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Upper GI and Hepatobiliary MCQ revision ‘A game of 20(?) questions’Overview of the session 20 MCQ questions Polls Learning points ● Taken from Passmedicine ● Will show the question on ● Once the correct answer is screen, along with a poll to shown, we’ll walk through ● Covers major themes put your answer why this is the case ● As per the progress test, you will have 80 seconds to answer the question ● The main learning point from each question will be ● I won’t pick anyone out to shown answer any questions!Question 1Answer 1● Acute cholecystitis is inflammation of the gallbladder ● Usually caused by gallstonesExplanation 1 ● Typical history of acute cholecystitis ● RUQ pain and systemically unwell ● There’s also a specific sign for this… ● Murphy’s sign, which is? ● Inspiratory arrest on palpation of RUQQuestion 2Answer 2● Gallstones - formed when bile becomes very concentrated and saturated ● Biliary colic - condition where the neck of the gallbladder is impacted by a gallstone but NO INFLAMMATIONExplanation 2 ● Commonly presents with abdominal pain (RUQ) after meals + nausea + vomiting (especially true for fatty meals). But why? ○ Fatty acids stimulate the duodenum endocrine cells to release cholecystokinin (CCK), which stimulates contraction of gallbladder ● Classically radiates to the interscapular region. Why? ○ Because of referred pain from the diaphragmQuestion 3Answer 3● Ascending cholangitis - inflammation of biliary tree due to a blockage ● Anything that can cause blockage can cause ascending cholangitis ● Most commonly - stones ● Others - cholangiocarcinomaExplanation 3 ● Patient has a specific triad of symptoms called… ○ Charcot’s triad ○ RUQ pain, fever and jaundice ○ Classical for ascending cholangitis ● There’s also something called Reynold’s pentad ○ Charcot’s triad + hypotension and confusion RUQ pain Biliary colic Acute cholecystitis Cholangitis ● colicky RUQ pain (worse ● RUQ pain (may radiate to ● Charcot’s triad: RUQ pain, after fatty foods, may right shoulder) fever and jaundice radiate to right shoulder) ● fever and signs of ● Reynold’s pentad: ● nausea and vomiting systemic upset Charcot’s triad + common hypotension + confusion ● peritonism ● no fever ● Others: raised ● Murphy’s sign inflammatory markers ● LFTs & inflammatory markers usually normal ● LFTs typically normalFirst form of imaging for RUQ pain when you’re suspecting biliary colic, acute cholecystitis or ascending cholangitis? ✨ Ultrasound ✨ Can detect: The presence of gallstones or sludge (the start of gallstone formation) Gallbladder wall thickness (if thick walled, then inflammation is likely) Bile duct dilatation (indicates a possible stone in the distal bile ducts)Question 4Which of the following is the most appropriate next step in management? A. Laparoscopic cholecystectomy B. Endoscopic retrograde cholangiopancreatography (ERCP) C. Magnetic retrograde cholangiopancreatography (MRCP) D. Extracorporeal shock wave lithotripsy E. Percutaneous cholecystostomyAnswer 4Explanation 4 ● Patient is currently presenting with… ● Charcot’s triad + high inflammatory markers = ascending cholangitis ● Ultrasound scan was already done so the next best step is ERCP ● MRCP is basically just an MRI image of the biliary tract and has no therapeutic benefitAscending cholangitis investigations ● Ultrasound - can confirm bile duct dilatation and even the possible cause like gallstones ● ERCP - gold standard and is both diagnostic and therapeutic ● A stent can be put in to prevent any future obstructions ● An MRCP is usually done for more detailed imaging before they do the scope RUQ pain imaging Biliary colic Acute cholecystitis Cholangitis ● Ultrasound initially ● Ultrasound initially ● Ultrasound initially ● MRCP if unclear ● MRCP if unclear (or HIDA ● ERCP (gold-standard scan) imaging + therapeutic)Question 5Answer 5Explanation 5 ● Patient is presenting with… ● Acute cholecystitis ● Management for acute cholecystitis: ○ IV antibiotics ○ Laparoscopic cholecystectomy within 1 week of diagnosisQuestion 6Answer 6Explanation 6 ● Patient presenting with… ● Biliary colic ● Management for biliary colic: ○ Elective laparoscopic cholecystectomy ○ No time-frame like in acute cholecystitis RUQ pain treatments Biliary colic Acute cholecystitis Cholangitis ● Elective laparoscopic ● IV abx ● IV abx cholecystectomy ● Laparoscopic ● Endoscopic retrograde cholecystectomy within 1 cholangio- week of diagnosis pancreatography (ERCP) after 24-48 hours to relieve any obstructionQuestion 7Answer 7Explanation 7 ● E. coli is a common causative organism for ascending cholangitis ● Other common conditions caused by E. coli: ○ UTIs ○ GI infectionsQuestion 8Answer 8Explanation 8 ● Patient presenting with… ● Biliary colic, and biliary colic is usually caused by gallstones ● Crohn’s disease is a risk factor for gallstones. But why? ○ Crohn’s affects terminal ileum ○ Terminal ileum involved in metabolism of bile salts ○ Excessive bile salts escape into colon and reabsorbed by liver ○ This causes excess secretion of bile pigments - stonesOther risk factors for gallstones: ● Remember the 4 F’s: ○ Fat ○ Female ○ Fertile ○ Forty ● Other risk factors: ○ Crohn’s disease ○ Diabetes ○ Rapid weight loss - weight reduction surgeryQuestion 9 ● Ampulla of vater ● Common bile duct ● Common hepatic duct ● Cystic duct ● Sphincter of OddiAnswer 9Explanation 9 ● Pathology of the cystic duct is the one least associated with jaundiceAnatomy of the biliary treeQuestion 10Answer 10Explanation 10 ● Patient is presenting with… ● Acute pancreatitis ● Most helpful investigation in suspected pancreatitis is… ● Serum lipase or amylase, usually >3 times upper limit of normal ● What about the CXR and AXR? ○ Not helpful in diagnosing but helpful in ruling out other causes (obstruction or perforation)Acute pancreatitis symptoms: ● Symptoms: severe epigastric pain (may radiate to the back), vomiting common ● Examination: may reveal epigastric tenderness and low-grade fever ● Rare: Cullen's sign and Grey-Turner's sign ● Patients may have history of alcohol abuse (one of the causes)A: Cullen’s signs (C looks like a belly button = peri-umbilical bruising) B: Grey-Turner’s sign (flank discolouration/bruising)Question 11Answer 11Explanation 11 ● Patient is presenting with… ○ Acute pancreatitis ● What was done? ○ Serum amylase ● So what’s next? ○ Transabdominal ultrasoundAcute pancreatitis investigations: ● 1st step: confirm pancreatitis - ○ Serum amylase: raised to > 3 times the upper limit of normal ○ Serum lipase: more sensitive and specific than amylase, longer-half life (useful for presentations > 24 hours) ○ + other bloods ● 2nd step: find aetiology ○ Ultrasound scan ○ Useful to rule out pancreatitis caused by gallstones or biliary tract obstructionQuestion 12Answer 12 It’s lipase… https://pubmed.ncbi.nlm.nih.gov/28720341/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393381/ Although, I’ve never actually seen a question comparing the two come out in exams…Question 13Answer 13Explanation 13 ● Hypercalcaemia can CAUSE pancreatitis ● Hypocalcaemia is an INDICATOR of pancreatitis ● What do we use to measure the severity of pancreatitis? ● Glasgow scale of Pancreatitis Severity ○ PaO2< 7.9kPa ○ Age > 55 years ○ Neutrophils (WBC > 15) ○ Calcium < 2 mmol/L ○ Renal function: Urea > 16 mmol/L ○ Enzymes LDH > 600IU/L ○ Albumin < 32g/L (serum) ○ Sugar (blood glucose) > 10 mmol/LQuestion 14Answer 14Explanation 14 ● For nutrition in pancreatitis, always try oral nutrition ○ NG tube if can’t tolerate oral - vomitingAcute pancreatitis management: ● Supportive management ○ IV fluids + urine output montoring ○ Analgesia = IV opioids ○ Nutrition = enteral nutrition (by mouth) unless cannot tolerate oral ● Treat underlying cause ○ ERCP if gallstones etcQuestion 15Answer 15Chronic pancreatitis symptoms: ● Pain (typically epigastrium and back, worse 15 - 30 minutes after a meal) ● Exocrine insufficiency (digestive enzymes) = steatorrhoea: usually develop 5 - 25 years after the onset of pain ● Endocrine insufficiency (insulin) = diabetes mellitus: develops in the majority of patients, typically occurs > 20 years after symptoms beginQuestion 16Answer 16Explanation 16 ● Patient presenting with… ○ Chronic pancreatitis ● Investigation of choice: ○ Abdominal CT scan ● Some tests used before CT: ○ AXR and abdo US to rule our other causes but not as sensitive as CTQuestion 17Answer 17Explanation 17 ● For exocrine function: faecal elastase is a useful test ○ What do I mean by exocrine function? ○ Means the production of digestive enzymesChronic pancreatitis investigations: ● Bloods: Amylase or lipase, will it be raised in chronic pancreatitis? ● NO, it’s usually normal or even decreased, why? ● Chronic pancreatitis causes fibrosis and scarring of the pancreatic tissue effecting enzyme production (one of the symptoms) ● Faecal elastase good measure of exocrine function ● Blood glucose and HbA1c also important to check for diabetesChronic pancreatitis: imaging ● AXR: shows pancreatic calcification in 30% of cases ● ✨ CT ✨: more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85%Chronic pancreatitis causes: ● Chronic alcohol abuse 🍻 (60%) ● Idiopathic (30%) ● Others (less common): ○ Stones in the biliary tract ○ Cystic fibrosis ○ AutoimmuneLast questionLast answerLast explanation ● What are the symptoms of subacute combined degeneration of spinal cord? ○ Loss of vibration sense, ataxia, absent ankle reflexes suggest this ● What causes this? ○ B12 deficiency ○ This causes impairment of dorsal columns, lateral corticospinal tracts and spinocerebellar tracts ● What caused the B12 deficiency? ○ Intrinsic factor needs to bind to B12 before it can be absorbed in the intestines ○ Intrinsic factor is produced by gastric parietal cells on the stomach lining ○ So when you perform a gastrectomy, there’s less of these cellsCovered topics: ● Biliary colic ● Acute cholecystitis ● Ascending cholangitis ● Acute pancreatitis ● Chronic pancreatitis ● Gastrectomy complications Summary table Biliary colic Acute Ascending Acute Chronic cholecystitis cholangitis pancreatitis pancreatitis Symptoms Colicky RUQ pain RUQ pain, fever, Charcot’s triad (RUQ Severe epigastric pain Pain (15-30 min after (worse after fatty food),Murphy’s sign pain + fever + (may radiate to back), meal), steatorrhoea or N&V jaundice) vomiting, Cullen’s/ diabetes (~ 20 years Grey-Turner’s (rare) after initial pain starts) Investigations Ultrasound Ultrasound → Ultrasound → Serum amylase/lipase Abdo x-ray → MRCP (if unclear) ERCP (both diagnostic (tests for pancreatitis) CT scan (gold and therapeutic) → ultrasound abdo standard) → (look for aetiology) Faecal elastase (functional test) Treatment Elective laparoscopic IV abx, laparoscopic IV abx, ERCP Fluids, analgesia, Pancreatic enzyme cholecystectomy cholecystectomy nutrition (always try supplements, (within 1 week of orally first), treat analgesia diagnosis) underlying cause (stones etc) Thanks for joining in! Tune in for our next session on Urology on the 25th of April! Email: Luqman.aizan@student.manchester.ac.uk joshua.williams@student.manchester.ac.uk