Gastrointestinal Tract and Abdominal Wall
Gastrointestinal Tract and Abdominal Wall covers esophageal, gastric, small bowel, colorectal, appendiceal, hernia, and anorectal disease. The exam tests pattern recognition, staging, and when to operate.
Core rules
- Bowel obstruction: air-fluid levels and a transition point on CT; nasogastric decompression, isotonic fluids, and surgery for strangulation (fever, tachycardia, pain out of proportion, closed-loop).
- Appendicitis is clinical; CT or ultrasound in equivocal cases. Perforation with peritonitis requires surgery and antibiotics.
- Colon cancer: right-sided anemia, left-sided obstruction; stage with CT chest/abdomen/pelvis; adjuvant therapy for node-positive disease.
- Hernia: indirect through the deep ring, direct through Hesselbach; repair symptomatic or complicated hernias; watchful waiting for small asymptomatic inguinal hernias in men is acceptable.
Worked example
A 62-year-old has 24 h of periumbilical pain migrating to the right lower quadrant, fever 38.2°C, and CT showing an 11 mm appendix with fat stranding. The Alvarado score is high; management is laparoscopic appendectomy plus perioperative antibiotics. Reasoning: migration and CT findings make appendicitis likely; the appendix is not perforated with an abscess, so drainage alone is not enough.
Traps: attributing RLQ pain to appendicitis in an elderly patient without considering cecal tumor; assuming opioids mask the diagnosis; operating on a reducible asymptomatic hernia without discussing options; missing an anorectal abscess because of tender external hemorrhoids.