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SU28.{1-4,18} | Abdominal Wall and Peritoneal Conditions — Practice Quiz
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A 45-year-old labourer notices a groin lump that appears when he stands or coughs and disappears when he lies down. On examination the swelling emerges above and medial to the pubic tubercle and, when reduced, is controlled by pressure over a point 1.25 cm above the mid-inguinal point. Which anatomical relationship BEST defines this hernia?
Correct. Control of the reduced hernia by pressure over the deep ring (1.25 cm above the mid-inguinal point) indicates an indirect inguinal hernia, whose sac enters the deep ring lateral to the inferior epigastric vessels.
Indirect inguinal hernia = lateral to inferior epigastric vessels, through the deep ring (often congenital, controlled by deep-ring pressure); direct = medial, through Hesselbach's triangle.
An indirect inguinal hernia enters the deep ring lateral to the inferior epigastric vessels and is controlled by pressure over the deep ring; a direct hernia bulges medial to the vessels through Hesselbach's triangle.
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A 70-year-old woman presents with a small, tender, irreducible lump in the groin and 12 hours of vomiting with central abdominal pain. The lump lies below and lateral to the pubic tubercle. Which feature of this hernia explains its high risk of strangulation?
Correct. A femoral hernia passes through the narrow, unyielding femoral canal bounded laterally by the femoral vein and medially by the sharp lacunar ligament, so its contents are easily constricted and strangulated.
Femoral hernia: below and lateral to the pubic tubercle, commoner in women, narrow rigid neck → the groin hernia most likely to strangulate.
The femoral hernia (below and lateral to the pubic tubercle, commoner in women) strangulates readily because its neck is the narrow, rigid femoral canal — not because it is wide or reducible.
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A patient with a long-standing reducible inguinal hernia returns with a hernia that is now tense, exquisitely tender, irreducible, with overlying erythema, absent cough impulse, and colicky pain with vomiting. Which complication has occurred?
Correct. A tense, very tender, irreducible hernia with erythema, loss of cough impulse and features of obstruction indicates strangulation — the blood supply to the contents is compromised, demanding emergency surgery.
Strangulation = irreducible + tender + tense + erythematous + lost cough impulse ± obstruction; it threatens bowel viability and is an emergency.
Tenderness, irreducibility, erythema, absent cough impulse and obstructive symptoms together signal strangulation (vascular compromise), a surgical emergency — beyond simple incarceration.
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A fit 50-year-old man with an uncomplicated, reducible direct inguinal hernia is counselled on definitive management. What is the recommended principle of treatment?
Correct. In an adult, the definitive treatment of an inguinal hernia is surgical repair, and the standard is a tension-free mesh (Lichtenstein) reinforcement of the posterior wall; herniotomy alone suffices only in children.
Adult hernia repair = tension-free mesh (Lichtenstein) of the posterior wall; herniotomy alone is paediatric; truss is a last resort if unfit for surgery.
Adult inguinal hernias are repaired with a tension-free mesh (Lichtenstein); herniotomy alone is for children, and a truss is only a temporising measure when surgery is contraindicated.
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A 30-year-old man presents with sudden, severe upper abdominal pain. He lies absolutely still, the abdomen is board-rigid with rebound tenderness and absent bowel sounds, and an erect chest X-ray shows free gas under the diaphragm. What is the most likely underlying cause of this peritonitis?
Correct. Free gas under the diaphragm on an erect film indicates perforation of a hollow viscus (most often a perforated peptic ulcer), causing secondary peritonitis with board-like rigidity.
Sudden pain + board-like rigidity + free gas under the diaphragm = perforated viscus (secondary peritonitis), classically a perforated peptic ulcer.
Free gas under the diaphragm means a hollow viscus has perforated, causing secondary peritonitis; primary (spontaneous bacterial) peritonitis and pancreatitis do not produce free intraperitoneal gas.
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A child with nephrotic syndrome and ascites develops fever and diffuse abdominal tenderness, but no localising sign and no free gas on imaging. Ascitic tap grows a single organism. Which form of peritonitis is this?
Correct. Primary (spontaneous bacterial) peritonitis arises without a surgical source, typically in ascites (nephrotic children, cirrhotics), is usually monomicrobial and is treated with antibiotics, not surgery.
Primary/SBP: monomicrobial, in ascites (nephrotic children, cirrhotics), no surgical source → antibiotics; secondary = perforation/contamination → source control.
A monomicrobial peritoneal infection in ascites without a perforation or surgical source is primary (spontaneous bacterial) peritonitis — managed medically with antibiotics.
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A patient with established secondary peritonitis from a perforated duodenal ulcer is being managed. Which sequence correctly reflects the three pillars of management, all begun in parallel?
Correct. Secondary peritonitis is managed by resuscitation (fluids, analgesia, NG tube, monitoring), broad-spectrum antibiotics and source control (surgery to deal with the perforation) — all started in parallel, with resuscitation continuing throughout.
Secondary peritonitis = resuscitation + antibiotics + source control, in parallel. Resuscitate while taking the patient to theatre; do not delay source control.
The three pillars — resuscitation, antibiotics and source control — are begun together, not in sequence; you resuscitate while preparing for the source-controlling operation.
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During abdominal examination of a patient with suspected free fluid, you percuss from the resonant umbilical area to the flank, mark the dull point, then roll the patient toward you and re-percuss after a pause; the previously dull flank becomes resonant. Which sign have you demonstrated and what does it indicate?
Correct. A dull flank that becomes resonant when the patient rolls (fluid gravitating away) is shifting dullness — the bedside sign of free peritoneal fluid (ascites).
Shifting dullness (dull flank → resonant on rolling) detects free ascitic fluid; a palpable fluid thrill confirms large-volume tense ascites.
Dullness that shifts with position change is shifting dullness, the sign of free (ascitic) fluid; a fluid thrill is a transmitted wave across a tense abdomen and detects large-volume ascites differently.
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