SURG: Upper GI & Hepatobiliary Flashcards
1
Q
Mirizzi Syndrome?
A
A gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
> > Deranged LFTs
2
Q
Complications of acute cholecystitis?
A
- gangrenous cholecystitis
- perforation - may result in pericholecystic abscess or peritonitis
- cholecystoenteric fistula - results in air in the biliary tree (pneumobilia) > if a gallstone passes through the fistula may result in gallstone ileus
3
Q
Grey-Turner’s sign?
A
bruising of the flanks
4
Q
Cullen’s sign?
A
peri-umbilical bruising
5
Q
Investigations for acute pancreatitis?
A
- LIPASE
- Amylase
- If inconclusive - CT abdomen with contrast
6
Q
Severity scores for acute pancreatitis?
A
- Ranson score
- Glasgow score
- APACHE II
7
Q
Complications of acute pancreatitis?
A
- Pancreatic necrosis - surgical or radiological drainage or aspiration indicated if any suspicion of infection and drains placed with IV antibiotics commenced ASAP
- Pancreatic abscess - transgastric drainage or endoscopic drainage
- Pseudocyst formation - drainage (endoscopically/surgically) not indicated unless significant pressure symptoms as likely to resolve over time
- Ascites - multiple large bore ascitic drains placed and left in until no further fluid produced
- Retroperitoneal haemorrhage - CT angiography to identify source of bleeding then radiological embolisation
- ARDS
8
Q
Features indicating severe pancreatitis?
A
- age > 55 years
- hypocalcaemia
- hyperglycaemia
- hypoxia
- neutrophilia
- elevated LDH and AST
9
Q
Charcot’s triad?
A
> > Ascending cholangitis
- Fever
- Jaundice
- RUQ pain
10
Q
Reynold’s pentad?
A
> > Ascending cholangitis
- Fever
- Jaundice
- RUQ pain
- +Septic shock
- +Mental confusion
11
Q
Most common organism implicated in ascending cholangitis?
A
E coli
12
Q
Causes of ascending cholangitis?
A
> > Biliary obstruction
- Gallstones
- Strictures
- Malignant obstruction
- Parasitic infection
- Biliary stents / drainage procedures
13
Q
Management of ascending cholangitis?
A
- Broad spectrum IV antibiotics - piperacillin / tazobactam (gentamicin + metronidazole if pen allergic)
- IV fluids / correct electrolyte imbalances / analgesia
- Biliary decompression - ERCP ± sphincterotomy after 24-48hrs (preferred over surgery)
14
Q
Boerhaaves’s Syndrome?
A
spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting
15
Q
Diagnosis of Boerhaaves’s Syndrome?
A
CT contrast swallow
16
Q
Management of Boerhaaves’s Syndrome?
A
- Thoracotomy and lavage, if <12 hours after onset then primary repair is usually feasible
- Surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin
17
Q
Main risk factor for cholangiocarcinoma?
A
PSC
18
Q
Lymphadenopathy seen in cholangiocarcinoma?
A
- Periumbilical lymphadenopathy (Sister Mary Joseph nodes)
- Left supraclavicular adenopathy (Virchow node)
19
Q
Marker raised in cholangiocarcinoma?
A
CA 19-9
20
Q
Management of cholangiocarcinoma?
A
- Only surgery is currative - not always possible
- Adjunct with chemo or radio to prevent recurrence
- Pemigatinib - patients with previously treated, unresectable locally advanced or metastatic cholangiocarcinoma with certain gene mutations
Palliative:
- Stenting - ERCP/surgery used to stent bile duct relieving obstructive symptoms
- Chemo/radiotherapy - reduce symptoms, Gemcitabine and Cisplatin most commonly used
21
Q
Features of chronic pancreatitis?
A
- pain is typically worse 15 to 30 minutes following a meal
- steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain
- diabetes mellitus develops in the majority of patients. It typically occurs more than 20 years after symptom begin
22
Q
Investigations for chronic pancreatitis?
A
- AXR shows pancreatic calcification in 30% of cases
- CT pancreas is preferred diagnostic test
- faecal elastase may be used to assess exocrine function if imaging inconclusive
23
Q
Management of chronic pancreatitis?
A
pancreatic enzyme supplements
analgesia
24
Q
Malignant complication of H pylori infection?
A
Gastric MALT lymphoma
25
Management of pancreatic cancer?
- Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas
- Adjuvant chemotherapy usually given following surgery
- ERCP with stenting is often used for palliation
26
Causes of perforated peptic ulcer?
- NSAIDs
- H pylori
- Smoking
27
Clinical features of perforated peptic ulcer?
- Abdominal pain
- Tachycardia
- Rigid abdomen
- Abdominal distension
- Shoulder tip pain (Kehr's sign)
28
Investigations for peptic ulcer perforation?
- Erect AXR - air under diaphragm
- If unsure - CT - free gas / fluid within the peritoneal cavity
- If unsure - CT with contrast
29
Management of peptic ulcer perforation?
- IV fluids
- NBM + NGT
- IV PPI
- IV antibiotics
- If stable / improving after resus = non-surgical
- Unstable / ongoing sx = surgery (<2cm - closure of perforation, >2cm - resection of lesion with subsequent repair)
30
Post-operative management of peptic ulcer perforation?
*Upper endoscopy:*
- Identify cause of perforation (e.g. malignancy, biopsy for H pylori infection)
- Identify whether ulcer is healing appropriate after initial management
- Wai at least 2 weeks, ideally up to 8 weeks after perforation, to perform endoscopy as to allow for the original ulcer to heal appropriately
*H pylori eradication:*
- After initial management and stabilisation, if a patient is H pylori positive and this is the likely cause of the ulceration and therefore perforation, eradication is necessary
- Triple therapy with PPI and dual antibiotics (clarithromycin and amoxicillin) for 10-14 days
31
Types of bariatric surgery?
**Primarily restrictive operations:**
- Laparoscopic-adjustable gastric banding (LAGB) - normally first-line in patients with BMI of 30-39, produces less WL than malabsorptive or mixed procedures but fewer complications
- Sleeve gastrectomy - stomach reduced to ~15% of its original size
- Intragastric balloon - can be left in stomach for max 6 months
**Primarily malabsorptive operations:**
- Biliopancreatic diversion with duodenal switch
- Usually reserved for very obese patients (e.g. BMI >60)
**Mixed operations:**
- Roux-en-Y gastric bypass surgery
32
Drugs causing acute pancreatitis?
- azathioprine
- mesalazine
- didanosine
- bendroflumethiazide
- furosemide
- pentamidine
- steroids
- sodium valproate
33
Bloods in biliary colic?
Normal
34
Most common complication of ERCP?
Pancreatitis
35
Anatomical site causing hepatobiliary pathology least associated with jaundice?
Cystic duct
36
Ascending cholangitis on USS?
dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder
37
Screen for cholangiocarcinoma in patients with PSC?
CA 19-9
38
Complications of gastrectomy?
- B12 deficiency > subacute degeneration of the spinal cord
- Weight loss, early satiety
- Iron-deficiency anaemia
- Osteoporosis/osteomalacia
- Dumping syndrome
39
When to refer for bariatric surgery?
- Without contraindications = BMI is greater than 50
- Medical conditions affected by weight = BMI greater than 35
40
useful test of exocrine function in chronic pancreatits?
Faecal elastase
41
Absolute contraindications to laparoscopic surgery?
- haemodynamic instability/shock
- raised intracranial pressure
- acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
- uncorrected coagulopathy
42
