emrcs questions Flashcards
hepatobiliary and pancreatic surgery
A 34 year old lady undergoes an elective cholecystectomy for attacks of recurrent cholecystitis due to gallstones. Microscopic assessment of the gallbladder is most likely to show which of the following?
Dysplasia of the fundus
Widespread necrosis
Aschoff-Rokitansky sinuses
Metaplasia of the fundus
Gallbladder polyp
Aschoff=Rokitansky sinuses
Explanation Aschoff-Rokitansky sinuses are the result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall. They may be macroscopic or microscopic. AschoffRokitansky sinuses may be identified in cases of chronic cholecystitis and gallstones. Although gallstones may predispose to the development of gallbladder cancer the actual incidence of dysplasia and metaplastic change is rare. In the elective setting described above necrosis would be rare.
A 68 year old man with type 2 diabetes is admitted to hospital unwell. On examination, he has features of septic shock and right upper quadrant tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder. What is the most likely diagnosis?
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Acute calculous cholecystitis
Acute acalculous cholecystitis
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eMRCS 2021: Hepatobiliary and pancreatic surgery
Cholangitis
Mirizzi syndrome
Sphincter of oddi dysfunction
Acute acalculous cholecystitis
Explanation This is the classic description of acalculous cholecystitis and its commonest in patients with type 2 diabetes. If you answered it incorrectly, ensure that you were not caught out by the acute calculous cholecystitis as this is a common exam mistake if options are mis read in a rush.
A 34 year old lady is admitted with pancreatitis. The aetiology is unclear and it is classified as an attack of moderate severity according to the Glasgow criteria. Her imaging shows no gallstones and fluid around the pancreas. Which of the following is the most appropriate initial management option?
Laparotomy
Laparoscopy
Radiological aspiration of the fluid
Active observation
Administration of octreotide
Active observation
Mnemonic for the assessment of the severity of pancreatitis: PANCREAS (Ann R Coll Surg Engl 2000; 82: 16-17
P a02 < 60 mmHg
A ge > 55 years
N eutrophils > 15 x 10/l
C alcium < 2 mmol/l
R aised urea > 16 mmol/l
E nzyme (lactate dehydrogenase) > 600 units/l
A lbumin < 32 g/l
S ugar (glucose) > 10 mmol/l> 3 positive criteria indicates severe pancreatitis.
Acute early fluid collections are seen in 25% of patients with pancreatitis and require no specific treatment. Attempts at drainage may introduce infection and result in pancreatic abscess formation.
diagnosis of acute pancreatitis
Traditionally hyperamylasaemia has been utilised with amylase being elevated three times the normal range.
However, amylase may give both false positive and negative results.
Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.
Serum amylase levels do not correlate with disease severity.
Differential causes of hyperamylasaemia
Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis
surgical management of pancreatitis
Surgery
Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy.
Patients with obstructed biliary system due to stones should undergo early ERCP.
Patients with extensive necrosis where infection is suspected should usually undergo FNA for culture.
Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.
A 53 year old alcoholic develops acute pancreatitis and is making slow but reasonable progress. He is troubled by persisting ileus and for this reason a CT scan is undertaken. This demonstrates a large pancreatic pseudocyst. This is monitored by repeat CT scanning which shows no resolution and he is now complaining of early satiety. What is the best course of action?
Pancreatectomy
Emergency cystogastrostomy
Elective cystogastrostomy
ERCP
Staging laparotomy to assess severity
Elective cystogastrostomy
Explanation
A pseudocyst is a late complication of pancreatitis and is managed in the elective setting.
Drainage of this man’s pseudocyst is required. This could be accomplished radiologically or endoscopically or surgically. As the other options are not on the list this is the best option from those available.
A 45 year old man presents with an episode of alcoholic pancreatitis. He makes slow but steady progress. He is reviewed clinically at 6 weeks following admission. He has a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found to be located behind the stomach. His serum amylase is mildly elevated. Which of the following is the most likely explanation?
Early fluid collection
Pancreatic abscess
Peripancreatic necrosis
Pseudocyst
Sterile necrosis
Pseudocyst
Explanation Pseudocysts are unlikely to be present less than 4 weeks after an attack of acute pancreatitis. However, they are more common at this stage and are associated with a raised amylase.
