EMQs in Clinical Medicine.pdf - Peshawar Medical College

168 The abdomen and surgery
56 Abdominal masses
Answers: K C I E F
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A 65-year-old man collapses in the street. On examination he has an
umbilical mass that is expansile and pulsatile.
The presence of an expansile and pulsatile mass implies the presence of
an aneurysm. A true aneurysm is lined by all three layers of the arterial
wall, whereas a false aneurysm (caused by trauma, infection, etc.) is lined
only by connective tissue. The UK Small Aneurysm Trial suggested that
elective surgical repair of aneurysm is indicated with an aneurysm
diameter greater than 5.5 cm (Mortality results from randomised controlled
trial of early elective surgery or ultrasonographic surveillance for small
abdominal aortic aneurysms. Lancet 1998; 352: 1649–55). Early elective
surgery may prevent rupture although the mortality rate is 5–6 per cent.
Operative options include replacement with a prosthetic graft or
endovascular stent graft repair. Ultrasonographic surveillance for small
abdominal aortic aneurysms is safe and early surgery provides a longterm
survival advantage.
The mortality rate from aneurysm rupture without surgery is 100 per
cent and even if the patient reaches the hospital surgical unit alive, the
overall mortality rate is very high (80–95 per cent).
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 should always be considered in a patient complaining
of dyspepsia for over a month in someone this age. The presence of
Virchow’s node (left supraclavicular node) and ascites implies
disseminated disease and thus carries a poor prognosis. This finding is
sometimes referred to as a positive Troisier’s sign.
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.
The predominant symptoms/signs of carcinoma vary depending on the
site of colon affected. Right-sided lesions in the caecum/ascending colon
are associated with weight loss and anaemia, whereas symptoms of
change in bowel habit and bleeding per rectum are more common in the
sigmoid colon/rectum. The possibility of a caecal carcinoma must always
be considered in a patient over 40 years of age presenting with acute
appendicitis.