Upper GI Surgery

Question 1

What is murphy’s sign

Answer 1

Elicited in patients with acute cholecystitis
Ask the patient to take and hold a deep breath in while palpating the subcostal area - if the pain occurs on inspiration this is when the inflamed gallbladder comes into contact with the hand
This means murphy’s sign is positive

Question 2

Main causes of acute pancreatitis

Answer 2

Idiopathic
Gallstones
Ethanol (alcohol)

Question 3

Clinical features of acute pancreatitis

Answer 3

Severe epigastric pain that radiates to the back
Vomiting
Low grade fever
Flank discolouration (grey-turners sign) - rare
Periumbilical discolouration (cullen’s sign) - rare

Question 4

Investigations used to diagnose acute pancreatitis

Answer 4

Amylase
Lipase - more specific but not done routinely as more expensive (note this is better for late presentations >24 hours as it has a longer half-life than amylase so may still be raised while amylase has fallen)

USS - to assess the cause e.g, gallstones

Question 5

Management of acute pancreatitis

Answer 5

Conservative:
Analgesia
Fluids

Enteral nutrition - for patients with severe pancreatitis

Surgery in patients with pancreatis due to gallstones - early cholecystectomy

Question 6

Scoring system for severity of acute pancreatitis

Answer 6

Glasgow score (remember using PANCREAS mnemonic) - a score greater than 3 indicates severe pancreatitis 
P - PO2 <8kPa
A - age>55
N - neutrophils >15
C - calcium <2 (hypocalcemia)
R - renal function urea >16
E - enzymes raised AST or LDH
A - albumin <32
S - sugar BM >10

Question 7

Complications of acute pancreatitis

Answer 7

Peripancreatic fluid collections 
Pseudocysts 
Pancreatic necrosis 
Pancreatic abscess 
Haemorrhage

Question 8

Main cause of chronic pancreatitis

Answer 8

Alcohol

Question 9

Features of chronic pancreatitis

Answer 9

Long-standing epigastric pain - worse following food
Steatorrhoea
Diabetes

Question 10

Imaging modality for diagnosing chronic pancreatitis

Answer 10

CT pancreas

Question 11

Management of chronic pancreatitis

Answer 11

Pancreatic enzyme supplements

Analgesia

Question 12

What are the 5 F’s for bilary colic

Answer 12

Fat 
Female 
Forty 
Fair 
Fertile

Question 13

Features of biliary colic

Answer 13

Colicky RUQ pain worse after fatty foods
Pain may radiate to R shoulder
Nausea and vomiting

Question 14

How do you distinguish between acute Cholecystitis and ascending cholangitis

Answer 14

Both present with RUQ pain, jaundice and fever (charcot’s triad)
Fever is more significant in ascending cholangitis and systemic upset is more likely to be common

Question 15

What is the common organism that usually causes ascending cholangitis

Answer 15

E.Coli causes infection of biliary tree

Question 16

Management of acute cholecystitis

Answer 16

IV abx

Laparoscopic cholecystectomy - within 1 week of diagnosis

Question 17

Management of ascending cholangitis

Answer 17

IV abx

ERCP after 24-28 hours to relieve obstruction from gall stones