Hepatobiliary Surgery - Oxford Handbook MCQs Flashcards
A 42-year-old woman attends the emergency department with
severe epigastric pain after eating fish and chips. The pain resolves
after 2h. Her temperature is 37.2°C. She has no abdominal tenderness
and all blood investigations are within the normal range. Which is the
single most likely diagnosis?
A Biliary colic
B Cholangitis
C Cholecystitis
D Pancreatitis
E Perforated gallbladder
A - Biliary colic
- Biliary colic is severe epigastric pain caused by gallstones that typically lasts for half an hour or more and then eases off.
- Precipitation by foods high in fat is common due to the stimulating effect on cholecystokinin release which increases gallbladder contraction.
- There may or may not be right subcostal radiation.
- The absence of signs or features inflammation or infection make cholecystitis or cholangitis unlikely and the short-lived nature makes pancreatitis very unlikely.
A 48-year-old woman has had progressively worsening colicky
abdominal pain for 48h which has become severe and constant for
the last 12h. There is a past history of an abdominal hysterectomy. The
abdomen is slightly distended but non-tender. Blood investigations are
normal except for a white cell count of 13 × 109/L. Which is the single
most likely diagnosis?
A Acute cholecystitis
B Acute pancreatitis
C Ascending cholangitis
D Ischaemic bowel
E Perforated peptic ulcer
D - Ischaemic bowel
- The symptoms would be consistent with several diagnoses but the most important feature is the disproportion between the severe symptoms and minimal physical signs.
- This is always highly suggestive of intestinal ischaemia
- An urgent CT scan is the diagnostic test of choice if the patient is rapidly deteriorating, sometimes emergency surgery is directly indicated.
A 48-year-old man has been vomiting fresh blood with clots for
3h. He drinks 40 units of alcohol per week. A gastroscopy is performed
within 12h and reveals evidence of bleeding from oesophageal
varices. Which is the single most likely cause of his varices?
A Alcoholic gastritis
B Budd–Chiari syndrome (hepatic vein thrombosis)
C Essential hypertension
D Pancreatitis
E Portal hypertension
E - Portal hypertension
- Varices (esophageal and gastric) are most commonly caused by increased portal venous pressure.
- This is commonly caused by liver cirrhosis and alcohol related liver injury is the most common cause in the UK.
- Increased portal venous pressure causes the development of dilated vessels and increased blood flow through the portosystemic anastomoses particularly around the lower esophagus and upper stomach.
- These dilated vessels are prone to incidental trauma and resulting profuse bleeding.
- Hepatic venous thrombosis causes increased hepatic venous pressure but unless this is very longstanding with subsequent liver fibrosis and damage - the portal venous pressure is not greatly raised.
- Gastritis and pancreatitis are associated with alcohol use but not the presence of varices.
- Systemic (arterial) essential hypertension does not affect portal venous pressure.
A 47-year-old woman has 12h of progressive onset epigastric and
upper abdominal pain and rigors with temperatures up to 39.2°C.
Her pulse is 102bpm, blood pressure is 110/70mmHg, and there is mild
jaundice present. Which is the single most likely diagnosis?
A Ascending cholangitis
B Biliary colic
C Cholecystitis—acute
D Empyema of the gallbladder
E Hepatic failure
A - Ascending cholangitis
- This clinical syndrome seen in ascending cholangitis is known as Charcot’s triad.
- The epigastric pain is non-diagnostic but the jaundice is indicative of hepatocellular dysfunction and common bile duct obstruction.
- The high fevers or rigours is specific for common bile duct infection rather than gallbladder sepsis since the organisms more readily enter the bloodstream via the upper biliary tree.
An 82-year-old man has a diagnosis of inoperable cancer of the
head of the pancreas. He has developed jaundice over the last
5 days and is symptomatic with pruritus. An abdominal ultrasound scan
confirms dilated common and intrahepatic bile ducts. Which is the single
most suitable means of palliation for his jaundice?
A Chlorpheniramine PO
B Choledochojejunostomy
C Endoscopic retrograde cholangiopancreatography (ERCP) and
internal stent
D Naloxone IV
E Percutaneous transhepatic external drain
C - Endoscopic retrograde cholangiopancreatography and internal stent (ERCP)
- This man almost certainly has jaundice due to external compression of the bile duct.
- Although antihistamines may be helpful acutely to reduce the symptoms of pruritus - the most important thing is to reduce his bilirubin by acheiving adequate drainage of the common bile duct and bile flow.
- Even palliative bypass surgery should be avoided if at all possible ; it has a high morbidity and mortality rate in patients with advanced malignancy.
- A percutaneous external drain is uncomfortable and not a definitive solution other than in terminal care where the life expectancy is very short.
- It may be used as a prelude to attempting a combined endoscopic and transcutaneous ‘‘rendezvous’’ procedure.
- If it can be done a stent placed at ERCP is most likely to be effective in the medium term.
- Although it may require to be replaced, most stents will allow relief of jaundice for up to 3 months.
- Naloxone IV in low doses is used to relieve pruritus of morphine administration which might complicate this man’s care but it is not the cause of the symptom here.
A 46-year-old woman has a 24h history of sudden onset of constant
epigastric pain radiating to the back with nausea. There is
central and upper abdominal tenderness. The amylase is 1642IU. Which
is the single most likely aetiology for the presenting condition?
A Alcohol
B Combined oral contraceptive pill
C Gallstones
D Hyperlipidaemia
E Systemic viral infection
C - Gallstones
- This lady has acute pancreatitis. The mnemonic GET SMASHED:
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune disease
- Hyperglycaemia
- Hyperlipidemia
- ERCRP
- Drugs
- Although no history of gallstones is given, at her age this remains the most likely although close review of alcohol intake history, even modest amounts is necessary and the diagnosis must always be confirmed with abdominal ultrasound scanning - ideally within 24h of admission.
A 52-year-old man has been drinking up to 30 units of alcohol
per week and has longstanding epigastric pain. He has had multiple
admissions to hospital with pain. He is admitted with further epigastric
pain, mild epigastric tenderness, a white cell count of 7 × 109/L, and an
amylase of 102IU. Which is the single most likely diagnosis?
A Acute pancreatitis
B Biliary colic
C Chronic pancreatitis
D Hiatus hernia
E Intestinal ischaemia
C - Chronic pancreatitis
- Chronic epigastric pain accompanied by long term alcohol excess can lead to chronic pancreatitis
- The pain is typically recurrent often with no features of significant inflammation (i.e. normal white cell count and amylase).
- The recurrent nature of the symptoms and the lack of a raised white cell count or amylase is against this being acute pancreatitis and makes intestinal ischaemia very unlikely.
- Hiatus hernia might give rise to epigastric pain but retrosternal pain and problems with swallowing might be expected.
- Biliary colic is possible since the associated pain is not always right upper quadrant but it would less likely in a 52 year old man with a history of alcohol use.
A 43-year-old man has had multiple previous admissions for
alcohol-related problems and has had 2h of acute vomiting with
copious amounts of bright and dark red blood. An urgent OGD has
shown the cause to be bleeding oesophageal varices which have been
banded but the vomiting of blood continues on the ward. An anaesthetist
is present who has established IV access and is administering blood
and fluid transfusions. Which is the single most important next step in
this patient’s management?
A Take blood for clotting and LFTs
B Contact endoscopy to arrange a further endoscopy
C Contact X-ray to arrange a portable chest-ray
D Contact X-ray to arrange an emergency CT scan with embolization
E Contact your consultant to discuss transfer to theatre for treatment
E - Contact your consultant to discuss transfer to theatre for treatment
- Failed endoscopic therapy with active ongoing bleeding is an indication for emergency ‘surgical’ control of the bleeding.
- There are two possible treatment if the patient is considered for active treatment.
- Emergency radiological portosystemic shunting procedures can be done (transjugular intrahepatic portosystemic shunt) but they are complex and difficult to arrange quickly.
- In the presence of active bleeding the most likely way of stabilizing the patient is with a Sengstaken-Blakemore tube (esophagogastric tube with compression balloon and drainage channels to control the bleeding of esophageal and/or gastric varices by direct compression).
- The anaesthetic team are best placed to continue the resuscitation and monitoring of the situation including bloods and basic investigations.
- The patient is too unstable to be transported to X-ray
- You are best placed to arrange the transfer to theatre where the tube can be placed.
- A Sengstaken-Blakemore tube consists of two or more inflatable balloons.
- The tube is inserted via the mouth into the stomach.
- The gastric balloon is inflated and gentle traction is applied.
- The esophageal balloon is then inflated and the combination of pressures occludes the bleeding varices.
- It is uncomfortable and usually requires eneral anaesthesia.
- Once control has been established, other radiological interventions may be appropriate.
A 23-year-old woman undergoes a laparoscopic cholecystectomy
for symptoms of recurrent biliary colic. On examination of the
gallbladder there are stones present.
Which is the single most likely underlying diagnosis to explain her
condition?
A Crigler–Najjar syndrome
B Gilbert’s syndrome
C Hereditary spherocytosis
D Hypercholesterolaemia
E Pregnancy
C - Hereditary spherocytosis
- All of these conditions may give rise to jaundice.
- Gilbert’s syndrome and Crigler-Najjar syndrome are causes of jaundice but do not give rise to the formation of gallstones being conditions affecting hepatocellular processing of bilirubin.
- The stones are dark black which means they have a high proportion of bilirubin present.
- Pregnancy and hypercholesterolaemia may affect the proportion of cholesterol in the bile but high bilirubin production most commonly comes from increased breakdown of red blood cells.
- Hereditary spherocytosis leads to red cell membrane abnormalities which reduce the life span of the cells and leads to chronic haemolysis with pigment stones being a common feature.
- This fits with the young age of the patient.
A 47-year-old man has had malaise and anorexia for 2 weeks
and 3 days of developing jaundice. Serum testing has confirmed
a positive result for hepatitis A infection. Blood tests are taken to assess
the cause of his jaundice
Which is the single most likely combination of blood results in this
patient?
A ALP 270IU/L, ALT 27IU/L, AST 37IU/L
B ALP 330IU/L, ALT 105IU/L, CK 350IU/L
C ALP 105IU/L, ALT 75IU/L, AST 60IU/L
D ALP 450IU/L, ALT 55IU/L, γGT 120IU/L
E ALT 130IU/L, AST 25IU/L, LDH 135IU/L
C
- The most likely diagnosis is a viral hepatitis which fits the clinical picture and the positive hepatitis A result.
- In viral hepatitis the commonest pattern of enzyme abnormalities is an increase in hepatocellular enzymes (ALT, AST, gammaGT and LDH) but no change in membrane enzymes (ALP) unless there is secondary edema within the liver tissue causing obstructive changes.
- CK is not a hepatocellular enzyme but is raised in abnormalities of muscle (skeletal or cardiac)
- It would be extremely unlikely for one hepatocellular enzyme to be raised without the others.
A 48-year-old woman has recently undergone extensive bowel
resection for complications of ischaemia and has been receiving
total parenteral nutrition via a conventional central line. There is currently
mild abdominal discomfort and a non-productive cough. There
is no evidence of anaemia or jaundice. She has developed a swinging
pyrexia as high as 39.5°C over the last 12h. Which is the single most
likely diagnosis?
A Acute cholangitis
B Acute respiratory distress syndrome
C Central venous line infection
D Deep vein thrombosis
E Pneumonia
C - Central venous line infection
- Central venous line sepsis is a common complication of total paraenteral nutrition which is usually administered via a central line.
- It is typified by a high swinging with rigors but with little else in the way of symptoms.
- Acute cholangitis may occur in total paraenteral nutrition administration where there are long term abnormalities of bile flow and an increased risk of stasis with infection but the timescale makes this unlikely as does the absence of jaundice.
- All the other origins of sepsis tend to produce lower, more persistent temperatures.
- The feed should be stopped.
- It may be possible to clear the line with antibiotics but it may be necessary to remove it and send the tip for microbiological culture.
A 43-year-old man is referred by his GP with ongoing abdominal
pain, vomiting, and a persistent raised temperature several
weeks after an episode of acute pancreatitis. There is a palpable upper
abdominal mass. Which is the single most likely diagnosis?
A Abdominal aortic aneurysm
B Carcinoma of the pancreas
C Empyema of the gallbladder
D Pseudocyst of the lesser sac
E Small bowel obstruction
D - Pancreatic pseudocysts
- Pancreatic pseudocysts can form after an attack of acute pancreatitis.
- They are a collection of fluid formed from a coalescence of pancreatic fluid formed during an acute attack which lies in the lesser sac between the stomach and pancreas - usually sterile, enclosed by fibrous or inflammatory tissue.
- They can cause gastric irritation and nausea/vomiting or occasionally compression of the duodenum but the commonest presentation is persisting pain and an epigastric mass.
- Carcinoma of the pancreas is never caused by an acute attack but ocassionaly may be the precipitating cause.
- It is unlikely that the mass is palpable now and wasn’t at the time of the acute presentation and the symptoms of vomiting and raised temperature make this very unlikely.
- Empyema of the gallbladder would tend to be palpable in the right upper quadrant and would be uncommon coincidence after an episode of pancreatitis.
- A leaking abdominal aortic aneurysm would usually present with haemodynamic instability rather than pyrexia and vomiting - is a rare association.
A 47-year-old woman has had intermittent epigastric discomfort
and dyspepsia after food for 10 months. OGD reveals features of
moderate inflammation in the body and antrum of the stomach without
gastric or duodenal ulceration. A rapid urease test from a biopsy is positive.
Which is the single most appropriate treatment prescription for her?
A Gaviscon 10mL PO as needed + omeprazole 20mg once daily
B Omeprazole 20mg PO twice daily + amoxicillin 250mg PO three
times daily
C Omeprazole 20mg PO twice daily + metronidazole 400mg PO twice
daily + clarithromycin 250mg PO twice daily
D Omeprazole 20mg PO twice daily + ranitidine 150mg PO twice daily
E Ranitidine 150mg PO twice daily + metronidazole 400mg PO twice
daily + amoxicillin 250mg PO three times daily
C
- This patient has gastritis and gaviscon is a reasonable symptomatic treatment and ranitidine is also effective at symptom control but less so at acid suppression.
- Both could be used for simple gastritis.
- The positive fast urease result indicates that the underlying cause of gastritis is almost certainly H.pylori and thus first line treatment should include combination eradication therapy.
- This requires acid suppression (omeprazole and lansoprazole are used but not ranitidine) as well as antibacterial therapy.
- Amoxicillin is effective against H.pylori but should not be used alone and the dose is too small.
A 78-year-old man has acute severe pancreatitis caused by alcohol.
Blood results in a patient with acute severe pancreatitis
Serum amylase 1024IU
Serum corrected calcium 2.3mmol/L
White cell count 17 × 109/L
Serum glucose 12mmol/L
Albumin 40g/L
PaO2 14kPa
Which is his single correct Glasgow severity score?
A 1
B 2
C 3
D 4
E 5
C
Whilst amylase is used to diagnose acute pancreatitis the actual amylase does not predict severity. In the modified Glasgow severity score, a point is given for each of the following:
Age >55 years (age 78 = +1)
WBC >15 × 109/L (17 = +1)
Glucose >7mmol/L (12= +1)
Albumin <35g/L (40 = 0)
Corrected Ca <2mmol/L (2.3 = 0)
PaO2 <10kPa (14 = 0)
A 62-year-old man has an adenocarcinoma of the head of the
pancreas at the ampulla of Vater. There is no evidence of distant
disease and no obvious loco-regional involvement on CT scanning.
He is considered for potentially curative treatment. Which is the single
most appropriate operation for him to be offered?
A Cholecystectomy
B Distal pancreatectomy
C Gastrojejunostomy
D Pancreaticoduodenectomy
E Radical gastrectomy
D - Pancreaticoduodenectomy
- Whipple’s operation (pancreaticoduodenectomy) is the only potential curative option for carcinoma of the head of the pancreas.
- It involves en bloc resection of the first and second parts of the duodenum, the distal stomach, the head of the pancreas with the distal common bile duct and gallbladder.
- Although cholecystectomy is part of the procedure, it is not a treatment for pancreatic cancer alone.
- Radical gastrectomy may be used for gastric cancer and distal pancreatectomy for problems of the tail of the pancreas (usually benign).
- Gastrojejunostomy is a palliativeprocedure used to treat obstruction of the duodenum caused byadvanced pancreatic cancer.
- Unfortunately the majority of cases of carcinoma of the pancreas either
have distant metastases or involvement of vital structures around the
pancreas (e.g. mesenteric vessels) at the time of presentation which preclude curative treatment.
