surgery - upper GI and hepatobiliary

Question 1

65 y/o male

• severe abdominal pain following meals
• has diabetes
• steatorrhoea
• takes pancreatic enzymes

what is this a typical history of:

Answer 1

chronic pancreatitis

Question 2

common cause of chronic pancreatitis is…

Answer 2

alcohol abuse

Question 3

investigation of chronic pancreatitis? (3)

Answer 3

1. abdominal x-ray shows pancreatic calcification in 30% of cases
2. CT more sensitive at detecting pancreatic calcification
3. faecal elastase may be used if imaging inconclusive

Question 4

management of chronic pancreatitis? (3)

Answer 4

• pancreatic enzyme supplements
• analgesia
• antioxidants ?

Question 5

majority of causes of acute pancreatitis?

Answer 5

GET SMASHED

Gallstones 
Ethanol 
Trauma 
Steroids 
Mumps (others like coxsackie B)
Autoimmune (polyarteritis nodosa) 
Scorpion venom 
Hypertriglyceridaemia, hypercalcaemia, hypothermia 
ERCP
Drugs

Question 6

45 y/o heavy alcohol intake

• acute onset epigastric pain radiating to right side
• sclera yellow
• localised guarding
• fever

associated with:

Answer 6

Ascending cholangitis

• fever
• jaundice
• RUQ pain
• hypotension and confusion are common

Question 7

what typically caused ascending cholangitis?

Answer 7

• E.coli

- bacterial infection of biliary tree

Question 8

management of ascending cholangitis?

Answer 8

• intravenous antibiotics

- ERCP post 24-48hrs to relieve any obstruction

Question 9

72 y/o

• 6 month hx of unexplained weight loss
• noticed yellowing of eyes and skin
• no abdo pain or fever

pmh: UC, primary sclerosing cholangitis

likely diagnosis?

Answer 9

• primary sclerosing cholangitis is the main risk factor for cholangiocarcinoma

Question 10

pathophys of acute pancreatitis

Answer 10

• autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis

Question 11

raised amylase and a cystic lesion following pancreatitis are most likely to represent a:

Answer 11

• pancreatic pseudocyst

- collection is walled by fibrous or granulation tissue

Question 12

investigations for acute pancreatitis?

Answer 12

• serum amylase
• serum lipase (longer half life)
• imaging
• early USS important to assess cause

Question 13

40 y/o female

• recurrent pain in abdomen radiating to shoulder
• particularly after heavy meal
• associated with nausea and vomiting

Answer 13

biliary colic

Question 14

management of biliary colic

Answer 14

elective laparoscopic cholecystectomy

Question 15

what is mirizzi syndrome?

Answer 15

• common hepatic duct obstruction by an impacted gall stone

Question 16

what is the preferred diagnostic test for chronic pancreatitis

Answer 16

CT pancreas

CT more sensitive at detecting pancreatic calcification

Question 17

A 51-year-old woman presents with recurrent episodes of epigastric pain radiating through to her back, typically brought on by eating a heavy meal. She drinks around 20 units of alcohol per week. During the current episode she noticed that her sclera were yellow.

Answer 17

common bile duct stones

- epigastric pain rather than typical RUQ pain

Question 18

A 63-year-old man is admitted with obstructive jaundice that has developed over the past 3 weeks. He was previously well and on examination has a smooth mass in his right upper quadrant.

Answer 18

carcinoma of the head of pancreas
- development of jaundice in association with smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy

Question 19

A 45-year-old lady is referred to the Surgical Assessment Unit by her GP. She had an ultrasound scan last week which showed biliary dilatation and subsequent imaging has confirmed the presence of gallstones. This morning she woke up feeling sweaty, with severe right upper quadrant pain and her husband noticed her skin looked more yellow than usual. What is the most likely diagnosis?

Answer 19

ascending cholangitis