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THEME: Pancreatitis A Acute pancreatitisB Acute-on-chronic pancreatitisC Biliary obstructionD Cancer of the head of the pancreasE Pancreatic pseudocyst
For 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 1
A 43-year-old man, with a history of alcohol abuse, presents with pain radiating to his back, which is relieved by leaning forward. He has obstructive jaundice and has recent weight loss.
0
B Correct answer
B – Acute-on-chronic pancreatitis
The 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 2
A 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.
0
E Correct answer
E – Pancreatic pseudocyst
A 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.
Scenario 3
A 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.
0
A Correct answer
A – Acute pancreatitis
This final clinical case is typical of acute pancreatitis with a history of sudden onset of pain, vomiting and an increased serum amylase level.
THEME : Pancreatitis
A Carcinoma of the head of the pancreasB Chronic pancreatitisC Biliary obstructionD Acute pancreatitisE Pancreatic pseudocyst
For 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 1
A 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.
E
B Correct answer
A 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 2
A 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, an abdominal mass is palpable.
A
E Correct answer
A 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 3
A 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 Correct answer
This clinical case scenario is typical of acute pancreatitis – sudden onset of pain, vomiting and an increased serum amylase.
THEME: Pancreatic neoplasmsA Ductal adenocarcinomaB InsulinomaC GlucagonomaD Gastrinoma E VIPomas (VIP is vasoactive intestinal polypeptide)F Cystadenoma
For each of the situations below, select the single most likely option from the list above. Each option may be used once, more than once or not at all.
Scenario 1
A 65-year-old woman presents with recurrent episodes of confusion, dizziness and fainting. Gadolinium-enhanced MRI shows an enhancing 1.5 cm nodule in the body of the pancreas, which is also shown by selective mesenteric angiography.
0
B Correct answer
Insulinoma has an annual incidence of one per million and 90% are benign. Whipple’s triad consists of hypoglycaemic symptoms during fasting, low fasting blood sugar levels and symptoms relieved by intravenous dextrose. It is characteristic of insulinomas.
Scenario 2
A 70-year-old man presents with abdominal pain radiating to the back, anorexia and weight loss. His bilirubin and CA19-9 are elevated. Computed tomography shows a mass in the head of pancreas causing obstruction of the bile duct.
0
A Correct answer
Ductal adenocarcinoma accounts for 80–90% of all pancreatic cancers. Known risk factors are chronic pancreatitis and smoking. A palpable gallbladder (Courvoisier’s sign) and migratory thrombophlebitis (Trousseau’s sign) are associated clinical signs.
Scenario 3
A 32-year-old woman presents with epigastric pain, diarrhoea and recurrent duodenal ulcers. She previously had a parathyroidectomy. CT showed a mass 3 3 cm in the pancreatic head.
0
D Correct answer
Gastrinomas are about half as common as insulinomas but are the most common pancreatic endocrine tumour in multiple endocrine neoplasia type 1 (MEN-1). Gastrinomas give rise to the Zollinger–Ellison syndrome, which is a triad of
hypergastrinaemia, recurrent peptic ulcers and non- pancreatic islet cell tumour.
Scenario 4
A 68-year-old woman presents with abdominal pain and a mass in the epigastrium. CT shows a hypodense 8 cm diameter mass in the body of the pancreas, with calcification in its wall and multiple internal septa.
0
F Correct answer
Serous cystadenoma, mucinous cystic neoplasm and the intraductal papillary mucinous neoplasm account for most cystic neoplasms of the pancreas. Serous cystadenomas are generally benign whereas the other two have the potential for malignant change. The differential is of a pancreatic pseudocyst. On CT, a pseudocyst is unilocular and may have associated signs of acute or chronic pancreatitis.
THEME: Complications of acute pancreatitisA NecrosisB AbscessC PseudoaneurysmD PseudocystE Ascites
For each of the situations below, select the single most likely option from the list above. Each option may be used once, more than once or not at all.
Scenario 1
A 45-year-old man recovering from severe acute pancreatitis develops abdominal pain and abdominal distension. There is no palpable abdominal mass. Chest X-ray shows an associated pleural effusion.
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E Correct answer
Pancreatic ascites refers to the accumulation of free pancreatic fluid in the peritoneal cavity from either the disruption of the main pancreatic duct or
leakage from a pseudocyst. The fluid has a high protein and amylase content. A pancreato-pleural fistula results in a pleural effusion.
Scenario 2
Four weeks after an attack of severe acute pancreatitis, a 35-year-old man complains of constant abdominal pain. He is unwell, tachycardic and pyrexial with a palpable abdominal mass.
0
B Correct answer
A pancreatic abscess is a collection of purulent peripancreatic material resulting from the progressive liquefaction of necrotic tissue and infection. The diagnosis should be considered in patients who remain or become febrile 2 weeks or more after an attack of acute pancreatitis. CT and FNA are useful for confirming the diagnosis.
Scenario 3
Five weeks after an attack of acute pancreatitis, a 32-year-old woman presents with abdominal pain and a palpable central abdominal mass. Her serum amylase and inflammatory markers are not raised.
0
D Correct answer
A pseudocyst is a localised fluid collection that is rich in amylase and other pancreatic enzymes within a well-defined fibrous wall that lacks an epithelial lining. They arise from disruption of a pancreatic duct. Most small cysts resolve spontaneously but symptomatic persistent large pseudocysts (> 6 cm) may require intervention.
Scenario 4
Three weeks after an attack of severe acute pancreatitis while recovering in the high dependency unit, a 36-year-old man develops acute abdominal pain and an episode of haematemesis.
0
C Correct answer
Pseudoaneurysms most commonly affect the splenic artery followed by the gastroduodenal artery; they occur as a result of autodigestion and erosion of the walls of adjacent arteries. In most cases, they present as gastrointestinal bleeding. Angiography is useful for both diagnosis and treatment. Successful embolisation (up to three-quarters of attempted cases) can avoid the need for surgery.
THEME: Conditions that may require splenectomy A Autoimmune haemolytic anaemiaB Chronic myeloid leukaemiaC Congenital spherocytosisD Felty’s syndromeE Gaucher’s diseaseF Hodgkin’s lymphomaG Idiopathic thrombocytic purpuraH MyelofibrosisI Sickle cell diseaseJ Splenic abscessK ThalassaemiaL TraumaM Tropical splenomegaly
The following are descriptions of patients with splenomegaly. Please select the most appropriate diagnosis from the list. The items may be used once, more than once, or not at all.
There are a myriad of causes of splenomegaly which the ‘diagnostic sieve’ approach can usually resolve. The list above includes some of the more common faced by the surgeon for consideration of splenectomy. The main indication outside trauma (blunt or iatrogenic) for splenectomy is ‘hypersplenism’, which is a rather indefinite syndrome characterised by enlargement, and any combination of anaemia, leukopenia and thrombocytopaenia, bone marrow hyperplasia and improvement after splenectomy.
Scenario 1
A 13-year-old boy is referred with intermittent colicky right upper quadrant pain. Examination reveals clinical anaemia, jaundice and splenomegaly. Abdominal ultrasound reveals a moderately enlarged spleen and multiple, small gallstone calculi.
0
C Correct answer
C – Congenital spherocytosis
Approximately 75% of cases are autosomal dominant disorders characterised by defects in the red cell membrane that render erythrocytes spheroidal, less deformable and vulnerable to splenic sequestration. Anaemia, moderate splenomegaly and jaundice are characteristic. After 10 years of age, 40–50% of patients develop gallstones secondary to hyperbilirubinaemia. Splenectomy is indicated in the majority of patients, as red cell survival reverts to normal even though the abnormality persists.
Scenario 2
A 50-year-old man, with a 3-year history of fatigue, weight loss and anorexia, is referred for recent onset of a dragging sensation in the upper abdomen. Examination reveals generalised lymphadenopathy and massive splenomegaly.
0
B Correct answer
B – Chronic myeloid leukaemia
This primarily affects adults in the 4th and 5th decades of life, accounting for 15–20% of all cases of leukaemia. It is a clonal disorder of pluripotent stem cells that predominantly differentiate along the granulocytic pathway. Initial symptoms are non-specific; however, a dragging sensation in the abdomen caused by extreme splenomegaly is characteristic. Symptomatic hypersplenism may occur during the chronic phase of the disorder and may require splenectomy.
Scenario 3
A 26-year-old woman, with a history of intravenous drug abuse, presents with severe upper left abdominal pain, fever and rigors. On examination she is tachycardic and pyrexial with a mildly enlarged tender spleen.
0
J Correct answer
J – Splenic abscess
Splenic abscesses are rare, probably because of the spleen’s exceptional ability to cope with septic and foreign material. They may, however occur as a result of haematogenous spread as in this case with the clinical triad of left upper quadrant pain, fever and systemic signs of sepsis. Treatment is usually by percutaneous drainage of the abscess and treatment of the cause.
THEME: Complications of splenectomy A Basal atelectasisB Deep vein thrombosisC Gastric perforationD Gastric stasisE Lower lobe pneumoniaF Overwhelming post-splenectomy sepsisG Pancreatic fistulaH Pancreatic pseudocystI Portal vein thrombosisJ Pulmonary embolusK SplenosisL Subphrenic abscess
The following are descriptions of patients with post-splenectomy complications. Please select the most appropriate diagnosis from the list. The items may be used once, more than once, or not at all.
Some operations have a good list of specific complications that are beloved of examiners. Favoured are probably thyroidectomy, splenectomy, laparoscopic cholecystectomy and inguinal hernia repair.
Scenario 1
A 13-year-old boy presents to The Emergency Department with a severe headache and vomiting; for the past 2 to 3 days he has been off school for presumed influenza. On examination he is flushed and has a temperature of 39°C. There are no specific findings; however, on further questioning his parents state that he had an emergency splenectomy following a road traffic accident 1 year ago.
0
F Correct answer
F – Overwhelming post-splenectomy sepsis
After splenectomy the ability of the spleen to destroy encapsulated organisms is lost and infection can lead to the distinct clinical syndrome of overwhelming post-
splenectomy infection (OPSI). In children splenectomised for trauma the incidence is about 1–2%, while for adults it is about 0.5%. Long-term penicillins are of proven value in children, as the maximal incidence of OPSI occurs within 2 years of surgery. Prophylaxis with polyvalent vaccines is also recommended (usually to pneumococcus, meningococcus and Haemophilus influenzae).
Scenario 2
A 42-year-old woman complains of left-sided chest and abdominal pain, worse on inspiration, 7 days post-splenectomy. Examination reveals a temperature of 38.6°C, decreased air entry at the left lung base, dullness to percussion and left upper quadrant tenderness (Abd).
0
L Correct answer
L – Subphrenic abscess
Post-operative haematomas are common post-splenectomy. They may collect in the subphrenic space, and infection can readily lead to a subphrenic abscess. They may cause an associated pleural effusion as in this case. Characteristically they present with swinging pyrexia, sweats, rigors and left-sided pain on deep inspiration. Treatment is usually by percutaneous drainage.
THEME: Pancreatic carcinoma - surgical management
A Proximal pancreatoduodenectomyB Radical pancreatectomyC Distal pancreatectomy and splenectomyD Total pancreaticoduodenectomyE Endoscopic biliary stentingF CholecystojejunostomyG Surgical biliary bypass
For 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.
Ductal 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.
Scenario 1
A 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.
0
A Correct answer
Scenario 2
A previously fit and well 55-year-old women was diagnosed with carcinoma of the head of the pancreas with retroperitoneal lymph node involvement.
0
B Correct answer
Scenario 3
An 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.
0
E Correct answer
Scenario 4
A 67-year-old man was found to have carcinoma of the tail and body of the pancreas with no evidence of local spread on laparotomy.
0
C Correct answer
THEME: Disorders of the pancreas A Acute pancreatitisB Adenocarcinoma of the pancreasC ß-cell tumour of the pancreasD Chronic pancreatitisE Cystic fibrosisF Type I diabetesG Type II diabetesH VipomaI Zollinger–Ellison syndrome
The 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 1
A 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 µmol/litre, corrected calcium 2.00, amylase 89.
0
A Correct answer
A – Acute pancreatitis
The 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 2
A 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. Of note, her serum potassium is 2.8.
0
H Correct answer
H – Vipoma
These 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.
Scenario 3
A 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.
0
C Correct answer
C – ß-cell tumour of the pancreas
ß-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.
THEME: SpleenA RuptureB Post-splenectomy C HypersplenismD CystE Splenosis
For each of the situations below, select the single most likely option from the list above. Each option may be used once, more than once or not at all.
Scenario 1
On examination, both flanks are dull to percussion. On the right flank, the dullness shifts when the patient is tilted to the left and, on the left flank, the dullness is fixed.
0
A Correct answer
The patient is demonstrating Ballance’s sign. This occurs when a large blood clot forms around a ruptured spleen with free intraperitoneal blood in the right flank. Left shoulder-tip pain can also occur from irritation of the left hemidiaphragm (Kehr’s sign).
Scenario 2
A full blood count (FBC) shows leucocytosis and thrombocytosis.
0
B Correct answer
Two to three days after splenectomy, there is a rise in the WCC and platelet count. The thrombocytosis may require prophylactic anticoagulation.
Scenario 3
An FBC shows anaemia, leucopenia and thrombocytopenia.
0
C Correct answer
The criteria for hypersplenism are (1) splenomegaly, (2) any combination of anaemia, leucopenia or thrombocytopenia, (3) bone marrow hyperplasia, and (4) improvement after splenectomy.
Scenario 4
There is recurrence of thrombocytopenia and Howell–Jolly bodies are not identified on the peripheral blood smear.
0
E Correct answer
Ectopic seeding of splenic tissue or accessory spleens may lead to recurrence after splenectomy. Red cells with cytoplasmic inclusions (Howell–Jolly bodies) are seen in the peripheral blood after splenectomy and its absence would indicate residual splenic tissue.
THEME: Scoring in acute pancreatitis
A APACHE II B Balthazar–Ranson grading systemC Computed tomography severity indexD Glasgow score = 2 E Glasgow score = 3F Glasgow score = 4G Hong Kong scoringH Ranson score = 2I Ranson score = 3J Ranson score = 4
K Ranson score = 5
The 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.
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 commonly used and found in most textbooks (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 scoring (interleukin-6); and radiological scoring (Balthazar–Ranson and computed tomography severity system) also exist.
Scenario 1
A 50-year-old woman with known gallstone disease presents to The Emergency Department one morning complaining of gnawing epigastric pain that radiates through to her back. Bloods on admission were amylase 950 iu/litre; full blood count: haemoglobin 12.4 g/dl, white cell count 17.2 x 109/litre, platelets 300 x 109/litre, haematocrit 0.38; glucose 7.8; lactate dehydrogenase 300 units/litre; liver function tests: albumin 38 g/litre, -glutamyltransferase 27 units/litre, aspartate aminotransferase 30 iu/litre, alkaline phosphatase 200; urea 6.4. Forty-eight hours later further tests are undertaken: full blood count: haemoglobin 11.9 g/dl, white cell count 18.2 x 109/litre, platelets 320 x 109/litre, haematocrit 0.25; liver function tests: albumin 34 g/litre, ?-glutamyltransferase 29 units/litre, aspartate aminotransferase 38, alkaline phosphatase 250; blood gases: pA(O2) 10.4 kPa, base deficit -4.2; urea 7.4, Ca2+ 2.20.
0
I Correct answer
I – Ranson score = 3
This scenario demonstrates the use of the Ranson scoring system. It looks at five specific criteria on admission and a further six criteria at 48 h. Mortality can be predicted on the result (0–2 < 5% mortality, 3–4 ~ 15–20%, 5–6 ~ 40%, > 6 ~ 100%). The three positive factors in this clinical case are white cell count > 16 on admission, haematocrit drop > 10% since admission and base excess < 4 at 48 h.
Scenario 2
A 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, ?-glutamyltransferase 18, aspartate aminotransferase 115, alkaline phosphatase 320; urea 6.1, Ca2+ 2.25.
0
D Correct answer
D – Glasgow score = 2
This 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 > 100 are the two positive criteria.
Scenario 3
A radiological scoring system that assesses pancreatic size, inflammation and fluid collections; that does not use intravenous contrast.
0
B Correct answer
B – Balthazar–Ranson grading system
The 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.)
THEME: Interventions in acute pancreatitisA Oxygen supplementation and fluid resuscitationB Antibiotic prophylaxisC Fine needle aspiration (FNA)D ERCP and sphincterotomy E CholecystectomyF Surgical débridement
For each of the situations below, select the single most likely option from the above list. Each option may be used once, more than once or not at all.
Scenario 1
A 35-year-old man with severe acute pancreatitis has been in the intensive therapy unit for the past 10 days. He has a past history of excessive alcohol intake. CT has revealed pancreatic necrosis involving more than half of the pancreas. He is now pyrexial with a rising WCC and C-reactive protein (CRP).
0
C Correct answer
Current UK guidelines for the management of acute pancreatitis (2005) suggest that, in patients with persistent symptoms over > 7 days and clinical suspicion of sepsis, image-guided FNA should be performed to obtain samples for culture. Although FNA has been shown to have a low complication rate in experienced hands, with high sensitivity/specificity for the diagnosis of infected necrosis, there are concerns that it can introduce infection into a previously sterile necrosis. Other reported iatrogenic complications after FNA include bleeding, aggravation of acute pancreatitis and death. These risks need to be considered before FNA.
Scenario 2
A 56-year-old man presents to A&E with acute epigastric pain radiating to theback, associated with nausea and vomiting. On examination, he is tachycardic and
has generalised abdominal tenderness with decreased bowel sounds. Blood testsshow a raised serum amylase, WCC and CRP.
0
A Correct answer
The initial management in acute pancreatitis is supportive. Early O2 and fluid resuscitation can help prevent the development of organ failure. Oxygen saturation should be > 95% and urine output >0.5 ml/kg.
Scenario 3
A 45-year-old woman was admitted with epigastric pain, raised serum amylase and
mildly deranged LFTs. Her admission Glasgow Score was 2 and her APACHE II
score 6. Over the next few days her symptoms fully resolve. Abdominal
ultrasonography shows multiple gallstones and no bile duct dilatation.
0
E Correct answer
This patient had mild acute pancreatitis. She should undergo cholecystectomy to prevent recurrent acute pancreatitis, preferably during the same admission or within 6 weeks after discharge.
Scenario 4
A frail 78-year-old woman was admitted with epigastric pain and raised serum
amylase. Over the subsequent week, her symptoms gradually resolve. Abdominal
ultrasonography shows multiple gallstones and no bile duct dilatation.
0
D Correct answer
For patients unfit to have cholecystectomy and therefore definitive treatment for their gallstones, ERCP and sphincterotomy are an alternative option.
THEME: Pancreatic tumours
A AdenocarcinomaB GlucagonomaC InsulinomaD Non-secreting, islet-cell tumourE Zollinger–Ellison syndrome
For 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 1
A patient with glossitis and stomatitis has diabetes and a rash on his buttocks.
0
B Correct answer
B – Glucagonoma
Glucagonomas are rare, but present with long-standing eczematous rash (usually > 1 year), glossitis, stomatitis, diabetes and wasting.
Scenario 2
A patient 4 weeks after parathyroidectomy presents with loss of consciousness and dizziness.
0
C Correct answer
C– Insulinoma
Clinical 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.
THEME: splenomegaly
A BrucellosisB Infectious mononucleosisC Sickle cell diseaseD LymphomaE LeukaemiaF SpherocytosisG Polycythaemia rubra vera
Which of the above diagnoses fit the following clinical scenarios? Select the single most likely condition from the options listed above. Each option may be used once, more than once or not at all.
Scenario 1
A young man with splenomegaly fever and titres positive to Epstein–Barr virus (EBV)
0
B Correct answer
Infectious mononucleosis or glandular fever is a common disease of young adults and may present with a sore throat, lethargy, fever, lymphadenopathy, splenomegaly and hepatitis. It is caused by EBV.
Scenario 2
An 18-year-old White girl with gallstones, splenomegaly and jaundice
0
F Correct answer
Spherocytosis is a cause of haemolytic anaemia and can lead to jaundice, gallstones and splenomegaly.
Scenario 3
An Afro-Caribbean nurse with joint pains, splenomegaly and low haemoglobin (HB)
0
C Correct answer
Sickle cell disease can cause severe haemolysis. There is typically anaemia, jaundice and splenomegaly. Crisis can lead to severe bone pain.
THEME: Pancreatic diseases
A Pancreatic pseudocystB Carcinoma head of pancreasC Pancreatic fistulaD InsulinomaE Chronic pancreatitisF Carcinoma tail of pancreasG Gastrinoma
For each of the following patients, select the most likely diagnosis from the above list. Each option may be used once, more than once, or not at all.
Because of its close proximity to the tail of the pancreas, it is not uncommon for pancreatic fistulae to develop after splenic surgery. Whipple’s triad relates to overproduction of insulin. Courvoisier’s sign is a palpable gallbladder which does not occur with cholecystitis or gallstones.
Scenario 1
Obstructive jaundice, Courvoisier’s sign present
A
B Correct answer
Scenario 2
Plain abdominal X-ray shows calcification in the ducts
A
E Correct answer
Scenario 3
Computed tomography (CT) shows localised collection in the lesser sac
A Correct answer
Scenario 4
Post-splenectomy
A
C Correct answer
Scenario 5
Whipple’s triad of symptoms present
A
D Correct answer
THEME: Pancreatic tumour
A Dumping syndromeB GlucagonomaC InsulinomaD VIPomaE Zollinger–Ellison syndrome
For 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 1
A vicar who missed breakfast swore during his sermon, but felt better after a late breakfast.
A
C Correct answer
C – Insulinoma
Insulinomas 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.
Scenario 2
A 52-year-old man with hypercalcaemia suffers from recurrent gastric ulcers.
A
E Correct answer
E – Zollinger–Ellison syndrome
In 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.
