Surgery A - Upper GI and hepatobiliary disorders

Question 1

55 y/o female
pc: becomes unwell following dinner, constant pain tummy, appears flushed

hpc: refereed to SAU, 6hr hx upper abdo pain 3 days ago.
pmh: high cholesterol, BMI 32

Obs: 100bpm

possible differential diagnosis?

Answer 1

• biliary colic
• cholecystitis
• pancreatic
• MI
• chest infection
• peptic ulcer disease
• MSK causes?

most likely cholecystitis

Question 2

what is acute cholecystitis?

Answer 2

• acute inflammation of gall bladder
• primary complication of cholelithiasis
• cholelithiasis is the formation of gall stones

Question 3

main presenting symptom of cholecystitis is:

Answer 3

• pain in RUQ
• may radiate to shoulder

other features: fever, nausea, vomiting, t.cardia, RUQ tenderness, Murphy’s sign, raised inflammatory markers

Question 4

what is Murphy’s sign and what is it suggestive of:

Answer 4

• suggestive of acute cholecystitis
• place hand in RUQ, apply pressure
• ask patient to take deep breath
• gall bladder moves down in inspiration
• comes into contact with hand
• stimulation of inflamed gallbladder results in acute pain
• sudden stopping of inspiration

Question 5

first investigation for suspected acute cholecystitis?

Answer 5

• abdominal USS
• thickened gallbladder wall
• stones or sludge In gallbladder
• fluid around the gall bladder

Question 6

if common bile duct stone is suspected but not seen on USS, what might be done?

Answer 6

MRCP

- can help visualise biliary tree in more detail

Question 7

management of cholecystitis?

Answer 7

conservative

• NBM
• IV fluids
• antibiotics
• NG if required for vomiting

surgical
- ERCP to remove stones trapped in CBD

• cholecystectomy

Question 8

complications of acute cholecystitis?

Answer 8

• sepsis
• gallbladder empyema (infected tissue and pus collecting in gall bladder)
• gangrenous gallbladder
• perforation

Question 9

68 y/o male

pc: 5 day hx generally unwell. currently having rigorous, looks sweaty and pale, upper abdo pain
pmh: pancreatitis secondary to gall stones , laparoscopic cholecystectomy 3 years ago

Obs: 90/65mmHg, 110bpm, urinary catheter, urine very dark, looking a bit jaundice and itchy

some differentials:

Answer 9

• sepsis?
• cholangitis
• obstructive jaundice
• pancreatitis
• MI
• upper GI perforation

most likely
- biliary stones with cholangitis

Question 10

right iliac fossa pain possible differentiations

Answer 10

• appendicitis
• Crohn’s
• ectopic pregnancy

Question 11

left iliac fossa pain possible differentials

Answer 11

• diverticulitis

- ectopic pregnancy

Question 12

epigastric pain possible differentials?

Answer 12

• oesophagitis

- gastritis

Question 13

right upper quadrant possible differentials?

Answer 13

• cholecystitis

- hepatitis

Question 14

flank pain possible differentials?

Answer 14

• renal colic

- pyelonephritis

Question 15

suprapubic pain possible differential

Answer 15

UTI

Question 16

Abdominal pain that crescendos, becomes very severe and then goes away

Answer 16

colic

- most common types are biliary, uretic colic, bowel obstruction

Question 17

56 y/o homeless male
pc: extremely unwell, dishevelled, pale, clammy and lying very still

drinking 6 L of cider a day, smoking 30 roll ups a day. Eats very little.

some features of peritoneum

IV bolus helps perk patient up:

differentials

Answer 17

visceral perforation

sepsis

pancreatitis

MI

pneumonia

Question 18

what are most common causes of gastrointestinal perforation?

Answer 18

1. chemical: peptic ulcer disease, foreign body (battery)
2. infection: diverticulitis, cholecystitis, meckel’s diverticulum
3. infection: mesenteric ischaemia, obstructing lesions
4. colitis: toxic megacolon
5. trauma: iatrogenic, endoscopy, excessive vomitting

Question 19

what is done to confirm GI perforation?

Answer 19

gold standard: CT scan

abdominal XR

• may show free air under diaphragm
• psoas sign

Question 20

management of patient with GI perforation sus?

Answer 20

• resuscitation, early treatment
• broad spec abx
• NBM, NG tube?

Question 21

common risk factors for gall stone disease?

Answer 21

5Fs

• fat
• female
• fertile
• forty
• FH