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1Theme: Liver lesionsA Haemangioma?B Liver abscessC Hepatic pseudotumourD Hydatid cystE Hepatocellular carcinoma (HCC)F Hepatic metastasisFor each of the following clinical situations listed below, select the single most likely diagnosis from the options above. Each option may be used once, more than once or not at all.Scenario 1A 34-year-old man presented to the Accident and Emergency Department with a 2-day history of abdominal pain, fever, malaise and jaundice. On examination he was pyrexial and jaundiced with no other abdominal signs. An ultrasound scan of the liver showed a 5-cm hypoechoic lesion with a fluid level.B - Liver abscess?? CORRECT ANSWERPatients with liver abscesses are systemically unwell with abdominal pain, fever and jaundice. Pyrexia is present in 75% of cases. Ultrasound scan is invariably diagnostic and will demonstrate a fluid-filled cavity, which will appear as a hypoechoic lesion. Computed tomography (CT) may be useful to exclude the presence of other abscesses and to identify a primary source within the abdomen. Management includes percutaneous aspiration of pus or drainage. The key to successful management is the administration of appropriate antibiotics.Scenario 2A 40-year-old lady was seen in the Out-patients’ Clinic with a short history of vague epigastric and right upper quadrant pain. She denied any other symptoms of altered bowel habit or weight loss. Liver function tests (LFTs) and tumour markers were normal. An ultrasound scan of the abdomen showed a well-defined 4-cm hyperechoic lesion.A - Haemangioma?? CORRECT ANSWERHaemangiomas are the most frequently found benign tumours in the liver and these are usually congenital. It presents between the 3rd and 4th decade of life and is more common in women. It is generally accepted that pain is the presenting symptom in 28% of patients, being in the epigastrium and right hypochondrium. It is associated with Osler–Weber–Rendu syndrome, hepatic or pancreatic cysts and other benign tumours, mainly adenomas particularly after the use of the oral contraceptive.YOUR ANSWER WAS CORRECTScenario 3A 75-year-old man attended the Out-patients’ Clinic with increasing shortness of breath. He was otherwise fit and well and was a retired farmer. As part of his investigations he had an erect chest X-ray, which showed a large rounded calcified lesion in the right upper quadrant.D - Hydatid cyst?? CORRECT ANSWERHydatid cyst is due to?Echinococcus granulosus?and is found in patients in direct contact with dogs and sheep. Clinical symptoms are often insidious. Distension of the liver capsule may produce right upper quadrant pain. They may also present with jaundice. LFTs are generally abnormal and eosinophilia is present in up to one-third of patients. Once diagnosis is made surgery is generally required but in elderly frail patients this might best be avoided.Scenario 4A 60-year-old man with longstanding alcoholic liver cirrhosis presented to the Accident and Emergency Department with right upper quadrant pain. On examination he has evidence of chronic liver disease. LFTs on admission showed worsening liver failure. An ultrasound scan of the liver showed ascites, splenomegaly and a 1-cm lesion in the right lobe of the liver.E - Hepatocellular carcinoma (HCC)?? CORRECT ANSWERHCC usually presents below the age of 50. Clinical features include weight loss, anorexia, fever, a right upper quadrant pain, and ascites. Serum a-fetoprotein is raised. In countries were hepatitis B virus (HBV) is prevalent, 90% of patients with HCC are positive for hepatitis B. Surgical resection is occasionally possible. Chemotherapy and radiotherapy are unhelpful. Survival, except in very selected groups, is seldom more than 6 months.2Theme: Management of gallstone diseaseA Endoscopic Retrograde Cholangio-Pancreatogram (ERCP) andsphincterotomyB Early laparoscopic cholecystectomy +/- pre-operative cholangiographyC Interval laparoscopic cholecystectomy +/- pre-operativecholangiographyD Laparoscopic cholecystectomy + common bile duct explorationE Laparotomy with cholecystotomy/drainageF Magnetic resonance cholangiopancreatogram (MRCP)G Open cholecystectomy + common bile duct explorationH Non-surgical treatment, eg chemical dissolution therapyI Percutaneous (radiological) gallbladder drainageThe following scenarios describe patients suffering from a complication of gallstone disease. From the above list, choose the single most appropriate definitive management option. Each item may be used once, more than once, or not at all.Scenario 1A 45-year-old woman presents with a 2-day history of right upper quadrant pain, rigors, nausea and vomiting. She is febrile and her sclerae are noted to be yellow. Abdominal examination reveals a tender right hypochondrium. Liver function tests: bilirubin 29 ?mol/l, alkaline phosphatase 450, aspartate aminotransferase 25 iu/litre. Ultrasound demonstrates a common bile duct diameter of 8 mm with multiple stones present.A - Endoscopic Retrograde Cholangio-Pancreatogram (ERCP) and sphincterotomy?? CORRECT ANSWERA – ERCP and sphincterotomyThis lady is suffering from cholangitis as defined by Charcot’s triad. The common bile duct is dilated (> 6–7 mm). She requires urgent drainage. This should be performed using ERCP with a laparoscopic cholecystectomy deferred to a later date. Failure to clear the duct by simple measures should prompt the use of a stent or, if this fails, transhepatic drainage (percutaneous transhepatic cholangiogram). Open surgical drainage is rarely required.YOUR ANSWER WAS CORRECTScenario 2A 35-year-old woman presents with worsening pain in her right upper quadrant associated with nausea and vomiting. She is neither clinically nor biochemically jaundiced but is febrile. An ultrasound reveals gallstones, thickening of the gallbladder wall and a common bile duct diameter of 3 mm.B - Early laparoscopic cholecystectomy +/- pre-operative cholangiography?? CORRECT ANSWERB – Early laparoscopic cholecystectomy?+/-pre-operative cholangiographyThis lady has acute cholecystitis with no evidence of common bile duct stones. The main choice lies between early (on the index admission) or interval cholecystectomy +/- pre-operative cholangiography. Opinion is divided but, increasingly, surgery is being advocated on the index admission. This is in the acceptance that although the rate of conversion to open surgery is high (20% approximately), it is similarly high at a later date and further complications, including further episodes of inflammation, occur with regularity while on the waiting list.YOUR ANSWER WAS CORRECTScenario 3A 79-year-old man with a history of ischaemic heart disease presents with a 5-day history of progressive right upper quadrant pain. On examination, he is clearly septic. Examination reveals a very tender mass in the right upper quadrant. White cell count 21 x 109/litre.I - Percutaneous (radiological) gallbladder drainage?? CORRECT ANSWERI – Percutaneous (radiological) gallbladder drainageIn a fit person, empyema of the gallbladder (as presented here) might be managed by emergency open cholecystectomy. Before the advent of interventional radiology, if experience was not available, laparotomy could be performed with open drainage. The best treatment, however, in this case would be radiological drainage with antibiotics/resuscitative measures, which will hopefully rectify the situation without recourse to life threatening surgery.YOUR ANSWER WAS CORRECTThe AnswerThe management of symptomatic gallstone disease has changed greatly over the last 20 years. It is an area of contention in many respects, and many algorithms exist (especially for the suspected bile duct stone) all of which have their merits. The final decision probably rests with the experience of the surgeon and the equipment available. The MRCS candidate might be advised to select the simplest and safest answer where doubt exists. These are given below.3A 41-year-old male is referred from his GP with a long history of epigastric pain which is relieved by eating. He is otherwise well, and drinks alcohol only occasionally. The only other feature of note is a long standing history of diarrhoea which hasn’t responded to several changes in diet. An OGD reveals multiple small duodenal ulcers.What is the most likely diagnosis?Select one answer onlyCurling’s ulcerCushing’s ulcerDuodenal carcinomaVIPomaZollinger-Ellison syndrome?? YOUR ANSWERYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionZollinger-Ellison syndrome (gastrinoma) is the 2nd most common islet-cell tumour and around a third have MEN-1 syndrome. The tumour produces very large quantities of a gastrin-like substance into the bloodstream resulting in increased gastric acid secretion. Patients complain of epigastric pain due to peptic ulceration, some will have oesophagitis and diarrhoea is common (thought to be due to the high acid output).4Theme: Pancreatic tumoursA AdenocarcinomaB GlucagonomaC InsulinomaD Non-secreting, islet-cell tumourE Zollinger–Ellison syndromeFor each of the patients described below, select the most likely diagnosis from the list of options above. Each option may be used once, more than once, or not at all.Scenario 1A patient with glossitis and stomatitis has diabetes and a rash on his buttocks.B - Glucagonoma?? CORRECT ANSWERB – GlucagonomaGlucagonomas are rare, but present with long-standing eczematous rash (usually > 1 year), glossitis, stomatitis, diabetes and wasting.YOUR ANSWER WAS CORRECTScenario 2A patient 4 weeks after parathyroidectomy presents with loss of consciousness and dizziness. He has a complex past medical history including previous resection of a pituitary adenoma.C - Insulinoma?? CORRECT ANSWERC– InsulinomaClinical features of insulinomas include disturbances of consciousness and ‘odd’ behaviour; in fact almost any neurological or psychiatric syndrome can be mimicked. Conversation and movement may be restricted during attacks, but the patient feels normal between attacks. This behaviour is part of the MEN-1 syndrome.?Glucagonomas and insulinomas should be treated surgically because of the malignant potential of these tumours.YOUR ANSWER WAS CORRECT5Theme: Disorders of the pancreasA Acute pancreatitisB Adenocarcinoma of the pancreasC ?-cell tumour of the pancreasD Chronic pancreatitisE Cystic fibrosisF Type I diabetesG Type II diabetesH VipomaI Zollinger–Ellison syndromeThe following are all descriptions of pancreatic disorders. Please select the most appropriate diagnosis from the list above. The items may be used once, more than once, or not at all.Scenario 1A 27-year-old man presents with a 7-day history of abdominal pain, which radiates through to the back. He has been vomiting continuously over the past 2 days and has not been able to keep any fluid down. His bowels are open regularly with no history of steatorrhoea. There is no history of any similar episodes in the past. On examination he is pale, dehydrated and in considerable pain. He has marked epigastric peritonism on abdominal examination. Serum biochemistry includes; glucose 6.5 mmol/litre, urea 9.3 mmol/litre, creatinine 95 ?mol/litre, corrected calcium 2.00, amylase 89.A - Acute pancreatitis?? CORRECT ANSWERA – Acute pancreatitisThe patient’s symptoms and signs are consistent with the diagnosis of acute pancreatitis. Of importance is the fact that a normal serum amylase concentration is not sufficiently sensitive to rule out the diagnosis. As in the case illustrated, late presentation makes this more likely; serum amylase typically peaks in the first 12–48 h and may return to normal after 72 h. In such cases the urinary amylase and serum lipase concentrations may be of value. Hypocalcaemia may occur in this potentially life-threatening disorder. The absence of previous episodes of pain, diabetes and symptoms suggestive of malabsorption make chronic pancreatitis unlikely. The diagnosis is confirmed on ultrasound and computed tomography scan findings.Scenario 2A 52-year-old woman presents with a long history of intermittent diarrhoea, which has now become acute. Over the past 2 weeks she has passed watery stools up to ten times a day. This has left her feeling generally weak and she complains of generalised muscular cramps. She is not on any medication. Her serum potassium is 2.8 but there is nothing else of note in her history.H - Vipoma?? CORRECT ANSWERH – VipomaThese tumours are of APUD cells of the gastroenteropancreatic endocrine system. Patients tend to be middle-aged, with more women affected than men.Episodes of profuse watery diarrhoea are typical and continue even in the presence of fasting. Hypokalaemia occurs following excessive gastrointestinal secretion and symptoms of such may be the presenting feature. Vasoactive intestinal peptide (VIP) normally inhibits acid secretion; therefore, patients are hypochlorhydric or achlorhydric. Other abnormalities include hypercalcaemia and hyperglycaemia. Plasma VIP levels are elevated. Initial treatment is directed toward correcting volume and electrolyte abnormalities. Octreotide controls diarrhoea in 80% of cases. Both computed tomography and magnetic resonance imaging are of value in diagnosis and staging. Surgical exploration with tumour resection leads to cure in 50% of patients.HYPOKALEMIAHYPERCALCAEMIAHYPERGLYCEMIAScenario 3A 36-year-old man presents with repeated fainting and feeling lightheaded. This seems to occur at irregular intervals and is most noticeable in the morning and during exercise. His general practitioner initially thought he might have a duodenal ulcer as he had been complaining of vague abdominal pain at night, which was relieved by eating. On examination he is pale, sweating and appears distracted. In addition, his hands are trembling.C - ?-cell tumour of the pancreas?? CORRECT ANSWERC – ?-cell tumour of the pancreas?-Cell tumour, or insulinoma, is the commonest form of islet cell tumour. Symptoms are related to hypoglycaemia and occur with increasing frequency and severity. Attacks may be more frequent in the early hours of the morning, with vague abdominal pain relieved by carbohydrates, hence the confusion with peptic ulcer disease. Episodes may similarly occur following exercise. The diagnosis is suggested by Whipple’s triad, ie:? attacks occurring in the fasting state? during the height of the attack there is hypoglycaemia below 2.5 mmol/litre? symptoms relieved by glucose.Confirmation is by the identification of fasting hypoglycaemia associated with elevated levels of human insulin. Pancreatic angiography may aid in preoperative localisation with treatment by surgical excision of the tumour.YOUR ANSWER WAS CORRECT6Theme: JaundiceA Acute viral hepatitisB Alcoholic cirrhosisC Ascending cholangitisD Carcinoma of the gallbladderE CholangiocarcinomaF Hepatocellular carcinomaG LymphomaH Multiple hepatic metastasesI Pancreatic carcinomaJ Primary biliary cirrhosisK Primary sclerosing cholangitisL Stone in the common bile duct (CBD)The following are descriptions of patients with jaundice. Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all.Scenario 1A 74-year-old woman is seen in The Emergency Department with a 4-week history of progressive jaundice and pruritis. On direct questioning, she has a 3-month history of anorexia and weight loss. On examination, she is cachectic, deeply icteric with evidence of weight loss. The gallbladder is palpable with no obvious hepatomegaly.I - Pancreatic carcinoma?? CORRECT ANSWERI – Pancreatic carcinomaThe patient has presented with progressive symptoms suggestive of underlying pancreatic carcinoma. The finding of a palpable gallbladder may imply gallbladder pathology (eg gallstones). However, if Courvoisier’s law (‘if in the presence of jaundice the gallbladder is palpable, the cause is unlikely to be related to stones’) is applied, the correct diagnosis is reached. The principle is that if the obstruction of the common bile duct is a stone, the gallbladder is usually fibrotic and therefore does not distend. Cholangiocarcinoma and multiple liver metastases can present similarly but the former is much less common than pancreatic cancer (this is therefore the more likely diagnosis) and the latter is associated with a palpable liver not gallbladder. Other characteristic symptoms of pancreatic cancer include severe abdominal and back pain. Investigations include ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography and cytology.YOUR ANSWER WAS CORRECTScenario 2A 57-year-old man presents with a 5-week history of right upper quadrant pain, weight loss and increasing jaundice. He is a known hepatitis B carrier. On examination he is wasted and obviously jaundiced. Examination of his abdomen reveals a stony hard mass in the right upper quadrant that extends across his epigastrium.F - Hepatocellular carcinoma?? CORRECT ANSWERF – Hepatocellular carcinomaThis accounts for approximately 90% of primary liver cancers, the typical presentation of which is illustrated in the case described. Associations include :chronic infection with hepatitis B,cirrhosis and aflotoxin (Aspergillus flavum). Hepatocellular carcinoma may give rise to a solitary large mass or, rarely, multifocal nodules. The finding of a raised serum α- protein is highly suggestive, with diagnostic confirmation via percutaneous biopsy and histology.YOUR ANSWER WAS CORRECTScenario 3A 49-year-old woman presents with recent onset of jaundice. On further questioning she has noticed bouts of pruritis and dark urine for several months. During the course of the consultation she continues to scratch her abdomen. Liver function tests: bilirubin 57 ?mol/l, alkaline phosphatase 556 iu/litre normal aspartate aminotransferase and alanine aminotransferase. A liver biopsy shows expansion of the portal tracts by lymphocytes, plasma cells and occasional granulomas. Bile ducts are scarce.J - Primary biliary cirrhosis?? CORRECT ANSWERJ – Primary biliary cirrhosisThe presentation described is fairly typical for this disorder, 90% of cases are female and the peak age is 45–50 years. This autoimmune disorder is suspected from the typical pattern of the liver function tests, is confirmed by the finding of anti-mitochondrial antibodies/smooth muscle antibodies, and is proven by characteristic histology from liver biopsy. Associated disorders include :thyroid disease and CREST (calcinosis, Raynaud phenomenon, oesophageal motility disorders, sclerodactyly, telangiectasia) syndrome. Treatment is symptomatic, eg nutritional support for malabsorption. Liver transplantation may be required.7A 65-year-old female presents with right upper quadrant pain and intermittent nausea and vomiting. She reports that recently she has lost weight and recalls an ultrasound scan several years ago which showed gallstones but as she was asymptomatic at the time did not undergo surgery. A cholecystectomy is subsequently performed and the histology for this shows a tumour of the gallbladder.What is the most likely type of tumour of the gallbladder?Select one answer onlyAdenocarcinoma?? CORRECT ANSWERHaemangiomaSarcomaSquamous cell carcinoma?? YOUR ANSWERTransitional cell carcinomaThe AnswerAround 85% of tumours of the gallbladder are associated with gallstones. The initial features can be very similar to chronic cholecystitis with right upper quadrant pain, nausea and vomiting. Patients can also develop weight loss, obstructive jaundice and a right upper quadrant mass may be palpable.Adenocarcinomas are the most common tumour type accounting for 90% of tumours, followed by squamous cell carcinomas which form around 10%.8Theme: Causes of biliary stricturesA Mirizzi's syndromeB Chronic pancreatitisC Choledochal cystD Papillary stenosisE Radiation cholangiocarcinomaF CholangiocarcinomaFor each of the following clinical situations listed below, select the single most likely diagnosis from the options above. Each option may be used once, more than once or not at all.Scenario 1A 3-year-old boy was admitted with jaundice and upper abdominal pain. On further questioning his mother mentioned previous episodes of jaundice. On abdominal examination he had a palpable mass in the right upper quadrant. As part of the investigations he underwent an ultrasound scan of the abdomen, which showed evidence of intrahepatic duct dilatation.C - Choledochal cyst?? CORRECT ANSWERCholedochal cysts are congenital anomalies of the bile duct. The clinical history of, and presentation of, a patient with a choledochal cyst varies with the patient's age. Children often present with jaundice with a palpable mass in the right upper quadrant, which may be accompanied with hepatomegaly. The treatment of these cysts is surgical, with complete excision of the cyst and restoration of biliary continuity.Scenario 2A 45-year-old lady was admitted with a 1-week history of colicky right upper quadrant pain, vomiting and pale stool. She had no history of previous abdominal surgery. Clinically she was jaundiced and tender in the right upper quadrant. Liver function tests showed a raised alkaline phosphatase (ALP) and bilirubin. An ultrasound scan of the abdomen showed a large gallstone impacted in Hartmann’s pouch with narrowing of the common hepatic duct at the level of impaction.A - Mirizzi's syndrome?? CORRECT ANSWERMirizzi’s syndrome is an unusual presentation of gallstones that lodge in either the cystic duct or Hartmann’s pouch, causing external compression of the common hepatic duct, which leads to symptoms of obstructive jaundice. Mirizzi’s syndrome is difficult to distinguish from other more common forms of jaundice based on clinical examination. An ultrasound scan is usually diagnostic which shows an impacted stone in Hartmann’s pouch or the cystic duct with dilatation of the common hepatic duct at the level of the stone.YOUR ANSWER WAS CORRECTScenario 3A 65-year-old gentleman presented to clinic with a 2-month history of worsening jaundice, itching and weight loss. He had a past medical history of ulcerative colitis. Clinically he was jaundiced and a positive Courvoisier’s sign. Liver function tests (LFTs) were deranged with a raised bilirubin, ALP and aspartate aminotransferase (AST). An ultrasound scan of the abdomen showed biliary duct dilatation with no evidence of gallstones.F - Cholangiocarcinoma?? CORRECT ANSWERCholangiocarcinoma is the most common primary malignancy of the bile ducts and the second most prevalent liver cancer. The average age at onset is 60–65 years, and it strikes men slightly more often than women (1.5 : 1). The most common presenting symptoms are unexplained weight loss and jaundice. Predisposing factors include :UC, choledochal cysts and parasitic infestation (Clonorchis sinensis). Management of cholangiocarcinoma is dependent on the stage at which it is diagnosed. Complete resection is the only possibility of a cure. The overall 5-year survival rate is 1–5%; this increases to 10–50% following an attempt at resection. In palliative cases, endoscopic retrograde cholangiopancreatography (ERCP) and stenting is the most appropriate line of management.YOUR ANSWER WAS CORRECT9Theme: JaundiceA Hepatic jaundiceB Post-hepatic jaundiceC Pre-hepatic jaundiceFor each of the clinical findings given below, select the correct type of jaundice from the above list. Each option may be used once, more than once, or not at all.Scenario 1Bilirubin in the urine.B - Post-hepatic jaundice?? CORRECT ANSWERB – Post-hepatic jaundiceScenario 2History of recent foreign travel.A - Hepatic jaundice?? CORRECT ANSWERA – Hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 3Positive Courvoisier’s sign.B - Post-hepatic jaundice?? CORRECT ANSWERB – Post-hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 4Associated pancreatitis.B - Post-hepatic jaundice?? CORRECT ANSWERB – Post-hepatic jaundiceYOUR ANSWER WAS CORRECTThe AnswerPre-hepatic jaundice: is associated with the presence of (urinary) urobilinogen and the absence of urinary bilirubin. Causes include:recent blood transfusion a family history of haemolytic syndromes. Hepatic jaundice :may be conjugated or unconjugated, and is associated with :a history of recent foreign travel, alcohol drug abuse, ingestion of hepatotoxic drugs (halothane, chlorpromazine) or liver tumours. Post-hepatic jaundice :is associated with bilirubin in the urine, a positive Courvoisier’s sign (extrahepatic duct obstruction), pruritus, a history of fever, jaundice and rigors (Charcot’s triad – due to ascending cholangitis) and a history of dark urine and pale stools.10Theme: PancreatitisA Carcinoma of the head of the pancreasB Chronic pancreatitisC Biliary obstructionD Acute pancreatitisE Pancreatic pseudocystFor each of the patients described below, select the most likely diagnosis from the list of options above. Each option may be used once, more than once or not at all. You may believe that more than one diagnosis is possible but you should choose the ONE most likely diagnosis.Scenario 1A 43-year-old man, who is an alcoholic, presents to the emergency department with pain radiating to the back. The pain is relieved by leaning forward.B - Chronic pancreatitis?? CORRECT ANSWERA 43-year-old alcoholic with pain radiating in his back which is relieved by leaning forward is most likely to be suffering from chronic pancreatitis. A very similar picture can be seen with carcinoma of the head of the pancreas but the one discriminating feature is that, in carcinoma, the pain is constant.Scenario 2A 52-year-old man, who is a heavy smoker and drinks 14 units/day, presents to the emergency department with acute onset of epigastric pain. He has a past history of chronic pancreatitis and steatorrhoea. On examination, a central abdominal mass is palpable.E - Pancreatic pseudocyst?? CORRECT ANSWERA patient who is an alcoholic and with a history of chronic pancreatitis, presenting with a palpable abdominal mass, would suggest a diagnosis of a pancreatic pseudocyst.Scenario 3A 40-year-old man presents to the emergency department with a history of sudden onset abdominal pain and vomiting. Serum amylase is elevated. There is no previous history of pancreatitis.D - Acute pancreatitis?? CORRECT ANSWERThis clinical case scenario is typical of acute pancreatitis – sudden onset of pain, vomiting and an increased serum amylase.YOUR ANSWER WAS CORRECT11A 57-year-old male patient with known alcoholic liver disease, presents with confusion and is generally unwell. On examination he is noted to have a distended abdomen with shifting dullness. Imaging later confirms a mass in his liver which is thought to be malignant in origin.What is the most likely nature of this mass?Select one answer onlyCholangiocarcinomaFibrolamellar carcinomaHaemangiomaHaemangiosarcomaHepatocellular carcinoma (HCC)?? YOUR ANSWERYOUR ANSWER WAS CORRECTThe AnswerHCC is the most common primary malignancy of the liver occurring mainly on a background of cirrhosis. It may be detected through screening – ultrasound and α fetoprotein (αFP) are used for this, or it may be associated with a marked deterioration in patients with chronic liver disease with encephalopathy, ascites and reduced synthetic function. Fibrolamellar carcinoma is a rare variant of HCC affecting children and young adults.12Theme: JaundiceA CholangiocarcinomaB Gall bladder calculiC Common bile duct calculusD Mucocele of the gall bladderE Empyema of the gall bladderFor each of the patients described below, select the most likely diagnosis from the list of options above. Each option may be used once, more than once or not at all. You may believe that more than one diagnosis is possible but you should choose the ONE most likely diagnosis.Scenario 1A 34-year-old lady presents to the emergency department with a palpable right upper quadrant mass, fever and being generally unwell.E - Empyema of the gall bladder?? CORRECT ANSWERA palpable right upper quadrant mass, fever and the feeling of being generally unwell would point to an empyema of the gall bladder.YOUR ANSWER WAS CORRECTScenario 2A 30-year-old female who had an open cholecystectomy presents with obstructive jaundice 48 h after surgery.C - Common bile duct calculus?? CORRECT ANSWERObstructive jaundice 48 h after open cholecystectomy is most likely to be due to common bile duct calculus that was missed at the time of surgery.YOUR ANSWER WAS CORRECTScenario 3A 38-year-old obese lady presents to the emergency department with right upper quadrant pain. Ultrasound scan shows a stone in the Hartmann’s pouch and a distended thick-walled gallbladder.D - Mucocele of the gall bladder?? CORRECT ANSWERIn most instances where an open cholecystectomy is performed, an intra-operative cholangiogram is performed and a T-tube is left?in situ.?A stone in Hartmann’s pouch (ie obstructing the cystic duct) causing right quadrant upper pain is probably due to a mucocele.YOUR ANSWER WAS CORRECT13Theme: HepatobiliaryA Medical therapyB Elective cholecystectomyC Emergency cholecystectomyD Endoscopic retrograde cholangiopancreatography (ERCP)For each of the clinical scenarios below select the best treatment. Each option may be used once, more than once, or not at all.Scenario 1An old woman not fit for surgery with stones in the common bile duct plus jaundice.D - Endoscopic retrograde cholangiopancreatography (ERCP)?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 2A young woman with fat intolerance, right upper quadrant pain and gallstones.B - Elective cholecystectomy?? CORRECT ANSWERThe AnswerComment on this QuestionIf patients are fit enough and have symptoms from gallstones, a cholecystectomy should be performed. Almost 90% of all cholecystectomies are performed laparoscopically in the UK. If patients are too elderly or unfit for general anaesthesia, an ERCP may be considered as an alternative.14A 57-year-old female is admitted under the general surgical team with severe epigastric pain radiating to her back. She has a history of profuse vomiting and a serum amylase comes back as 1200u/ml. She is commenced on treatment for acute pancreatitis and further tests are done. Bloods show a white cell count of 12x109/l, calcium 1.9mml/l, urea 17mmol/l, LDH 472 iu/l, Albumin 31g/l anda blood glucose of 11mmol/l. An ABG has a PaO2 of 13.1kPa on room air.How severe is her pancreatitis using the modified Glasgow criteria?Select one answer onlyMildModerateSevere?? YOUR ANSWERHaemorrhagicNecroticYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionThe modified Glasgow criteria can be used to assess the severity of acute pancreatitis and can be remembered through the mnemonic: PANCREAS.PaO28kPaAge> 55 year oldNeutrophilsWCC > 15 x 104/lCalcium<2mmol/lRenal FunctionUrea > 16mmul/lEnzymesLDH >600iunits/:AST>200iu/lAlbumin<32g/lSugar blood glucose>10mmol/lMild=1 positive factor, moderate=2 factors, severe=3 positive factorThe terms haemorrhagic and necrotic describe the CT appearance of the pancreas.15Theme: Complications of gallstone diseaseA Acute cholecystitisB Acute pancreatitisC Ascending cholangitisD Biliary colicE Chronic cholecystitisF Empyema of the gallbladderG Gallbladder perforationH Gallstone ileusI Mirizzi’s syndromeJ MucocoeleK Obstructive jaundiceThe following are descriptions of patients with complications of gallstone disease. Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all.Scenario 1A 72-year-old woman presents with severe colicky central abdominal pain and vomiting. On examination there is right upper quadrant tenderness, negative Murphy’s sign, abdominal distension and tinkling bowel sounds. Blood results: total bilirubin 12 ?mol/litre, aspartate aminotransferase 25 iu/litre, alanine aminotransferase 29 iu/litre, alkaline phosphatase 200 iu/litre, amylase 38 iu/litre; white cell count 8.0 x 109/litre.H - Gallstone ileus?? CORRECT ANSWERH – Gallstone ileusThis patient has symptoms typical of small bowel obstruction. Small bowel obstruction from impaction of a gallstone in the distal ileum is rare but most commonly occurs in women over 70 years old. It accounts for 20% of older patients with small bowel obstruction who do not have a history of a hernia or previous abdominal surgery. Plain abdominal films may show a classic triad of small bowel obstruction, a gallstone in the gut and gas in the biliary tree (although the Editor has yet to observe this in practice). Treatment is surgical with proximal enterotomy, removal of the stone, a search for further stones but not cholecystectomy (which is dangerous and unnecessary). A bonus mark could be given for this question for also choosing Mirizzi’s syndrome because most patients also have a fistula.YOUR ANSWER WAS CORRECTScenario 2A 63-year-old man presents with a 5-day history of severe upper abdominal pain and vomiting. On examination there is a profound tachypnoea and tachycardia; he has generalised upper abdominal tenderness. He has an Amylase level of 500.B - Acute pancreatitis?? CORRECT ANSWERB – Acute pancreatitisThe differential diagnosis is gallbladder perforation but this is much less common than pancreatitis. Typically patients present with severe upper abdominal pain radiating to the back, often associated with nausea and vomiting. Signs of cardiovascular or respiratory dysfunction may be present, abdominal signs range from mild epigastric or left upper quadrant tenderness to generalised peritonitis.YOUR ANSWER WAS CORRECTThe AnswerWhen considering this subject, the candidate is advised to think of complications within and without the gallbladder, starting with the former and progressing to the ileum.16Theme: CholecystectomyA CholestyramineB Elective cholecystectomyC Emergency cholecystectomyD Endoscopic retrograde cholangiopancreatography (ERCP)E LithotripsyFor each of the patients described below, select the most likely treatment from the list of options above. Each option may be used once, more than once, or not at all.Scenario 1A 77-year-old woman presents with abdominal pain and jaundice. Ultrasound reveals stones in the common bile duct. She is unwell and not fit for theatre.D - Endoscopic retrograde cholangiopancreatography (ERCP)?? CORRECT ANSWERD – ERCPAn ERCP is a useful method of removing stones from the common bile duct to relieve jaundice. It is associated with a 1% risk of pancreatitis and a 0.1% risk of mortality.YOUR ANSWER WAS CORRECTScenario 2A young woman presents to the outpatient department with a history of fat intolerance and abdominal pain in the right upper quadrant. An ultrasound scan reveals that she has gallstones. Upper GI endoscopy was normal.B - Elective cholecystectomy?? CORRECT ANSWERB – Elective cholecystectomyIf patients are fit enough and are symptomatic from gallstones, then a cholecystectomy should be performed. Nearly 90% of all cholecystectomies are performed laparoscopically in the?UK.YOUR ANSWER WAS CORRECT17A Proximal pancreatoduodenectomyB Distal pancreatectomy and splenectomyC Total pancreaticoduodenectomyD Endoscopic biliary stentingE CholecystojejunostomyF Surgical biliary bypassFor each of the following clinical situations listed below, select the single most likely surgical procedure from the options above. Each option may be used once, more than once or not at all.Scenario 1A 60-year-old man was diagnosed with pancreatic carcinoma. Investigations revealed that the disease was limited to the head and uncinate process of the pancreas with no evidence of lymph node involvement.A - Proximal pancreatoduodenectomy?? CORRECT ANSWERProximal pancreatoduodenectomyYOUR ANSWER WAS CORRECTScenario 2An 80-year-old women was admitted with a 6-month history of weight loss and jaundice. She had a past medical history of two myocardial infarctions, angina and chronic obstructive pulmonary disease (COPD). Computed tomography (CT) scan confirmed the presence of pancreatic carcinoma.D - Endoscopic biliary stenting?? CORRECT ANSWEREndoscopic biliary stentingYOUR ANSWER WAS CORRECTScenario 3A 67-year-old man was found to have carcinoma of the tail of the pancreas with no evidence of local spread on laparotomy.B - Distal pancreatectomy and splenectomy?? CORRECT ANSWERDistal pancreatectomy and splenectomyDuctal adenocarcinoma of the pancreas accounts for 90% of all malignant pancreatic exocrine tumours. It has a propensity for perineural invasion within and beyond the gland and for rapid lymphatic spread. The commonest sites of extralymphatic involvement are the liver, peritoneum and lung. Surgical excision offers the only chance of cure in pancreatic cancer. Unfortunately only 20% of patients with cancer of the head, and less than 3% of those with carcinoma of the body or tail, have lesions that are suitable for resection. For tumours confined to head or uncinate process of the pancreas, proximal pancreatoduodenectomy may be considered to spare the remaining pancreas. Patients with signs of pancreatic outflow obstruction and multiple co-morbidities may be more suitable for ERCP and stenting to avoid the physiological burden of major surgery. As with the final scenario, tumours confined to the tail of the pancreas may be amenable to distal pancreatectomy (plus splenectomy if appropriate) to preserve the rest of the pancreas and its endocrine/exocrine function.YOUR ANSWER WAS CORRECT18Theme: JaundiceA Hepatic jaundiceB Post-hepatic jaundiceC Pre-hepatic jaundiceSelect the most likely type of jaundice from the above list that would be indicated by the clinical findings or associated with the conditions listed below. Each option may be used once, more than once, or not at all.Scenario 1PruritusB - Post-hepatic jaundice?? CORRECT ANSWERB – Post-hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 2Intake of hepatotoxic drugsA - Hepatic jaundice?? CORRECT ANSWERA – Hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 3Incompatible blood transfusionC - Pre-hepatic jaundice?? CORRECT ANSWERC – Pre-hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 4Chlorpromazine-induced jaundiceA - Hepatic jaundice?? CORRECT ANSWERA – Hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 5Chronic active hepatitisA - Hepatic jaundice?? CORRECT ANSWERA – Hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 6Halothane-induced jaundiceA - Hepatic jaundice?? CORRECT ANSWERA – Hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 7ThalassaemiaC - Pre-hepatic jaundice?? CORRECT ANSWERC– Pre-hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 8Sclerosing cholangitisB - Post-hepatic jaundice?? CORRECT ANSWERB – Post-hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 9Hepatic abscessesA - Hepatic jaundice?? CORRECT ANSWERA – Hepatic jaundiceYOUR ANSWER WAS CORRECTScenario 10Rotor's syndromeA - Hepatic jaundice?? YOUR ANSWERB - Post-hepatic jaundice?? CORRECT ANSWERB – Post-hepatic jaundiceYOUR ANSWER WAS INCORRECTThe AnswerJaundice (icterus) is the yellow pigmentation of skin, sclera and mucosa due to a raised plasma bilirubin (> 35 mmol/l). conjugated hyperbilirubinaemia with bilesalt deposition in the skin. Unconjugated hyperbilirubinemia does not typically cause pruritus. Pre-hepatic jaundice is associated with haemolytic anaemia and familial non-haemolytic hyperbilirubinaemia, such as in Gilbert’s syndrome. Hepatic causes include: acute viral or drug-induced (halothane, chlorpromazine) hepatitis; other hepatoxic substances (alcohol, carbon tetrachloride); cirrhosis, chronic active hepatitis; hepatic tumours, hydatid disease and liver abscesses. Post-hepatic causes include: porta hepatis lymph nodes, sclerosing cholangitis, biliary atresia, bile duct carcinoma, pancreatic carcinoma and choledocholithiasis. Rotor's syndrome gives a cholestatic jaundice. Cholestatic jaundice is post-hepatic.19THEME: JAUNDICEA Gilbert's syndromeB Common bile duct stone?C Acute alcoholic hepatitisD Carcinoma of the head of the pancreasE Primary biliary cirrhosisF Ascending cholangitisG Hepatic metastasesH CholangiocarcinomaI Primary sclerosing cholangitisFor each of the patients described below, select the single most likely diagnosis from the options listed above. Each option may be used once, more than once, or not at all.Scenario 1A 30-year-old man with a 7-year history of ulcerative colitis complains of fluctuating jaundice, pruritus, right upper quadrant pain and weight loss for the previous 6 months. Plasma alkaline phosphatase is 270 U/l (normal 30-130 U/l). Immunological studies show elevated immunoglobulim M, anti-smooth muscle antibodies but no rise in antimitochondrial antibodies.I - Primary sclerosing cholangitis?? CORRECT ANSWERUlcerative colitis is associated with primary sclerosing cholangitis in 50-70% of cases. Patients present with a progressive cholastatic picture with RUQ pain, jaundice, and fever. Investigation reveals a raised alkaline phosphastase. Immunological studies show elevated immunoglobulim M, anti-smooth muscle antibodies but no rise in antimitochondrial antibodies.Scenario 2A 25-year-old man, who has noticed mild intermittent jaundice for the past 6 years, becomes more icteric during a chest infection. There is a moderate unconjugated hyperbilirubinaemia, otherwise he has normal liver function tests and liver histology.A - Gilbert's syndrome?? CORRECT ANSWERGilbert’s syndrome is an inherited metabolic disorder leading to increased unconjugated hyperbilirubinaemia. Jaundice usually occurs during intercurrent illness.YOUR ANSWER WAS CORRECTScenario 3A 57-year-old woman presents with a 5-week history of itching, pale stools, dark urine and fatigue. She has tender 12 cm hepatomegaly, splenomegaly, mild ascites, widespread spider naevi and palmar erythema. Laboratory investigations show a leucocytosis of 20x109/l, plasma alanine transaminase 280 U/l (normal 2-50 U/l), plasma albumin 24 g/l (normal 35-50 g/l), and a prothrombin time of 20 s (control 13 s). Immunoglobulin M is increased. She is positive for antimitochondrial antibodies.3505200-490855E - Primary biliary cirrhosis?? CORRECT ANSWERPrimary biliary cirrhosis is a slowly progressive cholangiohepatitis. It is more common in women than men, with a peak age of 45 years. Treatment is mainly symptomatic. Liver transplantation is offering encouraging results.Scenario 4A 62-year-old man presents with a 3-month history of weight loss, increasing jaundice, dyspepsia and nocturnal epigastric pain radiating to his back. He had undergone colonoscopy 2 months previously, with no abnormalities detected. Examination reveals a right upper quadrant mass. Laboratory investigations show plasma alkaline phosphatase of 752 U/l (normal 30-130 U/l) and 1% glycosuria.D - Carcinoma of the head of the pancreas?? CORRECT ANSWERCarcinoma of the head of the pancreas usually presents insidiously with weight loss, epigastric pain radiating to the back and features of obstructive jaundice. Only approximately 13% of patients at presentation are suitable for a Whipple’s procedure. Operative mortality is high, at around 20%. Often palliative bypass surgery is all that can be done.20Theme: JaundiceA CholangiocarcinomaB Common bile-duct stoneC Empyema of the gallbladderD Gallbladder calculiE Mucocele?of the gallbladderFor each of the patients described below, select the most likely diagnosis from the list of options above. Each option may be used once, more than once, or not at all.Scenario 1A 34-year-old woman presents with a palpable right upper quadrant mass. She has a fever and is generally unwell.C - Empyema of the gallbladder?? CORRECT ANSWERC – Empyema of the gallbladderA palpable right upper quadrant mass, fever and the feeling of being generally unwell would point to an empyema of the gallbladder.YOUR ANSWER WAS CORRECTScenario 2A 30-year-old woman who had an open cholecystectomy presents with obstructive jaundice 48 hours after surgery.B - Common bile-duct stone?? CORRECT ANSWERB – Common bile-duct stoneObstructive jaundice 48 hours after open cholecystectomy is most likely the result of a common bile duct (CBD) calculus, which was missed at the time of surgery. This could have been avoided if a pre-operative ultrasound had shown dilatation of the CBD stones would have been visualised and removed by pre-operative ERCP.Alternatively, during an open cholecystectomy, an intraoperative cholangiogram can be performed to visualise stones in the CBD. The CBD can then be opened, the stones removed and a T-tube left in situ.YOUR ANSWER WAS CORRECTScenario 3A 38-year-old obese woman presents with right upper quadrant pain. She is apyrexial. On examination there is a large tense gallbladder. WBC is normal. Ultrasound scanning shows a stone in Hartmann’s pouch.E - Mucocele of the gallbladder?? CORRECT ANSWERE – Mucocele of the gallbladderA stone in Hartmann’s pouch causing right quadrant upper pain is most likely to lead to a mucocele.21A 48-year-old obese female presents with right upper quadrant (RUQ) pain and nausea, she reports similar episodes in the past which have resolved spontaneously. On examination she is afebrile and has a soft abdomen which is tender in the RUQ and a plain X-ray shows radio-opaque round opacities in the RUQ. These are thought to represent gallstones.What proportion of gallstones can be seen on a plain abdominal X-ray?Select one answer only<1%10%?? CORRECT ANSWER30%50%>75%?? YOUR ANSWERYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionAround 10-15% of gallstones can be seen on plain imaging. These often appear as rings due to calcium deposition around a central organic core. In some cases the gallbladder may be calcified (‘porcelain gallbladder’).22THEME: JAUNDICEA Common bile duct damageB Biliary spasmC Acute pancreatitisD Transfusion reactionE Drug-induced biliary stasisFor each of the patients described below, select the single most likely diagnosis from the options listed above. Each option may be used once, more than once, or not at all.Scenario 1A 45-year-old woman undergoes a hysterectomy for fibroids. She experiences a 1.5 litre intra-operative blood loss and requires a blood transfusion. She makes slow post-operative progress and develops mild jaundice and a low-grade fever.D - Transfusion reaction?? CORRECT ANSWERD - Transfusion reactionThe patient who has had a hysterectomy and then develops a low grade fever and mild jaundice following a blood transfusion is likely to have a transfusion reaction.YOUR ANSWER WAS CORRECTScenario 2A 45-year-old man undergoes an endoscopic retrograde cholangiopancreatography (ERCP) for removal of a common bile duct stone. The procedure is particularly difficult but is eventually successful. Following the operation, he deteriorates badly, developing a pyrexia and severe abdominal pain, with increased amylase of 500.C - Acute pancreatitis?? CORRECT ANSWERC - Acute pancreatitisERCP is associated with acute pancreatitis in 1% of cases.YOUR ANSWER WAS CORRECTScenario 3A 54-year-old woman undergoes laparoscopic biliary surgery. The operation is difficult. Following the operation, she becomes unwell. On the third day, there is bile in the drain and mild jaundice.A - Common bile duct damage?? CORRECT ANSWERA - Common bile duct damageFollowing laparoscopic cholecystectomy, any biliary leak and jaundice should make one suspicious of bile duct injury. This is best investigated with ERCP.YOUR ANSWER WAS CORRECT23A 45-year-old woman with known gallstones is admitted with epigastric pain and vomiting. Her serum amylase is 1194u 1ml. An abdominal ultrasound shows gallstones in the CBD with a dilated CBD and it is thought she has acute gallstone pancreatitis. Her other test results are as follows:CXR and AXR unremarkable, WCC 9x109/l, Calcium 2.3 mmo1/l, Urea 9mmol/l LDH 352 iu/l, Albumin 35g/l, blood glucose 7mmol/l and an ABG shows a PaO2 of 12kPa.With this information, which scoring system can be best used to assess the severity of her pancreatitis?Select one answer onlyAPACHEBalthazarGlasgow?? YOUR ANSWERHincheyRansonYOUR ANSWER WAS CORRECTThe AnswerSeveral different scoring systems exist to grade the severity of pancreatitis. The APACHE score requires additional information to those provided e.g.blood pressure, urine output. The Balthazar grade is based on the CT appearance of the pancreas, Ranson’s criteria are valid for alcohol-induced pancreatitis and can only be applied after 48 hours. The Hinchey classification grades diverticulitis not pancreatitis.24Theme: Pancreatic tumourA AdenocarcinomaB GlucagonomaC InsulinomaD VIPomaE Zollinger–Ellison syndromeFor each of the patients described below, select the most likely pancreatic tumour from the list of options above. Each option may be used once, more than once, or not at all.Scenario 1A vicar who missed breakfast swore during his sermon, but felt better after a late breakfast.C - Insulinoma?? CORRECT ANSWERC – InsulinomaInsulinomas produce episodes of hypoglycaemia leading to altered behaviour and disturbances of consciousness. Characteristically, the patient feels well between episodes. It is a difficult diagnosis to make unless there is a degree of clinical suspicion.YOUR ANSWER WAS CORRECTScenario 2A 52-year-old man with hypercalcaemia suffers from recurrent gastric ulcers.E - Zollinger–Ellison syndrome?? CORRECT ANSWERE – Zollinger–Ellison syndromeIn the second case, the patient has MEN-1. The hypercalcaemia arises from hyperparathyroidism. He also has Zollinger–Ellison syndrome, which causes markedly raised levels of gastrin and gastric acid hypersecretion. This leads to severe ulceration not only in the stomach and duodenum but also the jejunum.YOUR ANSWER WAS CORRECT25An 18-year-old gap year student presents to A&E with right sided abdominal pain and rigors. On examining him he is clammy to touch, has a temperature of 38.5 and is tender in the right upper quadrant. His only medical history of note is dysentery whilst on a backpacking trip to Mexico 2 months ago.What is the most likely diagnosis?Select one answer onlyAmoebic liver abscess?? YOUR ANSWERCholangiorcarcinomaGallstonesHydatid diseasePancreatitisYOUR ANSWER WAS CORRECTThe AnswerAmoebic liver abscesses often occur secondary to entamoeba histolytica infection in the gut entering the portal circulation and spreading to the liver. The condition occurs mostly in endemic areas and affects travellers visiting them. Clinical features include abdominal pain (most commonly in the right upper quadrant), fever, rigors and nausea/vomiting. Some patients will report a history of dysentery recently. Imaging with ultrasound scan or CT is useful in the diagnosis, and can be combined with aspiration which produces a thick fluid resembling anchovy sauce. Treatment mostly consists of metronidazole sometimes with percutaneous drainage.26Theme: Causes of jaundiceA Hereditary spherocytosisB Gilbert's syndromeC Pancreatic carcinomaD GallstonesE Primary sclerosing cholangitisF Hepatitis AFor each of the following clinical situations listed below, select the single, most likely, diagnosis from the options above. Each option may be used once, more than once or not at all.Scenario 1A 30-year-old man presented to his GP feeling unwell, with non-specific symptoms including nausea, anorexia and a distaste for cigarettes. He then presented 2 weeks later with jaundice, dark urine and pale stool. When questioned further he had been abroad before the onset of his symptoms.F - Hepatitis A?? CORRECT ANSWERHepatitis A is the most common type of viral hepatitis occurring world-wide, often in epidemics. Spread of infection is mainly by the faecal–oral route and arises from the ingestion of contaminated food or water. The viraemia causes the patient to feel unwell with non-specific symptoms. Some patients will present 2 weeks later with jaundice.YOUR ANSWER WAS CORRECTScenario 2A 20-year-old man presents with a 6-month history of upper abdominal pain and leg ulcers. His mother had noticed that he had become jaundiced. Investigations showed a slight rise in bilirubin and mild anaemia. An ultrasound scan of the abdomen showed evidence of splenomegaly.A - Hereditary spherocytosis?? CORRECT ANSWERHereditary spherocytosis is the most commonly inherited haemolytic anaemia in northern?Europe, affecting 1 in 5000. It is inherited in an autosomal dominant manner, but in 25% of patients neither parent is affected. It may present with jaundice at birth however sometimes it is delayed for many years and some patients may go through life with no symptoms. The patient may eventually develop anaemia, splenomegaly and ulcers on the leg.YOUR ANSWER WAS CORRECTScenario 3A 35-year-old lady was admitted to the Accident and Emergency Department with upper abdominal pain and a 2-month history of progressive jaundice and pruritus. She also reported occasional episodes of blood mixed in with faeces, as well as significant weight loss. There was a family history of inflammatory bowel disease.E - Primary sclerosing cholangitis?? CORRECT ANSWERPrimary sclerosing cholangitis results from inflammation and fibrosis of the intrahepatic and extrahepatic bile duct, leading to multiple areas of narrowing throughout the biliary system. Around 75% of patients have inflammatory bowel disease (usually ulcerative colitis), but this may be asymptomatic. The mean survival time from diagnosis to death or liver transplantation in symptomatic patients is 2 years, while 75% of asymptomatic patients are alive at 5 years.YOUR ANSWER WAS CORRECTScenario 4A 70-year-old lady presented with a 2-month history poor appetite and weight loss. Her husband had noticed her turning yellow. On further questioning she also reported symptoms of dark urine and pale stools. On examination patient she was profoundly jaundiced with no obvious signs of chronic liver disease. On abdominal examination she had a non-tender palpable mass in the right upper quadrant.C - Pancreatic carcinoma?? CORRECT ANSWERCarcinoma of the head of the pancreas presents more frequently with symptoms of obstructive jaundice, weight loss and abdominal pain. Anorexia, nausea and vomiting are often present. Pain is present in about 70% of patients at the time of diagnosis and is usually located in the epigastrium or left upper quadrant. An episode of acute pancreatitis can occasionally be the first presenting feature. Hepatomegaly occurs in approximately 80% of patients at the time of presentation. A palpable gall-bladder (Courvoisier’s sign) is commonly found on careful examination in jaundiced patients with malignant obstruction of the lower bile duct (as opposed to ductal gallstones).YOUR ANSWER WAS CORRECT27A 75-year-old man who has had a prolonged intensive care unit admission following an emergency abdominal aortic aneurysm repair is referred to the surgical team because of increased abdominal pain and discomfort noted when he is moved. His bloods and urine show normal amylase and lipase levels respectively. A CT showed no leak from the anastomosis, but an ultrasound scan shows a dilated gallbladder with oedema in the wall. However, no gallstones were noted.What is the most likely diagnosis?Select one answer onlyAorta-enteric fistulaeBiliary colicCholeystitis?? YOUR ANSWERIleusPancreatitisYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionAcalculous Choleystitis is rare, but can occur in critically ill patients often on intensive care unit. The mechanism for this is thought to involve gallbladder stasis due to analgesia or parenteral nutrition. Imaging includes ultrasound which can show dilated gallbladder with oedema in the wall28Theme: Scoring in acute pancreatitisA APACHE II?B Balthazar-Ranson grading systemC Computed tomography severity indexD Glasgow score = 2?E Glasgow score = 3F Glasgow score = 4G Hong Kong scoringThe above are examples of scores or scoring systems used in the early assessment of acute pancreatitis. From the descriptions below please choose the most appropriate answer from the list above. Each item may be used once, more than once, or not at all.Scenario 1A 58-year-old woman with a prior history of acute pancreatitis presents with symptoms similar to her previous attack. Her amylase is 920. Full blood count: haemoglobin 13.4 g/dl, white cell count 10.2 x 109/litre, platelets 300 x 109/litre; glucose 7.8, lactate dehydrogenase 300; liver function tests: albumin 37,γ?-glutamyltransferase 18, aspartate aminotransferase 300, alkaline phosphatase 320; urea 6.1, Ca2+ 2.25, PaO2 (on air) 11.5 kPa.A - APACHE II?? YOUR ANSWERD - Glasgow score = 2?? CORRECT ANSWERD - Glasgow score = 2This presentation uses the Glasgow score to demonstrate disease severity. This is a nine-point scoring system. No haematocrit has been measured and no base deficit included. All tests were performed at the same time. Age > 55 and aspartate aminotransferase > 200 are the two positive criteria.YOUR ANSWER WAS INCORRECTScenario 2A radiological scoring system that assesses pancreatic size, inflammation and fluid collections; that does not use intravenous contrast.B - Balthazar-Ranson grading system?? CORRECT ANSWERB - Balthazar-Ranson grading systemThe distinction between interstitial and necrotising pancreatitis cannot be made unless intravenous contrast is used. A non-enhanced computed tomography (CT) does provide important information in accordance with the Balthazar-Ranson criteria of severity (graded A-E). When intravenous contrast is used a 'CT severity index' can be used. This index awards points on the basis of the CT grade and the amount of necrosis. (NB Patients with a combined score of 7-10 have a higher morbidity than those with a score < 7.)The commonest causes of acute pancreatitis are gallstones (50-60% of attacks in the UK) and alcohol. The rationale of a scoring system is to attempt to predict the presence of severe disease, to allow patient series to be compared, and to permit rational selection of patients for potential new treatment strategies. Ranson's score (HC Ranson, 1974) is not commonly used in the UK (this is a multiple-factor scoring system based on a North American population with alcohol as the predominant aetiological factor). The Glasgow score is a modification of Ranson's scoring system, and was designed for use in a typical UK population with gallstone-predominant disease. Both of these systems are limited in that they cannot be completed immediately on admission; requiring 48 h of assessment. (A score of greater than 3 indicates severe disease.) The Acute Physiology and Chronic Health Evaluation (APACHE II, or more recently APACHE III) has the advantage of being able to be employed daily, but is extensive and time consuming (NB a score of > 8 implies severe disease). Biochemical scoring methods eg C-reactive protein and the Hong Kong system (based on glucose and urea); immunological scoringg (interleukin-6); and radiological scoring (Balthazar-Ranson and computed tomography severity system) also exist.YOUR ANSWER WAS CORRECT29Theme: JaundiceA Acute cholangitisB Biliary colicC Chronic pancreatitisD Duodenal carcinomaE Gilbert’s diseaseF Hepatitis CG Hepatocellular carcinomaFor each description listed below, select the most appropriate diagnosis from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 30-year-old man underwent total colectomy 9 months ago for familial adenomatous polyposis (FAP) and now presents with abdominal pain and jaundice; he is passing dark urine and pale stools.D - Duodenal carcinoma?? CORRECT ANSWERD – Duodenal carcinomaPatient 1 has FAP. Such patients have adenomas in the colon and duodenum. The commonest extraintestinal manifestation of FAP is a duodenal carcinoma. Duodenal carcinoma should be suspected in a patient with FAP who becomes jaundiced. The tumour here appears to be causing extrahepatic biliary obstruction.YOUR ANSWER WAS CORRECTScenario 2A 70-year-old man presents with epigastric pain, jaundice, rigors and fever.A - Acute cholangitis?? CORRECT ANSWERA – Acute cholangitisPatient 2 exhibits altered features of Charcot’s triad: fever, pain and rigors. Cholangitis is usually the result of a stone in the common bile duct.YOUR ANSWER WAS CORRECTScenario 3A 40-year-old woman presents with right upper quadrant pain. She is nauseated, but does not have jaundice or rigors.B - Biliary colic?? CORRECT ANSWERB – Biliary colicPatient 3 is most likely to have biliary colic, as this does not usually cause jaundice.YOUR ANSWER WAS CORRECT30A 55-year-old male with a history of chronic pancreatitis secondary to alcohol is being managed conservatively as an out-patient. It is decided to assess the exocrine function of his pancreas prior to nutritional interventions.Which of the following techniques is the best assessment technique for the exocrine status of the pancreas?Select one answer onlyAlbumin levelsBarium mealCTLundh meal?? YOUR ANSWERUltrasoundYOUR ANSWER WAS CORRECTThe AnswerThe Lundh meal is a meal of skimmed milk powder mixed with corn oil and dextrose used to assess pancreatic function. Following this serum lipase measurements can provide a good indicator of exocrine pancreatic status. A barium meal, CT and ultrasound don’t provide a functional assessment of the pancreas, and serum albumin levels may be decreased for many reasons e.g. inadequate diet, sepsis, nephrotic syndrome.The faecal elastase test is increasingly used for detecting exocrine insufficiency and is more acceptable to patients.31Theme: PancreatitisA Acute pancreatitisB Acute-on-chronic pancreatitisC Biliary obstructionD Cancer of the head of the pancreasE Pancreatic pseudocystFor each of the patients described below, select the most likely diagnosis from the list of options above. Each option may be used once, more than once, or not at all.Scenario 1A 43-year-old man, with a history of alcohol abuse, presents with pain radiating to his back, which is relieved by leaning forward. No jaundice or significant weight loss is evident.B - Acute-on-chronic pancreatitis?? CORRECT ANSWERB – Acute-on-chronic pancreatitisThe 43-year-old alcoholic with pain radiating to his back relieved by leaning forward is most likely to have chronic pancreatitis. A very similar picture can be seen with carcinoma of the head of the pancreas, but the one discriminating feature is that pain is constant and persistent in carcinoma. Moreover, the peak incidence of pancreatic adenocarcinoma is 60–80 years of age.Scenario 2A 52-year-old man who drinks 14 units/day and is a heavy smoker presents with acute onset of epigastric pain. He has a history of chronic pancreatitis, steatorrhoea and also has a palpable abdominal mass.E - Pancreatic pseudocyst?? CORRECT ANSWERE – Pancreatic pseudocystA patient who is alcoholic with a history of chronic pancreatitis and a palpable abdominal mass suggests a pancreatic pseudocyst. This can be easily diagnosed by ultrasound or CT scan.YOUR ANSWER WAS CORRECTScenario 3A 40-year-old man with a history of sudden onset abdominal pain and vomiting has an increased serum amylase. He has no previous history of pancreatitis.A - Acute pancreatitis?? CORRECT ANSWERA – Acute pancreatitisThis final clinical case is typical of acute pancreatitis with a history of sudden onset of pain, vomiting and an increased serum amylase level.YOUR ANSWER WAS CORRECT32A surgical registrar is performing his 3rd solo laparoscopic cholecystectomy in a 47-year-old female. When attempting to dissect out Calot’s triangle to identify the cystic artery great difficulty is experienced as the anatomy appears aberrant.What proportion of patients have anomalies of the gallbladder and biliary tree?Select one answer only<1%?? YOUR ANSWER10%?? CORRECT ANSWER40%75%>90%YOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionCalot’s triangle, also known as the cystohepatic or hepatobiliary triangle is an anatomic space which is of great relevance when performing a laparoscopic cholecystectomy. It is bounded by the common hepatic duct medially, cystic duct laterally and liver superiorly, and is used to locate the cystic artery which runs within.Anomalies of the gallbladder or biliary tree are found within 10% of subjects and are important during surgery. They include:A long cystic duct travelling alongside the common hepatic duct.The gallbladder opening directly into the side of the common bile duct i.e. the cystic duct is absent.Variation in the blood vessel arrangement supplying the gallbladder e.g. in 25% of people the right hepatic artery crosses in front of the common hepatic duct instead of behind it.33Theme: JaundiceA Duodenal carcinomaB Biliary colicC Hepatitis CD Acute cholangitisE Hepatocellular carcinomaF Chronic pancreatitisG Gilbert's diseaseFor each of the clinical scenarios below select the most appropriate disease from the list above. Each option may be used once, more than once or not at all.Scenario 1A 39-year-old man presents to the surgical outpatient clinic with severe abdominal pain, loss of appetite and loss of weight. He says that he is passing dark urine and pale stools. On examination, he is jaundiced and mildly anaemic. His relevant surgical history includes total colectomy for familial adenomatous polyposis.A - Duodenal carcinoma?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 2A 70-year-old man presents to the emergency department with epigastric pain, fever and rigors. He appears jaundiced.D - Acute cholangitis?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 3A 40-year-old woman presents to the emergency department with right upper quadrant pain and nausea. The pain is spasmodic in nature. She has no fever or rigors. She is not icteric.B - Biliary colic?? CORRECT ANSWERYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionThe commonest extra-colonic manifestation of familial adenomatous polyposis (FAP) is a duodenal carcinoma. In a patient presenting with jaundice, with a history of FAP, duodenal carcinoma should be suspected. Cholangitis is usually the result of a stone in the common bile duct. The classical features of cholangitis are fever, pain and jaundice; this is also known as the Charcot’s triad. Jaundice may or may not be seen with cholangitis. In young patients, particularly ‘female, fat, fertile and forty’, biliary colic due to gall stones is a common cause of right upper quadrant pain. This pain is, as the name suggests, colicky in nature. Fever and rigors are not usually present unless the patient has associated cholangitis. Jaundice is a very unlikely feature in such patients. ................
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