Hepatobilliary and upper GI surgery

Question 1

Cholecystitis picture w/ derranged LFTs -

Answer 1

MIRIZZI syndrome - Gallstone impacted in the distal cystic duct causing extrinsic compression of CBD

Question 2

Cholecystitis first-line Ix. of choice:

If this is unclear:

Answer 2

Ultrasound

HIDA scan

Question 3

Cholecystitis Tx. :

Answer 3

IV antibiotics

Early laparoscopic cholecystectomy (w/in 1 week)

Question 4

Acute pancreatitis: Ix.

Answer 4

Serum amylase (3X upper limit of normal) 
Serum LIPASE (more sensitive and specific and longer-half life which is helpful in delayed presentations)

Imaging: Ultrasound however, diagnosis may be made clinically if symptoms w/ 3X normal amylase/lipase

Question 5

Pancreatitis scoring systems:

Answer 5

Apache II, Glasgow (pancreas), Ranson

Question 6

Electrolyte disturbances in acute pancreatitis:

Answer 6

HYPOcalcaemia

Hyperglycaemia

Question 7

Acute pancreatitis mx.

Answer 7

KEY aspects of care =
Fluid resuscitation with crystalloids
Analgesia
Nutrition - not made nil-by mouth unless vomiting. enteral nutrition or if this fails/contraindicated -> parenteral

Question 8

Should acute pancreatitis pts. receive prophylactic antibiotics?

Answer 8

No

Question 9

Surgery in Pancreatitis:
Due to gallstones:
Obstructed biliary system:
Infected necrosis:

Answer 9

Urgent cholecystectomy

ERCP

Debridement, FNA

Question 10

Ascending cholangitis - infective organism

Answer 10

E.coli

Question 11

Ascending cholangitis. Ix. and Mx.

Answer 11

Ultrasound
IV antibiotics
ERCP after 24-48 hours to relieve any obstruction

Question 12

Biliary colic Ix and Mx.

Answer 12

Ultrasound

Elective laparoscopic cholecystectomy

Question 13

Boerhaave syndrome 
Giveaway: 
Diagnostic investigation: 
Tx.
Complication:

Answer 13

Subcutaneous emphysema

CT swallow

Thoracotomy and lavage

severe sepsis due to secondary mediastinitis

Question 14

PSC w/ Raised CA 19-9 level w/ Periumbilical lymphadenopathy (sister Mary Joseph nodes) and Virchow node:

Answer 14

Cholangiocarcinoma

Question 15

Chronic pancreatitis fx. :

Answer 15

Pain 15 to 30 minutes following a meal
Steatorrhoea
Diabetes mellitus (loss of endocrine function)

Question 16

Chronic pancreatitis Ix.

Answer 16

Functional tests: Faecal elastase
Abdominal X-ray - shows pancreatic calcification in 30% of cases
CT more sensitive at picking up calcifications

Question 17

Functional test for chronic pancreatitis and which function does it assess:

Answer 17

Faecal elastase

Assesses EXOCRINE function

Question 18

Complications of Gastrectomy:

Answer 18

Dumping syndrome - rebound hypoglycaemia
IDA
Osteoporosis/Osteomalacia
Vit B12 deficiency

Question 19

Gastric MALT lymphoma:
assoc. with which infection?
Tx.

Answer 19

Associated w/ H.pylori (95%)

H.pylori eradication if low grade

Question 20

First-line bariatric surgery for obese pts.

Answer 20

Laporoscopic-adjustable gastric banding (LAGB)

Question 21

Bariatric surgery for very obese pts. (BMI>60)

Answer 21

Bilopancreatic diversion with duodenal switch

Question 22

Double duct sign:

Answer 22

Pancreatic cancer

Question 23

Majority of patients will undergo ___ in suspected ascending cholangitis after 24-48 hours:

Answer 23

ERCP