a line drawn from the umbilicus to the right anterior superior iliac spine. (b) The presence of an appendix mass necessitates immediate surgical intervention. (c) A normal white cell count excludes appendicitis. (d) Loss of appetite is a common feature of acute appendicitis. (e) Rovsing's sign is an increase in pain in the left iliac fossa when the right iliac fossa is palpated.

(a) False. McBurney's point lies two thirds of the way along a line drawn from the umbilicus to the right anterior superior iliac spine. (b) False. An inflammatory appendix mass can occur when the presentation of appendicitis is delayed. It is usually initially managed conservatively with IV antibitotics. Some advocate an interval appendicectomy 6 weeks or more later once the mass has resolved. (c) False. The white cell count can be normal, especially in early appendicitis. (d) True. (Loss of appetite is a common feature of acute appendicitis.) (e) False. Rovsing's sign indicates that the pain in the RIF is made worse by palpating the LIF. It is a sign of peritoneal irritation. (2) With respect to gallstones: T F True False False False False (a) Most people with gallstones are asymptomatic. (b) CT is the imaging modality of choice in diagnosing gallstones. (c) Approximately 90% of gallstones are visible on plain abdominal x-ray. (d) Gallstone ileus occurs when a gallstone travels through the bile duct into the small bowel and causes an obstruction. (e) Mirizzi's syndrome is caused by a stone in the common bile duct.

(a) True. (Most people with gallstones are asymptomatic.) (b) False. Gallstones are not always well visualised on CT. Ultrasound is the best imaging modality for diagnosing simple gallstone disease. (c) False. Only about 10% of gallstones are visible on plain abdominal x-ray. (d) False. Stones that are able to pass through the bile duct and the sphincter of Oddi will not be large enough to block the bowel. In gallstone ileus a large stone erodes through the wall of the gallbladder and duodenum creating a fistula. This stone then passes through the small bowel and obstructs at its narrowest point, ie. approximately 2 feet from the ileo-caecal

valve. The same site as a Meckel's diverticulum. (e) False. Mirrizi syndrome is caused by a stone in the gallbladder (Hartmanns pouch) that causes a localised inflammatory reaction and compresses the bile duct thus giving obstructive liver function tests. (3) Peptic ulcer disease: (a) A minority of duodenal ulcers are caused by Helicobacter Pylori infection. (b) A raised serum creatinine is a sign of a significant upper GI bleed. (c) Triple therapy for H. Pylori eradication involves the combination of an H2 receptor antagonist, a proton pump inhibitor and an antibiotic. (d) Following endoscopic therapy for a bleeding ulcer, a rebleed warrants immediate open surgical intervention. (e) A bleeding duodenal ulcer can be treated by oversewing a patch of omentum.

F False False False False False

(a) False. A significant number of duodenal ulcers are caused by Helicobacter Pylori infection. (b) False. A raised serum urea (relative to creatinine) is a sign of a significant upper GI bleed. (c) False. Triple therapy involves the use of 2 antibiotics (eg. Amoxicillin and Clarithromycin) and a proton pump inhibitor (eg. Omeprazole). (d) False. The British Society of Gastroenterology guidelines advise one further attempt at endoscopic therapy for a rebleed. (e) False. A bleeding ulcer can be managed by under-running the bleeding vessel. A perforated ulcer is managed by oversewing a patch of omentum onto the perforation. (4) Inguinal hernia: T F False False True True False (a) A direct hernia passes through the deep inguinal ring into the inguinal canal. (b) A femoral hernia is more common than an inguinal hernia in females. (c) An inguinal hernia can be distinguished from a femoral hernia by its relationship to the inguinal ligament. (d) The inferior epigastric vessels lie medial to the deep inguinal ring. (e) The floor of the inguinal canal is formed by the conjoint tendon.

(a) False. That is an indirect hernia. A direct hernia does not pass through the deep ring but arises in an area medial to this known as Hesselbach's triangle.

(b) False. Femoral hernias are more common in women than in men, but inguinal hernias are still more common that femoral hernias in women. (c) True. Inguinal hernias arise above and medial to the inguinal ligament. Femoral hernias arise below and lateral to it. (d) True. (The inferior epigastric vessels lie medial to the deep inguinal ring.) (e) False. The floor is formed by the rolled edge of the inguinal ligament. The conjoint tendon forms part of the posterior wall. (5) The acute abdomen: T F True False False False False (a) Mesenteric adenitis is a common cause of abdominal pain in children. (b) The absence of free air on an erect chest x-ray excludes an intra-abdominal perforation. (c) Free air under the right hemi-diaphragm can be mistaken for gas within the stomach. (d) A raised serum amylase is diagnostic of acute pancreatitis. (e) Diverticulosis is a common cause of acute left iliac fossa tenderness assosciated with pyrexia and a raised white cell count.

(a) True. Generalised viral illnesses can cause swelling of the mesenteric lymph nodes which can cause pain. (b) False. Free air cannot always be detected. (c) False. The stomach lies on the left side. It can be difficult to distinguish between gas in the lumen of the stomach and free air under the left hemi-diaphragm. (d) False. A significantly elevated serum amylase is usually suggestive of pancreatitis, but it can be elevated in a number of other conditions. (e) False. Diverticulosis is simply the presence of diverticulae. These signs suggest diverticulitis, inflammation in a diverticulum. (6) Testicular pain: T F True False False False True (a) Testicular torsion can present with lower abdominal pain. (b) Testicular pain in children is commonly due to epididymoorchitis. (c) Torsion can be easily excluded on careful clinical examination alone. (d) A varicocoele will readily transilluminate. (e) Testicular pain may be due to a viral infection.

(a) True. (Testicular torsion can present with lower abdominal pain.) (b) False. Testicular torsion must be excluded in all children presenting with testicular pain. Epididymo-orchitis is rare in children as it is usually caused by a sexually transmitted organism. (c) False. The only way to confidently exclude torsion is to surgically explore the scrotum. Ultrasound of the testes is not diagnostic. (d) False. A hydrocoele will transillunate but a varicocoele will not. (e) True. Classically mumps infection can cause a viral orchitis. (7) Colorectal cancer: T F False False True False True (a) Most tumours occur in the right side of the colon. (b) Neo-adjuvant radiotherapy has no role in the management of rectal tumours. (c) Left sided tumours are more likely to obstruct than right sided tumours. (d) Colorectal cancer has been associated with a diet high in fibre and low in saturated fat. (e) Villous adenomas have a greater malignant potential than tubular adenomas.

(a) False. Most tumours occur distally in the rectum (45%) and sigmoid colon (25%). (b) False. Radiotherapy is of benefit in preventing local recurrence for some rectal tumours. (c) True. The lumen of the bowel is smaller and therefore more likely to obstruct on the left side. (d) False. It is associated with a diet low in fibre and high in saturated fats. (e) True. (Villous adenomas have a greater malignant potential than tubular adenomas.) (8) Obstructive jaundice: T F True False False True False (a) Ultrasound can readily reveal intrahepatic ductal dilatation. (b) Obstructive jaundice is suggested by raised AST and ALT. (c) Malabsorption of vitamin D in jaundiced patients can affect the synthesis of coagulation factors. (d) Endoscopic retrograde cholangio-pancreatography (ERCP) is of diagnostic and therapeutic value in jaundiced patients. (e) Pale urine and dark stools are suggestive of obstructive jaundice.

(a) True. (Ultrasound can readily reveal intrahepatic ductal dilatation.)

(b) False. These enzymes arise from the liver parenchyma and suggest a hepatitic picture. ALP and GGT arise from the ductal cells and suggest biliary obstruction. (c) False. Malabsorption of the fat soluble vitamins A, D, E and K does occur but it is vitamin K that is involved in making clotting factors II, VII. IX and X. (d) True. (Endoscopic retrograde cholangio-pancreatography (ERCP) is of diagnostic and therapeutic value in jaundiced patients.) (e) False. Dark urine (due to increased urobilinogen) and pale stools (due to decreased stercobilinogen) suggests obstructive jaundice. (9) Thyroid disease: T F True True False False False (a) Anaplastic carcinoma generally has a poor prognosis. (b) Medullary carcinoma is associated with other endocrine neoplasms. (c) Thyroid swelling characteristically do not move on swallowing. (d) Hypocalcaemia following a total thyroidectomy is rare. (e) The recurrent laryngeal nerve is a branch of the phrenic nerve.

(a) True. (Anaplastic carcinoma generally has a poor prognosis.) (b) True. It can occur in Multiple Endocrine Neoplasia (MEN); type 2 is association with disease of the parathyroids and the adrenals. (c) False. The thyroid is contained within the pre-tracheal facia which moves upwards along with the trachea on swallowing. (d) False. Hypocalcaemia is common due to damage to the parathyroid glands. This is usually temporary provided the glands have not been excised or rendered permanently ischaemic. (e) False. It is a branch of the vagus nerve and must be thoroughly protected in thyroid surgery. (10) Intestinal stomas: T F True False False False False (a) Ileostomies should have a spout. (b) A right sided stoma is invariably an ileostomy. (c) A Hartmann's procedure involves resection of a segment of colon and formation of an ileostomy. (d) A loop ileostomy is usually permanent. (e) A defunctioning stoma is performed to protect an anastomosis proximal to the stoma.

(a) True. This is to protect the skin from the liquid contents of the ileum which contains digestive enzymes. (b) False. An ileostomy is usually right sided and a colostomy is usually left sides, but in certain situations it may be necessary to form a left sided ileostomy or a right sided colostomy. (c) False. A Hartmann's procedure involves resection of a segment of bowel, closure of the distal end and forming a colostomy with the proximal end. (d) False. A loop ileostomy is commonly performed to protect an anastomosis distal to this and can then later be reversed to restore intestinal continuity. (e) False. See above.