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Upper Gastrointestinal Surgery Questions

Upper Gastrointestinal Surgery Questions

Written October 2012 by Calum Johnston, Lee Wu Chean and Andrew Lazarus

PANCREATITIS MEQ – 2005

You are asked to see a patient who has lost 5kg in weight and has recently become diabetic. He has a
longstanding history of alcohol abuse and has been diagnosed with chronic pancreatitis in the past.

a. Other than pancreatic insufficiency, what is the main symptom of chronic pancreatitis? (1)
- Chronic epigastric pain radiating to the back, which is typically exacerbated by alcohol

b. What are the 3 main cell types in the islets of Langerhans and what hormones do they
secrete? (3)
- Alpha → Glucagon
- Beta → Insulin
- Delta → Somatostatin

c. What are the 2 main symptoms of pancreatic exocrine insufficiency? (2)

- Weight loss
- Steathorrea

d. Name 3 digestive enzymes secreted by acinar cells. (3)

- Target Protein → Trypsinogen, Chymotrypsinogen, Proelastase, Procarboxypeptidase A/B
- Target Carbs → Pancreatic Amylase
- Target Fats → Colipase, Pancreatic Lipase
- DNA/RNA etc → Ribonuclease, Deoxyribonuclease, Phospholipase A2
- Cholesterol → Bile-Salt-Acid Lipase, Cholesterol Ester Hydrolase

e. What treatment is available for management of exocrine insufficiency (1)

- Creon (pancreatic enzyme supplements)
- PPI should also be given to minimise Creon destruction in stomach
- Fat soluble vitamins e.g. Multivite
- Though the above 2 are relevant neither is correct as Creon is what actually corrects the insufficiency
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Upper Gastrointestinal Surgery Questions

PANCREATIC CANCER MEQ – 2005 (Resit)

A 54 year old man presents with a 3 week history of painless jaundice. He has lost 2kg in weight and
has pruritus.

a. Name two additional features that you would expect to elicit if his jaundice is obstructive in
nature? (1)
- Dark urine
- Pale Stools (steatorrhea)

b. You had recently prescribed a course of antibiotics and are concerned that he may have a drug-
induced jaundice. Name 3 mechanisms by which antibiotics may cause jaundice and for each
cause give one example of a drug that may be responsible. (3)
- Pre-Hepatic: Impaired Bilirubin Uptake (e.g. Rifampicin) → ↑ unconjugated bilirubin → jaundice
- Intra-Hepatic: Induce Liver Failure (e.g. Rifampicin) → ↓ excretion of bilirubin → ↑ bilirubin → jaundice
- Post-Hepatic: ↑ risk of gallstones (e.g. Flucloxacillin) → blocks duct → ↓ excretion → jaundice
- Allergic Haemolytic Anaemia (e.g. Cephalosporins) → ↑ RBC breakdown → ↑ bilirubin → jaundice

c. An abdominal ultrasound is arranged. What findings would lead you to conclude that he has
extrahepatic biliary obstruction? (1)
- Dilatation of the Common Bile Duct/Common Hepatic Duct

d. Name the two main causes of extrahepatic biliary obstruction in a man of this age? (2)
- Neoplastic Disease → of pancreatic head, ampulla or bile duct (i.e. Cholangiocarcinoma)
- Choledocolithiasis (common bile duct stone)
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Upper Gastrointestinal Surgery Questions

UPPER GI BLEED – 2005 (Resit)

A 72 year old lady presents to the Accident and Emergency department with a history of haematemesis
and collapse. She is resuscitated and taken for immediate upper GI endoscopy where she is found to
have a large bleeding duodenal ulcer.

a. What drugs are commonly responsible for this complication in elderly patients? (1)
- NSAIDs e.g. Ibuprofen
- Antiplatelets/Anticoagulants e.g. Warfarin

b Name two tests available to identify H. Pylori as a cause for peptic ulcer disease? (2)
- Urease Breath Test
- H. Pylori Stool Antigen Test or Serology
- Gastroscopy and CLO test or histological assessment

c. Apart from blood transfusion list two treatment options for the management of the acute bleed
in this patient. (2)
- Resuscitation
- Endoscopic Haemostasis e.g. Thermal Coagulation, Mechanical Clips, Adrenaline Injection
- PO or IV PPI e.g. Omeprazole.

We have been told this is a badly worded question. It should really just be asking “What is the most appropriate
management for this patient?” with the answer being Resuscitation followed by Endoscopic Haemostasis.
Also, with regards to IV PPI, it is expensive and there is limited evidence as to its efficacy. IV PPI (normally
Omeprazole) is indicated following successful endoscopic haemostasis (commonly referred to as the Hong
Kong protocol). In conclusion there is a role for PPI, but this should be given orally for the majority of patients.

d. Following successful control of the bleeding, she is returned to the ward and commenced
on an infusion of omeprazole. What is the mechanism of action of this drug? (1)
- Proton Pump Inhibitor
- Irreversibly blocks hydrogen/potassium ATPase in parietal cells
- Result is significantly reduced H+ secreted → ↓ HCl, which results in an increase in gastric pH
- ↑ pH is beneficial because it results in improved platelet function

e. What hormone is secreted by the gastric mucosa? What cell type is responsible? (1)
- Gastrin, G-cells

f. Name three conditions associated with increased plasma levels of this hormone. (3)
- Zollinger-Ellison Syndrome
- Atrophic Gastritis
- Pernicious Anaemia targeting parietal cells ONLY
- Peptic Ulcer Disease
- Atypical Site of Gastrin Secretion e.g. Meckel’s Diverticulum with Gastric Mucosa or Paraneoplastic
There are 2 types of Pernicious Anaemia. One targets the parietal cell H/K ATP-ase pump (causing ↓ acid → ↑
gastrin) with the other blocking B12/Intrinsic Factor binding or absorption (and hence never affecting gastrin
levels).
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Upper Gastrointestinal Surgery Questions

PANCREATITIS 2 MEQ – 2007

A 48 year old publican is admitted as an emergency under your care with an episode of severe upper
abdominal pain and vomiting of acute onset. He has no previous relevant history. On examination you
elicit the signs of peritonitis, mainly in the upper abdomen. Urgent investigations reveal a serum
amylase of 2,800 IU. There is no gas under the diaphragm on plain radiology.

a. What is the most likely diagnosis? (1)

- Acute Pancreatitis

b. Name 2 of the commonest identifiable causes of this condition. (2)

- Alcohol
- Gallstones

c. The acute episode settles with pain relief and intravenous fluids. You request an ultrasound
investigation, which demonstrates a common bile duct with a diameter of 12mm containing a
rounded mobile 5 mm echogenic focus. What techniques are currently available that would
permit you to image the bile duct using appropriate contrast? (Name 4) (4)
- Endoscopic Retrograde Cholangiopancreatography
- Percutaneous Transhepatic Cholangiography
- Operative Cholangiography
- HIDA
- NOT Magnetic Resonance Cholagiopancreatography as it does not use contrast
- NOT CT Pancreas because although it uses contrast, it is venous and never enters the bile duct

We have been told that this question is terrible due to the ‘contrast’ component. The patient has had an episode
of acute pancreatitis and has imaging, which suggests choledocolithiasis. With this in mind, the only appropriate
way to proceed is with ERCP.
If the US had not diagnostic (for example if it had demonstrated minimal dilatation of the CBD with no
choledocolithiasis) then MRCP is the most appropriate test.
Alternatively the patient could have a laparoscopic cholecystectomy with intra-operative cholangiography, but
this relies on the operator then having a strategy to manage choledocolithiasis surgically, so most surgeons
would ensure that the duct was clear with ERCP or MRCP prior to surgery.
There is no real role for CT in the imaging of the biliary tree as the images produced are not as good as on
MRCP. The only situation where a patient would get a CT over an MR would be if the surgeons anticipated
encountering neoplastic disease of the pancreatic head/CBD
HIDA is a functional investigation and I would not consider it useful/relevant in this situation

d. What definitive surgical management options would you like to discuss with your patient? (3)
- ERCP + Sphincterotomy and a combination of balloon trawl of CBD and/or stent
- Follow above with laparoscopic cholecystectomy if appropriate, OR
- Laparoscopic cholecystectomy with intra-operative cholangiography and laparoscopic CBD exploration

This question is asking about specific management of Choledocolithiasis.

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Upper Gastrointestinal Surgery Questions

EPIGASTRIC PAIN – 2010 (Resit)

A 48 year old gentleman presents to his GP with a 6 month history of epigastric pain which is made
worse by eating.

a. Name 3 organs which may cause food related pain. (3)

- Stomach
- Pancreas
- Gall Bladder

b On examination there is mild tenderness in the epigastrium. Your consultant tells you that
the Murphys’ sign is negative. What is the significance of a positive Murphys’ sign? (2)
- Positive → arrest of inspiration on palpation in the upper right quadrant but NOT in left upper quadrant
- Positive result due to pressure (from palpation) on peritoneal inflammation 2° to an inflamed gallbladder
- Hence, it suggests acute cholecystitis is the likely cause of his pain

c. You suspect the patient may have a peptic ulcer. Name 1 investigation which could be
performed to confirm the presence of Helicobacter pylori. (1)
- Urease Breath Test
- H. Pylori Stool Antigen Test
- The above 2 are correct for a patient presenting to a GP
- If the Hx was presenting to ER/Surgery → OGD + CLO test and biopsy

d. The patient undergoes endoscopy which reveals an ulcer in the lesser curve of the stomach
and triple therapy is commenced. Briefly outline the action of Lansoprazole in reducing acid
secretion. (2)
- Lansoprazole is a Proton Pump Inhibitor (PPI)
- PPIs irreversibly block hydrogen/potassium ATPase in parietal cells of the stomach
- The result is massively reduced H+ secretion → ↓ stomach acid formed

e. Two weeks later the patient presents with a rigid, tender abdomen, highly suggestive of
perforation. Name 2 other complications of peptic ulceration. (2)
- Acute Upper GI Bleed
- Fe Deficiency Anaemia 2° to chronic blood loss
- Gastric Outlet Obstruction (long-term complication)
- Gastric Cancer (long-term complication)
- Penetration (like perforation but erodes into an adjacent organ rather than peritoneal cavity) RARE

f. What important initial investigation should now be performed if you suspected perforation and
what would it show? (1)
- Erect CXR → air under the diaphragm i.e. pneumoperitoneum
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Upper Gastrointestinal Surgery Questions

EPIGASTRIC PAIN 2 – 2011

Mrs R.S. is a 75 year old, previously well, woman who has been admitted to hospital under your care as
an emergency with a history of two hours of severe upper abdominal pain and vomiting. On
examination she is obviously distressed with a tachycardia but is otherwise haemodynamically stable.
The abdomen is tender with guarding in the upper part. Bowel sounds are diminished. There are no
other relevant finding.

a. List 3 important likely diagnosis. (3)

- Acute Pancreatitis
- Cholecystitis
- Peptic Ulcer Perforation

b What key early investigations may help you resolve the differential diagnosis? List 3. (3)
- Blood Tests → FBC (infection), U+Es, LFTs, Serum Amylase or Lipase (pancreatitis)
- Basic Imaging → Erect CXR (? Pneumoperitoneum) or US (if RUQ tender)
- Advanced Imaging → CT with Contrast (if pneumoperitoneum not present)
- If pneumoperitoneum present → laparotomy

c. After the patient’s initial assessment, but before definitive treatment, what 4 urgent measures
would you institute? (4)
- Analgesia/Antiemetic
- Oxygen Therapy
- IV Access + Fluids
- Group and Save or Crossmatch if necessary
- Insert Catheter (if deemed immediately necessary) + Fluid Balance Monitoring
- If pancreatitis is excluded → prescribe broad spectrum antibiotics
- On-going monitoring of vital signs
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Upper Gastrointestinal Surgery Questions

OBSTRUCTIVE JAUNDICE – 2012

An 83 year old woman presents with a 2 week history of obstructive jaundice. She has been diabetic for
2 months and has lost 7kg in weight. She has pale stools and dark urine.

a. What 2 initial investigations would you organise? (2)

- Blood Tests → FBC, U+Es, LFTs
- Abdominal USS
- Pancreatic CT

b What are the 2 main diagnoses to consider? (2)

- Pancreatic Cancer
- Gallstones

c. Investigations reveal a dilated biliary tree and ERCP is planned. Name 3 potential complications
of this procedure. (3)
- Pancreatitis (3-5%)
- Bleeding
- Perforation
- Infection e.g. Acute Cholangitis
- Aspiration Pneumonia

d. Cytology reveals malignant cells; what 3 management options would you like to discuss with
your patient? (3)

1. Resection: Not appropriate for most patients because of disease stage and co-morbidity
For the patient in this question, as they have obstructive jaundice the neoplasm is going to be in
the pancreatic head or ampulla so pancreaticoduodenectomy (Whipple’s) or pylorus preserving
pancreaticoduodenectomy are the likely procedures

2. Oncology: Neoadjuvant or Palliative Chemotherapy (Gemcitabine)

Radiotherapy is not commonly used for the primary tumour but possibly for metastases

3. Palliative: Symptom control i.e. decompression of biliary tree (stent via ERCP or PTC), analgesia, anti-
emetics and nutritional supplementation
NOT Coeliac Nerve Block as very rare and NOT Cholestyramine as symptomatic benefit (relief
of itch) is frequently outweighed by side-effects
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Upper Gastrointestinal Surgery Questions

UPPER ABDOMINAL PAIN EMQ – 2005 (Resit), 2006, 2010 (Resit), 2012

For each of the patients described in Section 1 select the most likely diagnosis from the options listed
in Section 2
Section 1:

Q1 A 50 year old lady presents with sudden onset severe colicky pain in the right upper quadrant of the
abdomen. She is apyrexial..
Answer = A

Q2 A 45 year old known alcoholic presents with sudden onset severe epigastric pain followed by repeated
vomiting.

Answer = D

Q3 A 23 year old man presents with sudden onset epigastric pain and notices pain at his right shoulder.
Answer = B
This is not a good question either as shoulder pain indicates diaphragmatic inflammation, which can be due
many inflammatory pathologies. However, B is the most likely answer.

Q4 A 70 year old man presents with painless jaundice and central back pain.
Answer = H

Q5 A 55 year old lady presents with epigastric pain and heartburn, worse when she lies flat.
Answer = G

Section 2

A Biliary Colic
B Acute Cholecystitis
C Acute Gallstones
D Acute Pancreatitis
E Carcinoma of the Stomach
F Gallstone Ileus
G Hiatus Hernia
H Pancreatic Carcinoma
I Perforated Peptic Ulcer
J Splenic Infarction 2006: J = Stone in Common Bile Duct
J Umbilical Hernia
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Upper Gastrointestinal Surgery Questions

HERNIAS EMQ – 2011

For each of the patients described in Section 1 select the most likely diagnosis from the options listed
in Section 2
Section 1:

Q1 A 45-year-old man presenting with a reducible groin swelling.

Answer = E

Q2 An 85 year old lady presenting acutely with a small bowel obstruction and a groin swelling.
Answer = B

Q3 A 35 year old female with a tender midline swelling half way between the xiphisternum and umbilicus.
Answer = A

Q4 A one year old male child with umbilical swelling.

Answer = J

Q5 A subcostal swelling in a patient 10 years after open cholecystectomy.

Answer = D

Section 2

A Epigastric Hernia
B Femoral Hernia
C Hiatus Hernia
D Incisional Hernia
E Inguinal Hernia
F Lumbar Hernia
G Obturator Hernia
H Paraumbilical Hernia
I Spigellian Hernia
J Umbilical Hernia