Review Boxes

Abdominal pain
Box 1 lists the classical abdominal pain descriptions that come up in EMQs.
Box 1 Abdominal pain descriptions

Description Problem

Colicky loin pain radiating to groin Ureteric colic

Constant right upper quadrant pain Biliary colic
⫾ jaundice
Severe epigastric pain radiating to back Acute pancreatitis
Associated with vomiting
History of gallstones/qqalcohol
Periumbilical pain radiating to right iliac fossa Acute appendicitis
Central abdominal pain, expansile pulsatile Abdominal aortic aneurysm
mass
Iliac fossa pain, positive pregnancy test Ectopic pregnancy
Severe abdominal pain with rigid abdomen Perforated viscus

Weight loss
As shown in Box 2, weight loss is a classical soft sign towards malignancy in
an EMQ.
Box 2 Some associations between weight loss and malignancy

Symptoms Malignancy

Weight loss, anaemia, dysphagia Oesophageal carcinoma

Weight loss, painless obstructive jaundice Pancreatic head carcinoma
Weight loss, haemoptysis, smoker Bronchial carcinoma
Weight loss, painless haematuria Bladder carcinoma
Weight loss, change in bowel habit, rectal bleeding Sigmoid/rectal carcinoma
Flushing, abdominal pain, diarrhoea, heart failure Carcinoid syndrome

2
Hepatobiliary surgery
The two conditions in Box 3 are frequently confused with each other and commonly
crop up in EMQs.
Box 3 Primary biliary cirrhosis and primary sclerosing cholangitis

Presentation Condition

Middle-aged woman presents with: Primary biliary cirrhosis

Pruritus, jaundice, pigmentation
Antimitochondrial antibody positive
Associated with:
Rheumatoid arthritis
Sjögren’s syndrome
Thyroid disease
Keratoconjunctivitis sicca
Renal tubular acidosis
Membranous glomerulonephritis

Usually middle-aged male: Primary sclerosing

Pruritus, jaundice, abdominal pain cholangitis
qALP, antimitochondrial antibody negative
Associated with inflammatory bowel disease (esp. UC)

Chronic liver disease

Box 4 gives some examples of signs of liver disease particularly relevant to EMQs.
Box 4 Signs of liver disease

Clubbing
Flapping tremor
Dupuytren’s contracture
Palmar erythema*
Gynaecomastia
Spider naevi*
*denotes signs that also occur in acute liver disease

Chronic liver disease associated with:

Early-onset emphysema α-1 antitrypsin deficiency
Pigmentation, diabetes Haemochromatosis
Dysarthria, dyskinesia, dementia, Wilson’s disease
Kayser–Fleischer ring

3
Surgical radiology
Box 6 shows phrases to look out for describing x-ray features in EMQs.
Box 6 X-ray features

X-ray feature Condition

Free air under diaphragm Perforated viscus (e.g. diverticulum/

duodenal ulcer)
Sentinel loop Acute pancreatitis
Inverted U loop Sigmoid volvulus
Loss of haustral pattern Ulcerative colitis
Cobblestoning Crohn’s disease
Apple-core lesion Carcinoma of colon

Inflammatory bowel disease

Crohn’s disease and ulcerative colitis are the two major forms of inflammatory
bowel disease. There is significant overlap in the clinical features of these diseases.
Box 7 summarizes typical presentations and highlights differing features that are
likely to be mentioned in EMQs.
Box 7 Crohn’s disease and ulcerative colitis

Can affect anywhere between mouth and anus Crohn’s disease

Skip lesions
Weight loss, diarrhoea, abdominal pain
Strictures, anal fistulae
Barium enema:
‘cobblestoning’, ‘rose-thorn’ ulcers
Granulomas

Only affects colon Ulcerative colitis

Continuous disease
Diarrhoea with blood and mucus
Fever, tachycardia, toxic megacolon in
severe acute UC
Barium enema:
Loss of haustra
Sigmoidoscopy:
Oedematous, friable mucosa
No granulomas

4
The abdomen and surgery
EMQs describing abdominal pain are very common. Box 1 describes some classic
presentations that you may find in questions.

Box 1 Abdominal pain

Classic presentation Problem
Colicky loin pain radiating to groin Ureteric colic
Jaundice and constant right upper Biliary colic
quadrant pain
Severe epigastric pain radiating to back Acute pancreatitis
associated with vomiting
Periumbilical pain radiating to right Acute appendicitis
iliac fossa
Central abdominal pain, expansile Abdominal aortic aneurysm
pulsatile mass
Iliac fossa pain, positive pregnancy test Ectopic pregnancy

Box 2 summarizes various signs that may be mentioned in an EMQ which should
prompt you to look for particular options in the question.

Box 2 On examination of the abdomen

Signs Option
Asterixis (liver flap) Hepatic encephalopathy
Leuconychia Hypoalbuminaemia
Koilonychia Iron-deficiency anaemia
Angular stomatitis Iron-deficiency anaemia
Buccal pigmentation Peutz–Jeghers syndrome
Addison’s disease
Glossitis Vitamin B12 deficiency
Aphthous ulceration Inflammatory bowel disease
Coeliac disease
Expansile pulsatile mass Aneurysm
Craggy hepatomegaly Liver malignancy

5
Box 3 gives some examples of signs of liver disease particularly relevant to EMQs.
Box 3 Signs of chronic liver disease
Signs
Clubbing
Dupuytren’s contracture
Palmar erythema*
Gynaecomastia
Spider naevi*
Splenomegaly*
Testicular atrophy
Caput medusae
Signs of decompensation
Ascites*
Encephalopathy*
Asterixis*
Jaundice
Bruising

Signs Condition
Chronic liver disease associated with:
Early onset emphysema α1-Antitrypsin deficiency [57]
Pigmentation, diabetes Haemochromatosis [57]
Dysarthria, dyskinesia, dementia, Wilson’s disease [57]
Kayser–Fleischer ring
*Denotes signs that also occur in acute liver disease

The two conditions primary biliary cirrhosis and primary sclerosing cholangitis
are frequently confused with each other and commonly crop up in EMQs (Box 4).

Box 4 Differentiation of hepatobiliary conditions

Condition
Primary biliary cirrhosis [59]
Primary sclerosing cholangitis [59] Usually middle-aged man, presents with:
Associated problems
Middle-aged woman presents with:
Pruritus, jaundice, pigmentation
Anti-mitochondrial antibody (AMA) positive
Associated with: rheumatoid arthritis
Sjögren’s syndrome
thyroid disease
keratoconjunctivitis sicca
renal tubular acidosis
membranous glomerulonephritis
Pruritus, jaundice, abdominal pain
↑ ALP (alkaline phosphatase), AMA negative
Associated with inflammatory bowel
6 (especially ulcerative colitis)
disease
Crohn’s disease and ulcerative colitis are the two major forms of inflammatory
bowel disease. There is significant overlap in the clinical features of these diseases.
Box 5 summarizes typical presentations and highlights differing features that are
likely to be mentioned in EMQs.

Box 5 Features of inflammatory bowel disease (IBD)

IBD
Crohn’s disease [55, 76]
Ulcerative colitis (UC) [76, 77]
Features
Can affect anywhere between mouth and anus
Weight loss, diarrhoea, abdominal pain
Strictures, anal fistulae
Barium enema: ‘cobble-stoning’
‘Rose-thorn’ ulcers
Granulomas
Only affects colon
Diarrhoea with blood and mucus
Fever, tachycardia, toxic megacolon in severe
acute UC
Barium enema: loss of haustra
Sigmoidoscopy: oedematous, friable mucosa