GI Conditions of the Biliary Tree + Pancreas

Question 1

How do gallstones form?

Answer 1

Due to abnormal bile composition (usually excess cholesterol) which causes hardening of bile

Question 2

What are the risk factors for developing gall stones?

Answer 2

5 F's:
Fair
Fat 
Forty years +
Female 
Foetus

Question 3

What is biliary colic?

Answer 3

Pain associated with the temporary obstruction of the cystic or common bile duct by a stone

Question 4

How does biliary colic present?

Answer 4

Recurrent episodes of RUQ pain which subsides after several hours. The pain is usually provoked by eating a fatty meal

Question 5

How is the diagnosis of biliary colic made?

Answer 5

History + US showing gall stones

During an attack of pain there will be increased ALP and bilirubin

Question 6

What features differentiates biliary colic from acute cholecystitis?

Answer 6

Absence of inflammatory features, e.g. fever and raised CRP

Question 7

What is the treatment for biliary colic?

Answer 7

Cholecystectomy

Question 8

If a patient with biliary colic had abnormal liver biochemistry and US showed dilated common bile duct, what would the treatment be?

Answer 8

Pre-Operative MRCP

Question 9

What is acute cholecystitis?

Answer 9

Inflammation of the gall bladder following gall stone impaction

Question 10

How does acute cholecystitis present?

Answer 10

RUQ pain and fever

Question 11

What signs indicate acute cholecystitis on examination?

Answer 11

Murphy’s sign positive (tenderness worse on inspiration)

Muscle guarding

Question 12

How is acute cholecystitis treated?

Answer 12

IV fluids
Nil by mouth
IV Cefotaxime
Cholecystectomy within 48 hours

Question 13

What is acute cholangitis?

Answer 13

Bacterial infection of the biliary tree

Question 14

What can cause acute cholangitis?

Answer 14

Obstruction of common bile duct by gall stones
HIV cholangiopathy
Biliary strictures following surgery

Question 15

What is the classic presentation of acute cholangitis?

Answer 15

Charcot’s triad of RUQ pain, fever and jaundice

Question 16

Jaundice associated with acute cholangitis is cholestatic in type. What are the clinical features of this?

Answer 16

Dark urine
Pale stools
Pruritus (itching)
Raised ALP + Bilirubin

Question 17

Which organisms are the most common cause of acute cholangitis?

Answer 17

E.Coli and enterococcus

Question 18

What if the definitive investigation for acute cholangitis?

Answer 18

ERCP. Shows site and cause of obstruction and allows bile to be sampled for culture and drained

Question 19

Which antibiotics are given in acute cholangitis?

Answer 19

Cefotaxime + Metronidazole

or

Amoxicillin + Metronidazole + Gentamicin

Question 20

What is the best imaging modality for stones in the common bile duct?

Answer 20

MRCP

Question 21

What do the pancreatic acinar cells produce?

Answer 21

Pancreatic enzymes which are involved in the digestion of fat (lipase), carbohydrate (amylase) and protein (protease)

Question 22

Does acute pancreatitis occur in a previously normal or damaged pancreas?

Answer 22

Normal. Usually returns to normal structure and function after the episode

Question 23

How does acute pancreatitis commonly present?

Answer 23

Epigastric pain radiating to the back associated with nausea and vomiting. There is tenderness, guarding and rigidity on examination

Question 24

What do Cullen’s sign and Grey turners sign mean? What do they indicate?

Answer 24

Redness around the umbilicus (Cullens) or flanks (grey turners)
Severe necrosiating pancreatitis

Question 25

A high elevation of which substance is diagnostic of pancreatitis?

Answer 25

Serum amylase or serum lipase

Question 26

Which investigations are performed to confirm diagnosis of pancreatitis?

Answer 26

CT scan or MRI

Question 27

What are the causes of pancreatitis?

Answer 27

GET SMASHED

Gall stones
Ethanol 
Trauma
Steroids
Mumps/malignancy
Autoimmunity
Scorpion stings
Hyperlipidaemia/hypercalcaemia
ERCP
Drugs

Question 28

What does a sentinel loop on an XR indicate?

Answer 28

Pancreatitis

Question 29

What is chronic pancreatitis?

Answer 29

Continuing inflammation of the pancreas with irreversible structural changes

Question 30

What is the most common cause of chronic pancreatitis in the UK?

Answer 30

Alcohol

Question 31

How does chronic pancreatitis present?

Answer 31

Epigastric pain + weight loss

pancreatic carcinoma is the differential

Question 32

What is the best investigation to diagnose chronic pancreatitis? What would it show?

Answer 32

CT scan showing:
Calcification of the pancreas
Dilated pancreatic duct
Fluid collection

Question 33

How does chronic pancreatitis affect faecal elastase?

Answer 33

It reduces it

Question 34

What conditions can cause hereditary chronic pancreatitis?

Answer 34

Cystic fibrosis
Alpha 1 antitrypsin deficiency
Hyperparathyroidism

Question 35

What is the most common exocrine pancreatic cancer?

Answer 35

Adenocarcinoma

Question 36

How do carcinomas affecting the head of the pancreas present? What is the diagnostic clinical sign?

Answer 36

Painless jaundice and weight loss

A palpable gall bladder will ALWAYS be caused by cancer (Courvoisier’s law)

Question 37

How do carcinomas affecting the body or tail of the pancreas present?

Answer 37

Abdominal pain, anorexia and weight loss

Question 38

Which investigation is used to diagnose pancreatic cancer?

Answer 38

Ultrasound

Question 39

A patient presents with jaundice. An ultrasound and CT scan show a bile duct stricture and a hilar mass. What is the diagnosis?

Answer 39

Cholangiocarcinoma

Question 40

What does a gastrinoma cause? What are the symptoms?

Answer 40

Acid hyper-secretion due to increased gastrin release

Recurrent duodenal ulcers and severe diarrhoea

Question 41

What does an insulinoma cause?

Answer 41

Hypoglycaemia due to increased insulin secretion promoting storage of glucose

Question 42

What does a glucagonoma cause?

Answer 42

Hyperglycaemia due to increased glucagon secretion promoting breakdown of glycogen to release glucose