GI & Surgery 8

oelomar's version from 2018-11-17 15:41


Question Answer
What is hepatic veno-occlusive disease, when does it arise, and what condition is it similar to in presentation?A condition in which some of the small veins of the liver are blocked. It is a complication of high-dose chemotherapy given before a bone marrow transplant. It presents clinically like Budd-Chiari syndrome.
What is “nutmeg liver” and what is it normally caused by?Also known as congestive hepatopathy, this is liver dysfunction due to venous congestion, or backup of blood into the liver. It is normally caused by congestive heart failure.
Why is nutmeg liver called by this name?The gross pathological appearance of a liver affected by nutmeg liver is "speckled" like a grated inside of a nutmeg; the dark spots represent the dilated and congested hepatic venules and small hepatic veins. The paler areas are unaffected surrounding liver tissue.
What is “cardiac cirrhosis”?When severe and longstanding, the venous congestion seen in congestive hepatopathy (nutmeg liver) can lead to fibrosis. When the venous congestion seen in congestive hepatopathy (nutmeg liver) is caused by right-sided heart failure, it is called cardiac cirrhosis.
With regards to the liver, what are the implications of Schistosomiasis?This parasite obstructs the portal branches, producing granulomas, fibrosis and inflammation but not cirrhosis. Clinically there is hepatosplenomegaly and portal hypertension.
How is Schistosomiasis treated?Schistosomiasis is treatable using a single dose of the drug praziquantel (an antiparasitic drug) by mouth annually.
What is intrahepatic cholestasis of pregnancy, what does it present with, and what causes it?A medical condition in which cholestasis (inability of bile to flow from the liver to the duodenum) occurs during pregnancy, most commonly during the third trimester. This condition of unknown aetiology presents usually with just pruritus.
How is cholestasis treated?With ursodeoxycholic acid.
What is Reye’s syndrome and what causes it?This is rare, and often fatal childhood hepatoencephalopathy that usually begins shortly after recovery from an acute viral illness. The exact cause is unknown, but it has been associated with aspirin consumption by children with viral illness.
Hepatocellular carcinoma is the ___ most common cancer worldwide.3rd.
What is the most common worldwide cause of hepatocellular carcinoma?Chronic hepatitis B.


Question Answer
What investigations can be carried out to help diagnose hepatocellular carcinoma?Serum levels of α-fetoprotein may be raised. Ultrasound and CT scans can also help in diagnosis.
How is hepatocellular carcinoma treated?Radiofrequency ablation and liver transplantation. Chemotherapy is traditionally ineffective.
What is a cholangiocarcinoma?A form of cancer which originates in the bile ducts which drain bile from the liver into the small intestine.
What is the prognosis of cholangiocarcinoma?Poor. Patients usually die within 6 months.
How easy is it to treat cholangiocarcinoma?Cholangiocarcinoma is considered to be an incurable and rapidly lethal disease unless all the tumours can be fully resected (that is, cut out surgically). As such, patients are generally treated with palliative chemotherapy, with or without radiotherapy.
What is a haemangioma and how common is it?A benign tumour of endothelial cells (cells that line blood vessels). The endothelial cells multiply at an abnormally rapid rate. This collection of small blood vessels forms a lump in or under the skin. It is the most common benign tumour.
What is the link between hormonal contraception and hepatic adenomas?Hepatic adenomas have an association with the use of oral contraceptives.


Question Answer
What is the difference between cholesterol gallstones and pigment gallstones?Cholesterol gallstones contain at least 80% cholesterol by weight. Pigment gallstones contain less than 20% cholesterol (20-80% cholesterol is referred to as mixed gallstones).
What are the risk factors for developing gallstones?The 4 F’s: Female, fat, fertile, forty (but the disorder is common and can occur in any patient). Other risk factors include the oral contraceptive pill, a family history, and TPN.
What are the clinical features of symptomatic gallstones?The pain from symptomatic gallstones is called biliary colic. Patients present with postprandial abdominal pain (usually in the RUQ) that radiates to the right subscapular area or the epigastrium. Pain is abrupt, followed by gradual relief, and often associated with nausea and vomiting, fatty food intolerance, dyspepsia, and flatulence.
How are gallstones diagnosed?Ultrasound. Plain x-rays are rarely diagnostic; only 10–15% of stones are radiopaque.
What are the clinical features of acute cholecystitis?Patients present with RUQ pain, nausea, low-grade fever, and vomiting. Symptoms are typically more severe and of longer duration than those of biliary colic.
How is acute cholecystitis treated?Hospitalise patients, administer IV antibiotics and IV fluids, and replete electrolytes. Once symptoms settle in a few days perform cholecystectomy along with either a preoperative ERCP or an intraoperative cholangiogram to rule out common bile duct stones.
What is Mirizzi’s syndrome?Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct causing compression of the common bile duct or common hepatic duct, resulting in obstruction and jaundice.
What are the symptoms of chronic cholecystitis?The usual symptoms are those of recurrent attacks of upper abdominal pain, often at night and following a heavy meal.
What is porcelain gallbladder and what causes it?This is calcification of the gallbladder believed to be brought on by excessive gallstones, although the exact cause is not clear. Chronic cholecystitis (also caused by gallstones) can lead to porcelain gallbladder.
What is acute cholangitis and what causes it?Bacterial infection of the biliary tree commonly occurring secondary to obstruction (usually from gallstones or primary sclerosing cholangitis).
What are the clinical features of acute cholangitis?Charcot’s triad (RUQ pain, jaundice, and fever) is a set of three common findings in cholangitis. Reynold’s pentad (Charcot’s triad as well as septic shock and altered mental status) can also be found and indicates worsening of the condition.
How is acute cholangitis diagnosed?Look for leucocytosis, increased bilirubin, and increased ALP. Blood cultures should also be obtained to rule out sepsis. Ultrasound can be useful as it is the most easily available medical imaging technique, but ERCP is the gold standard. ERCP is both diagnostic and therapeutic (biliary drainage).
How is acute cholangitis treated?IV antibiotics, ERCP after 24-48 hours to relieve any obstruction.


Question Answer
What is choledocholithiasis and how common is it?Choledocholithiasis is the presence of gallstones in the common bile duct. Gallstones in the common bile duct occur in 10–15% of patients with gallstones.
Murphy's sign is commonly negative on physical examination in choledocholithiasis, helping to distinguish it from cholecystitis. True or false?True.
What are the signs/symptoms of choledocholithiasis?Symptoms vary according to the degree of obstruction, the duration of the obstruction, and the extent of bacterial infection. Although sometimes asymptomatic, it often presents with biliary pain, jaundice, episodic colic, fever, and pancreatitis.
What lab values can be abnormal in choledocholithiasis?The hallmark is increased alkaline phosphatase and total bilirubin, which may be the only abnormal lab values.
What is post-cholecystectomy syndrome?Post-cholecystectomy syndrome describes the presence of abdominal symptoms that occur a few months after surgical removal of the gallbladder, but may be delayed for a number of years. Symptoms of post-cholecystectomy syndrome may include: Upset stomach, nausea, and vomiting. Gas, bloating, and diarrhoea. Persistent pain in the upper right abdomen.
What percentage of patients who undergo cholecystectomy are affected by post-cholecystectomy syndrome?5-40%.


Question Answer
In acute pancreatitis, the gland can return to normal, whereas in chronic pancreatitis it can’t. True or false?True. In acute pancreatitis the gland can return to normal if the underlying cause of the pancreatitis is removed. By contrast, chronic pancreatitis is defined by the irreversible loss of exocrine pancreatic parenchyma.
What are the causes of acute pancreatitis?Many, including gallstones (most common cause), alcohol (2nd most common cause), following ERCP, and drugs. A useful mnemonic to remember the causes of pancreatitis is "I GET SMASHED", which stands for: Idiopathic, gallstones, ethanol, trauma, steroids, mumps/malignancy, autoimmune, scorpion venom, hypercalcaemia or high triglycerides, ERCP, and drugs.
What are the signs/symptoms of acute pancreatitis?Characteristically, pain is located in the epigastrium and periumbilical region and often radiates to the back. More symptoms include nausea, vomiting, and loss of appetite. Physical examination frequently reveals low-grade fever, tachycardia, and hypotension. Shock may result. Signs that are less common, and indicate severe disease include Grey-Turner’s sign and Cullen’s sign.
What is Grey-Turner’s sign and what is it normally predicative of?Bruising of the flanks (area between the last rib and the top of the hip). It takes 24-48 hours to develop and can predict a severe attack of acute pancreatitis.
What is Cullen’s sign and what is it normally predictive of?Cullen's sign is superficial oedema and bruising in the subcutaneous fatty tissue around the umbilicus. It takes 24-48 hours to appear and can predict acute pancreatitis.
What laboratory findings are useful in the diagnosis of acute pancreatitis?Marked elevation of serum amylase levels during the first 24 hours, followed within 72 to 96 hours by a rising serum lipase level. Values elevated threefold or more above normal are diagnostic. Leucocytosis, hypocalcaemia, and hyperglycaemia are common. CRP level is useful in assessing disease severity and prognosis.
What radiological investigations/interventions should be performed in someone with acute pancreatitis?An erect chest X-ray is mandatory to exclude gastroduodenal perforation. An abdominal ultrasound scan is used as a screening test to identify a possible biliary cause of pancreatitis (i.e. gallstones). CT scanning is diagnostic. MRCP assesses the degree of pancreatic damage and identifies gallstones within the biliary tree. ERCP is used as a treatment measure to remove bile duct stones.
How is acute pancreatitis managed?The key to the management of acute pancreatitis is “resting” the pancreas by total restriction of oral intake and by supportive therapy with intravenous fluids and analgesia.
What are the complications of acute pancreatitis?Many, including acute respiratory distress syndrome (usually as a result of sepsis), acute renal failure, multiple organ dysfunction syndrome, type II diabetes, and development of chronic pancreatitis. Fluid collection can also lead to pseudocysts, which give rise to potential complications such as infection, intraperitoneal bleeding, and gastric outlet obstruction.
What are the most common causes of chronic pancreatitis (in adults and children)?In adults: alcohol. In children: cystic fibrosis.
What are the clinical features of chronic pancreatitis?Abdominal pain (variable in pain, severity, and frequency) – eating may exacerbate the pain); steatorrhoea, chronic diarrhoea, fatigue, and weight loss (as a result of maldigestion); and diabetes mellitus.
Autoimmune pancreatitis is characterised by what features?Obstructive jaundice, relatively mild symptoms (such as minimal weight loss and nausea), and increased serum levels of IgG4 (immunoglobulin G4) which provides a marker for the disease.
What investigations can be carried out in someone with chronic pancreatitis?Serum amylase and lipase levels are usually not elevated in chronic pancreatitis. Faecal elastase level will be abnormal in the majority of patients with moderate to severe pancreatic disease. Transabdominal ultrasound scan is used for initial assessment. CT is diagnostic. MRCP is the diagnostic procedure of choice.
How is chronic pancreatitis treated?Abstinence for alcohol induced disease. For short-term flare-ups of pain, a combination of an NSAID and an opiate. Enzyme therapy (Creon) to restore pancreatic enzymes.
What are the complications of chronic pancreatitis?The most common structural complication of chronic pancreatitis is a pancreatic pseudocyst, a fluid collection surrounded by granulation tissue, which can rupture and lead to intra- or retroperitoneal bleeding or cyst infection. Note also that chronic pancreatitis is precancerous.
What are the two general classifications of pancreatic cancer and which is more common?Exocrine cancers (about 99%) and neuroendocrine cancers.
What does carcinoma of the head or ampulla of the pancreas present with?Tends to present earlier with obstruction to the bile duct as this passes through the head of pancreas giving jaundice. These more localised lesions are usually painless, although pain may become a feature with tumour progression.
What is pathergy, what is the pathergy test, and what is it used to diagnose?Pathergy is a skin condition in which a minor trauma such as a bump or bruise leads to the development of skin lesions or ulcers that may be resistant to healing. The pathergy test is a "skin prick test". Skin injury by a needle prick leads to papule or pustule formation within 24-48 hours. The pathergy reaction is a unique feature of Behcet's disease and, according to the International Study Group, is among the major criteria required for the diagnosis.