Gallbladder

Question 1

RF for gallstones

Answer 1

FFF, preg, rapid changes in weight, crohns (change in bile salt absorption in terminal ileum), haemolytic anaemias!

Question 2

what is murphys sign

Answer 2

press under ribs on right side and breath in –> if pain which stops inspiratory effort –> murphys +

Question 3

does biliary colic have a positive murphys sign

Answer 3

no

Question 4

Mx of billiary colic

Answer 4

simple analgesics, low fat diet, increased exercise, offer elective laparoscopic cholecystectomy due to recurrence of symptoms

Question 5

Presentation of acute cholecystitis

Answer 5

constant pain in RUQ and fever

Question 6

is murphys sign positive in acute cholecystitis

Answer 6

yes

Question 7

Mx of acute cholecystitis

Answer 7

IV abx, analgesia, antiemetics and laparoscopic cholecystectomy within one week

Question 8

Ix for gallstones

Answer 8

Bloods - FBC, LFT (ALP will be raised for all biliary problems but liver only affected in obstructive) and CRP
US firstline
MRCP (magnetic resonance cholangopancreatography) if US negative

Question 9

complications of cholecystectomy

Answer 9

stone retained in bile duct, damage post cholecystectomy syndrome, bile leak

Question 10

what is post cholecystectomy syndrome

Answer 10

non specific symptoms which result from having reduced bile like diarrhoea, flatulance and intolerance of fatty food

Question 11

incision for open cholecystectomy

Answer 11

kocher

Question 12

what can cause ascending cholangitis apart from an obstructing stone in CBD

Answer 12

cholangiocarcinoma / pancreatic cancer in head of pancreas (basically anything which obstructs bile flow as stasis of flow allows bacteria to invade)

Or ERCP

Question 12

complications of acute cholecystitis

Answer 12

1) mirizzi syndrome –> stone in the bile duct compresses the common hepatic duct so causes an obstructive jaundice even though there is no stone present in the duct
2) gall bladder empyema (pus in gb) –> this needs a cholestostomy and a cholecystectomy
3) fistula (cholecystoduodenal fistula) –> and then stones can obstruct either the proximal duodenum or cause a gallstone ileus (if they obstruct at the terminal ileum)

Question 13

triad of symptoms in ascending cholangitis

Answer 13

jaundice, fever, RUQ pain

Question 14

most common organisms in ascending cholangits

Answer 14

1) Ecoli 2) klebsiella

Question 15

MX of ascending cholangtiits

Answer 15

ERCP - endoscopic retrograde cholangiopancreatography

Question 16

what happens in a gallstone ileus

Answer 16

gallstone gets into the small bowel via a fistula (cholecystoduodenal fistula) after acute cholecystitis. It then get trapped in the small bowel in narrowest part (terminal ileum/ileocaecal valve)

Question 17

what does an xray show on a gallstone ileus

Answer 17

pneumobilia (gas in the cbiliary tree) and dilated small bowel

Question 18

where is cholangiocarcinoma most likely to affect

Answer 18

perihilar duct region

Question 19

RF for cholangiocarcinoma

Answer 19

PSC

Question 20

what is courvoisiers law

Answer 20

enlarged gallbladder and jaundice unlikely to be gallstones but more likely to be cholangiocarcinoma, gallbladder cancer or pancreatic cancer

Question 21

how does cholangiocarcinoma present

Answer 21

similar to cancer in the head of the pancreas - RUQ pain, jaundice, cachexia

Question 22

IX for cholangiocarcinoma

Answer 22

LFT, CA19-9, CT and biopsy, US may show dilation of ducts

MRCP IS GOLDSTANDARD

Question 23

MX of cholangiocarcinoma

Answer 23

normally too advanced for surgery but can put stents in by ERCP

Question 24

how does a patient with a gallbladder empyema present (This is a complication of cholecystitis)

Answer 24

tender mass in RUQ and often septic

Question 25

MX of gallbladder empyema

Answer 25

drainage (cholecystostomy) and removal (cholecystectomy)

Question 26

goldstandard IX for gallbladder cancer (this is rare so v unlikely to get a question on)

Answer 26

ERCP

Question 27

RF for gallbladder cancer

Answer 27

gallstones, chronic cholecystitis, PSC

Question 28

pathophysiology of appendicitis

Answer 28

luminal obstruction by faecolith / lymphoid hyperplasia causes stasis of fluid which allows commensal bacterias to multiply. This causes inflammation which then impedes venous drainage, increasing pressure and can eventually lead to ischaemia

Question 29

what is the point called where you check for rebound tenderness

Answer 29

McBurneys point

Question 30

what is psoas sign

Answer 30

lie patient on left side and extend right hip back --> cause pain (due to irritation of iliopsoas)

Question 31

imaging for appendicitis

Answer 31

Dx can be made clinically, in women do US to check for pelvic pathology and in men may do a CT

Question 32

apart from imaging other IX for appendicitis

Answer 32

urine dip, preg test, bloods (leucocytosis and raised cRP)

Question 33

what is the debate of using lanz incision over gridiron for open appendectomy

Answer 33

lanz --> better cosmetically but risks injury the ilioinguinal nerve (which is sensory to labia and supplies motor to anterior abdominal muscles)

Question 34

complications of acute appendicitis

Answer 34

perforation, SSI, appendiceal mass, pelvic abscess

Question 35

what is an appendeceal mass

Answer 35

in acute appendicitis when the momentum and small bowel adhere to the appendix. It is normally treated conservatively with IVabx due to high risk of visceral injury