A 35 year old woman presents with dysphagia for solids and liquids associated with regurgitation and weight loss. Barium swallow shows a dilated tapering oesophagus
Oesophageal Achalasia
- Failure of relaxation of LOS on initiating of swallowing
- Degenerative changes in myenteric plexus and vagus nerve
- First line treatment is endoscopic balloon dilatation of the sphincter
- Surgical: Heller’s Cardiomytomy
A 65-year-old smoker presents with a history of severe oesophagitis and gradually worsening dysphagia.
Oesophageal carcinoma
A 28-year-old woman presents with a feeling of a lump in her throat that causes some discomfort on swallowing. Examination and imaging of the pharynx and oesophagus reveal no abnormality.
Globus hystericus
A 40-year-old man complains of intermittent dysphagia associated with chest pain. Barium swallow reveals a corkscrew oesophagus.
Diffuse oesophageal spasm
A 55-year-old man presents coughing when he tries to swallow. On examination he has a flaccid fasciculating tongue.
Bulbar Palsy
A 55-year-old man presents coughing when he tries to swallow. On examination he has a flaccid fasciculating tongue.
Bulbar Palsy
- Cranial nerve impairment
- Flaccid fasciculating tongue= Nerve VII impairment
A 45-year-old man with a history of gallstones presents in A&E with severe epigastric pain radiating to the back and vomiting.
Acute Pancreatitis
- Gallstones and alcohol are the 2 most common causes
- Serum amylase is usually significantly raised
A 28-year-old man presents with sharp left loin and left upper quadrant pain radiating to the groin. He is not jaundiced.
Renal colic
-Provide adequate analgesia and morphine may be appropriate
A 44-year-old woman presents with continuous right upper quadrant pain, vomiting and fever. Murphy’s sign is positive.
Acute Cholesystitis
-The hand is placed over the right upper quadrant and the patient is asked to breathe in. The pain resulting from the inflamed gallbladder moving downwards and striking the hand is severe and arrests the inspiratory effort.
A 26-year-old man with a previous history of abdominal surgery presents with colicky central abdominal pain, rapidly followed by production of copious bile- stained vomitus.
Small bowel obstruction
-Early onset of vomiting and late development of distension
A 50-year-old man presents with epigastric pain worse at night and relieved by eating or drinking milk.
Duodenal ulcer
A 21-year-old student presents with a cramping diffuse abdominal pain associ- ated with alternating constipation and diarrhoea. Investigations are normal.
Irritable bowel syndrome
A 55-year-old smoker presents with severe epigastric pain. The chest radiograph reveals air under the diaphragm.
Perforated duodenal ulcer
A 9-year-old girl presents with fever, nausea and right iliac fossa pain. She says that the pain ‘was around my belly-button before’.
Acute appendicitis
- Rebound tenderness may be elicited
- Treatment: prompt appendicetomy
A 35-year-old man presents with weight loss, diarrhoea and abdominal pain. On examination, he has aphthous ulcers in the mouth and a mass is palpable in the right iliac fossa. Blood tests reveal low serum vitamin B12 and folate.
Crohn’s disease
- Most common in terminal ileum
- Can lead to malabsorption-vitamin B12 deficiency
A 45-year-old woman on treatment for TB presents with abdominal pain and malaise. On examination she is jaundiced.
Hepatitis
-Pyrazinamide, Isoniazid and Rimfampificin are all recognised causes of drug induced TB
A 65-year-old man collapses in the street. On examination he has an umbilical mass that is expansile and pulsatile.
AAA
- True aneurysms involve all 3 layers of the arterial wall
- False aneurysms involve a collection of blood in the outer layer only which communicates with the lumen after trauma
- Elective repair for aneurysms >5.5cm
- Stenting
A 75-year-old man with a 3-month history of dyspepsia presents with weight loss and abdominal distension. On examination a 3.5 cm, hard, irregular, tender epigastric mass can be felt which moves on respiration. Percussion of the distended abdomen reveals shifting dullness. The left supraclavicular node is palpable.
Gastric carcinoma
A 70-year-old woman presents with a mass in the right iliac fossa and severe microcytic anaemia. On examination the mass is firm, irregular and 4 cm in diameter. The lower edge is palpable.
Caecal carcinoma
- Right sided lesions in the caecum/ascending colon are associated with weight loss and anaemia
- Left sided sigmoid/rectum: change in bowel habit and bleeding PR
A 35-year-old woman is worried about an abdominal mass that has grown over the last 6 months and a similar length history of very heavy menstrual bleeding with no intermenstrual bleeding. On examination a knobbly mass can be felt in the middle lower quadrant that is dull to percussion. The lower edge is not palpable. She is otherwise well.
Fibroids
- Benign tumours of the uterine smooth muscle
- Increased menstral blood loss in middle aged women
A 70 year old with alcohol problems presents with a tender upper abdominal mass. Computed tomography (CT) shows a thick-walled, rounded, fluid-filled mass adjacent to the pancreas.
Pancreatic pseudocyst
- Usually located in the lesser sac adjacent to the pancreas
- Usually after ductal leakage after inflammation of the pancreas
- Chronic pancreatitis is the most common cause
A 69-year-old retired bricklayer presents with weight loss, fever and right upper quadrant pain. On examination, a hard, irregular liver can be felt on palpation. Serum AFP is grossly elevated.
Hepatocellular carcinoma
-Raised AFP is suggestive of this
A 45-year-old man presents with arthralgia, tiredness and development of diabetes. On examination his skin is pigmented and blood tests show increased serum ferritin.
Haemochromatosis
- “Bronzed diabetic”
- Autosomal recessive inherited disorder of iron metabolism
- Can also cause a dilated cardiomyopathy resulting in heart failure
- Venesection is required in long term management
A 60-year-old publican presents with signs of spider naevi, gynaecomastia and testicular atrophy. His hands show clubbing and leukonychia.
Alcoholic cirrhosis
