Upper GI and Hepatobiliary Surgery

Question 1

Acute Cholecystitis

a) i) What will 90% of patients have prior?
ii) If this is not the case what are the other types of patients it tends to be seen in?

b) What clinical features are seen?
c) What investigations are done?
d) How is it managed?

Answer 1

a)

ii) calculus
ii)
- immunosupressed patients secondary to CMV or cryptosporidium
- severely ill in hospital

b)
- RUQ pain (may radiate to shoulder tip!)
- fever
- Murphy’s sign positive -> inspiratory arrest upon RUQ palpation
- LFTs should be normal
(If not consider mirizzi syndrome - gallstone in distal cystic duct causing extrinsic compression of common bile duct)

c)
US
if unclear try cholescintigraphy (AKA HIDA scan)

d)
IV antibiotics
laparoscopic cholecystectomy within 1 week

Question 2

Acute Pancreatitis

a) What clinical features are seen?
b) What is seen on investigation?
c) What are the 2 most common causes?
d) How is it managed?
e) What can used to assess severity?

Answer 2

a)
- severe epigastric pain (may radiate to back)
- vomiting
- exam: epigastric tenderness, ileus, low grade fever

b)
- elevated amylase and lipase
(lipase more sensitive + has longer half life so may reveal late presentations >24hrs)

• early US important for diagnosing CAUSE as may effect management

(diagnosis can be confirmed by characteristic pain and amylase/lipase 3x normal level)

c) alcohol + gallstones

d)
- aggressive fluid resus
- IV opioids required as pain so severe

e) 
PaO2< 7.9kPa
Age > 55 years
Neutrophils (WBC > 15)
Calcium < 2 mmol/L
Renal function: Urea > 16 mmol/L
Enzymes LDH > 600IU/L
Albumin < 32g/L (serum)
Sugar (blood glucose) > 10 mmol/L

Question 3

Ascending Cholangitis

a) What is the most common cause?
b) What clinical features are seen?
c) What investigation is done?
d) how is it treated?

Answer 3

a) e. coli

b) Charcot’s triad:
- fever
- jaundice
- RUQ pain

+ maybe hypotension and confusion

c) US - bile ducts dilated or with stones

d)
- IV antibiotics
- 24-48hrs later ERCP to remove obstruction

Question 4

Gallstones

a) What are the risk factors?
b) What clinical features are seen?
c) What investigations are done?
d) How is it treated?

Answer 4

a) 
4Fs: fat, female, fertile, 40
- crohn's 
- drugs: fibrates, COCP
- diabetes

b)
- colicky RUQ pain worse after eating and especially if fatty foods
- N+V

NOTE: temp, LFTs + inflammatory markers all normal

c) US
d) elective cholecystectomy (if symptomatic)

Question 5

Boerhaave’s

a) What is it?
b) What clinical features can be seen?
c) What investigation is done?
d) How is it treated?

Answer 5

a) complete rupture in oesophagus due to repeated episodes of vomiting

NOTE: mallory-weiss is just a tear in mucosa

b)
- haematemesis
- severe chest pain
- shock
- exam: subcutaneous emphysema and crackle heard on auscultation of heart due to pneumomediastinum (AKA Hamman’s sign)

c) CT contrast swallow

d) 0-12hrs: thoracotomy + lavage
12-24hrs: T tube to control fistula between oesophagus + skin

Question 6

Cholangiocarcinoma

cancer of biliary tree

a) What is the main risk factor?
b) What clinical features are seen?

Answer 6

a) PSC

b)

• persistent colicky pain
• anorexia
• weight loss
• jaundice
  exam: Palpable gall bladder (courvoisier sign)
  inv: raised CA 19-9 (CEA and CA125 can also be raised)

Question 7

Chronic pancreatitis

a) What is responsible for 80% of causes?
b) What clinical features are seen?
c) What is seen on investigation?
d) How can the exocrine function of the pancreas be assessed?

e)
i) what enzyme may be reduced?
ii) what does this cause?

Answer 7

a) alcohol

b)
- pain 15-30 mins after eating
- pancreatic failure 5-25 years later (incl. DM)

c) Calcification of pancreas
(CT more sensitive and specific than AXR)

d) faecal elastase

e)
i) lipase
ii) steatorrhea (loose, greasy stools)

Question 8

Gastric MALT lymphoma

a) What are they highly associated with?
b) What clinical feature can be seen?

Answer 8

a) h. pylori infection (>95%)

NOTE: therefore 80% of low grade respond to h. pylori eradication

b) paraproteinaemia

Question 9

How can laparoscopy lead to bradycardia?

Answer 9

abdominal distension causes vasovagal reaction

Question 10

T/F: gallstones can present following cholecystectomy

Answer 10

true

Question 11

What can cause abdominal pain that is ‘medical’ in cause?

not including gynae stuff

Answer 11

• ACS
• DKA
• pneumonia
• acute intermittent porphyria
• lead poisoning

Question 12

Where is the most common place for an oesophageal rupture?

Answer 12

poster-lateral left wall of oesophagus 2-3cm from OG junction

Question 13

How would the history differ between adenocarcinoma of the oesophagus and squamous cell carcinoma of the oesophagus?

Answer 13

SCC - usually no history of GORD symptoms

adeno - likely pervious symptoms of GORD

(both would have progressive dysphagia and weight loss)

Question 14

Pancreatic Pseudocyst

1. When can these occur?
2. What clinical features are seen?
3. How are they managed?

Answer 14

1. complication of pancreatitis (acute or chronic)
2. • > 4 weeks after attack of pancreatitis
   • persistent slightly elevated amylase
3. 1st line: admit for conservative management to see if resolves in 12 weeks (50% will)

2nd line: endoscopic drainage

3rd line: cystogastrectomy - surgery creating connection between stomach and pancreatic pseudocyst so it drains into the stomach

Question 15

What is the most common complication of ERCP?

Answer 15

pancreatitis > cholangitis

also pancreatitis will show symptoms in 24 hrs cholangitis more likely 1 week

Question 16

What causes pigmented gallstones?

Answer 16

implies pre-hepatic jaundice, excess haemolysis