EMQs for Medical Students - PasTest

E M Q s F O R M E D I C A L S T U D E N T S – V O L U M E 2
are invariable clinical features. This is another surgical emergency that is an indication
for emergency laparotomy (usually with oversewing of the ulcer) after attention has
been paid to fluid and electrolyte replacement.
9. ABDOMINAL MASS
1. I – Pancreatic pseudocyst
This patient has a pancreatic pseudocyst. This is a collection of pancreatic secretions
that collect in the lesser sac, and is caused by pancreatitis (it is one of the classic
complications of pancreatitis). The patient might give a history of acute pancreatitis or
might present with epigastric fullness, pain, nausea and, sometimes, vomiting. Such
cysts can become complicated by infection or haemorrhage.
2. B – Carcinoma of the head of the pancreas
This patient has a carcinoma of the head of the pancreas. The history and findings are of
obstructive jaundice with a palpable gallbladder. Courvoisier’s law states: ‘When the
gallbladder is palpable and the patient is jaundiced the obstruction of the bile duct
causing the jaundice is unlikely to be a stone because previous inflammation will have
made the gallbladder thick and non-distensible.’ While there are a few exceptions to
this rule, the history of substantial weight loss and of pain radiating to the left side of the
back strongly indicate the likelihood of pancreatic carcinoma – the commonest cause
of malignant biliary obstruction.
3. D – Carcinoma of the sigmoid colon
This patient has a carcinoma of the sigmoid colon. The patient has presented with a
late complication of the disease, ie extensive hepatic metastasis sufficient to obstruct
biliary drainage. Colorectal cancer is the commonest cause of such intrahepatic
obstruction. The patient therefore has two masses – the primary in the left iliac fossa
and hepatomegaly.
4. F – Cirrhosis of the liver
This patient has cirrhosis of the liver. She has presented with features of portal hypertension
(decreased level of consciousness due to hepatic encephalopathy, ascites and
haematemesis secondary to oesophageal varices). The liver is enlarged (the palpable
mass) and she is jaundiced. Alcoholic liver cirrhosis is the commonest cause of
jaundice and portal hypertension in the developed world.
5. H – Gallstone disease
This patient has gallstone disease. This has become complicated by an empyema of the
gallbladder. The gallbladder distension is caused by a stone obstructing the cystic duct,
and the subsequent empyema (pus in the gallbladder) by infection of the stagnant bile.
This mass is palpable in the right upper quadrant and associated with a systemic febrile
illness. The patient is not jaundiced because the common bile duct and hepatic ducts
are not obstructed.
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