General Surgery, GI and HPB

Question 1

Gastro-Oesophageal Reflux Disease

Answer 1

1) Clinical diagnosis - resolution of symptoms after trial of PPI
2) If red flags/resistant GORD - Urgent OGD
3) If medical treatment fails, and surgery is being considered - 24hr pH monitoring + Oesophageal manometry

Question 2

Barrett’s Oesophagus

Answer 2

1) Histological diagnosis - OGD

Question 3

Oesophageal Cancer

Answer 3

1) OGD to be performed within 2 weeks - Biopsy and sent for histology
2) CT CAP/PET-CT - for distant met

Question 4

Oesophageal Perforation

Answer 4

1) Initial - CXR

2) Gold Standard = CT CAP with IV and Oral contrast

Question 5

Achalasia

Answer 5

1) Gold Standard = Oesophageal manometry

2) Urgent OGD - to exclude cancer

Question 6

Hiatus Hernia

Answer 6

1) Gold Standard = OGD

Question 7

Peptic Ulcer Disease

Answer 7

1) OGD
2) Non-invasive H.pylori testing
- Urea breath test
- Stool antigen test

Question 8

Gastric Cancer

Answer 8

1) Urgent OGD

2) Staging and planning treatment - CT CAP + Staging laparoscopy

Question 9

Angiodysplasia

Answer 9

1) Exclude malignancy - OGD/Colonoscopy depending on site of bleed
2) Small bowel bleeds - Wireless capsule endoscopy
3)

Question 10

Acute Appendicitis

Answer 10

1) First line - Ultrasound

2) CT - Good sensitivity and specificity

Question 11

Colorectal Cancer

Answer 11

1) Gold Standard = Colonoscopy with biopsy
2) CT - to look for distant mets
3) MRI - to assess depth of invasion

Question 12

Diverticulosis

Answer 12

1) Found incidentally during routine colonoscopy or CT

Question 13

Diverticulitis

Answer 13

1) Investigation of choice - CT Abdo-Pelvis
* Colonoscopy should never be performed in any presenting cases of suspected diverticulitis, due to the increased risk of perforation

Question 14

Uncomplicated diverticular disease

Answer 14

1) Flexible sigmoidoscopy (dont do in diverticulitis) - to identify any rectosigmoid lesion
2) If not suitable - CT colonography alternative

Question 15

Crohn’s Disease

Answer 15

1) Acutely - Abdo XR
2) Gold standard = Colonoscopy with biopsy
3) CT Abdo-Pelvis - Severe crohn’s (can demonstrate bowel obstruction, perforation, fistulae)
4) MRI scan – particularly useful for looking for enteric fistulae

Question 16

Ulcerative Colitis

Answer 16

1) Acutely - Abdo XR/CT
2) Gold standard = Colonoscopy with biopsy
3) A flexible sigmoidoscopy may be sufficient

*colonoscopy should be avoided in acute severe exacerbations

Question 17

Volvulus

Answer 17

1) Initial - CT Abdo-Pelvis with contrast

2) Some centres - AXR (Coffee bean sign)

Question 18

Haemorrhoids

Answer 18

1) Proctoscopy - to confirm diagnosis

2) Exclude malignancy - Flexible Sigmoidoscopy/Colonoscopy

Question 19

Perianal Fistula

Answer 19

1) Proctoscopy - visualise the opening of the tract

2) Complex Fistula - MRI (visualise anatomy of tract)

Question 20

Anal Cancer

Answer 20

1) Proctoscopy - take a biopsy too
2) USS-guided Fine Needle Aspiration - Inguinal lymph nodes
3) CT CAP - distant mets
4) MRI - to assess local invasion

Question 21

Biliary Colic and Cholecystitis

Answer 21

1) Trans-abdominal ultrasound - sensitive for visualising gallstone disease
2) Gold standard* = MRCP

*Any patient with symptoms suggestive of gallstones with inconclusive US (or CT scans) should undergo a MRCP

Question 22

Ascending Cholangitis

Answer 22

1) USS of biliary tract - bile duct dilation
2) Gold Standard = ERCP
(some donnies will also do MRCP, but ERCP here is both diagnostic and therapeutic)

Question 23

Cholangiocarcinoma

Answer 23

1) Initially - USS to confirm obstructive cause
2) Optimal imaging for diagnosis - MRCP
3) ERCP - may demonstrate site of obstruction and can be used for biopsy
4) Staging - CT (CT>MRI for locating distant mets)

Question 24

Hepatocellular Carcinoma

Answer 24

1) Gold standard = USS
2) For further evaluation - Staging CT
3) MRI - if suggestive US nodules and rising AFP
3) In still doubtful - biopsy or percutaneous fine-needle aspiration

Question 25

Acute Pancreatitis

Answer 25

1) Abdo USS

2) Contrast enhanced CT scan

Question 26

Chronic Pancreatitis

Answer 26

1) Pancreatic atrophy/calcification - seen on contrast enhanced CT
2) USS/MRI(MRCP) - to assess anatomy of pancreas and biliary tree
3) Special tests - Secretin stimulation test or Endoscopic Ultrasound (EUS)

Question 27

Pancreatic Cancer

Answer 27

1) Initial - Abdo USS
2) Most important for diagnosis and prognosis - CT
3) Endoscopic Ultrasound - used to guide FNA to for histology

Question 28

Pancreatic Cysts

Answer 28

1) Pancreatic Protocol CT Scan
2) MRCP
3) Further testing for biopsy - EUS-FNA