100 Cases in Surgery
ANSWER 33
The patient is jaundiced (bilirubin 122 mmol/L) and the high ALP to AST ratio would suggest the cause is obstructive. The pale stool is because the conjugated bilirubin fails to pass from the liver into the gastrointestinal tract. Conjugated bilirubin is then excreted in the urine giving it a dark appearance. Urinary bilirubin is normally absent and its presence confirms a raised conjugated bilirubin. The causes of obstructive jaundice are shown in Table 33.1.
Table 33.1 Causes of obstructive jaundice
Common |
Less frequent |
Rare |
Common bile duct stones |
ampullary carcinoma |
benign strictures – iatrogenic, |
|
|
trauma |
Carcinoma of the head of |
pancreatitis |
recurrent cholangitis |
pancreas |
|
|
malignant porta hepatis |
liver secondaries |
mirrizi’s syndrome |
lymph nodes |
|
|
|
|
Sclerosing cholangitis |
|
|
Cholangiocarcinoma |
|
|
biliary atresia |
|
|
Choledochal cysts |
Investigation aims to differentiate between hepatocellular and obstructive jaundice. In obstructive jaundice, blood results typically show an elevated conjugated bilirubin (>35 mmol/L) and an increase in ALP/GGT compared to AST/ALT. Ultrasound is the firstline investigation. Gallbladder stones are easily detected (sensitivity >90 per cent), but CBD stones are frequently missed (sensitivity <40 per cent). The detection of CBD stones can be impeded by the presence of gas in the duodenum. However, CBD dilatation (>8 mm) is identified in up to 90 per cent of cases of CBD obstruction. The liver function tests and the CBD calibre indicate the likelihood of CBD stones.
Based on these findings, patients will either proceed straight to laparoscopic cholecystectomy, or if there is a high risk of a stone(s) in the CBD, an ERCP will be performed to clear the duct prior to surgery. ERCP is used to image the biliary system if therapeutic intervention is likely to be needed. Complications include pancreatitis (less than 1 per cent), perforation, biliary peritonitis, sepsis and haemorrhage. Endoscopic ultrasonography and MRCP have a higher sensitivity and specificity for CBD stone detection (85–100 per cent) and are used when the presence of choledocholithiasis remains unclear. These techniques are diagnostic only, but have fewer risks than ERCP. Some specialist surgeons use intraoperative cholangiography or ultrasonography, negating the need for preoperative imaging and will explore the common bile duct at the time of cholecystectomy.
KEY POINTS
•If the bilirubin and ALP are elevated and the CBD is greater than 12 mm, the risk of CBD stones is over 90 per cent.
•If the bilirubin, ALP and CBD diameter are normal, the risk of CBD stones is approximately 0.5 per cent.
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Upper Gastrointestinal
CASE 34: poSt-pranDial pain
history
A 62-year-old man is attending the endoscopy unit for an oesophagogastroscopy. The GP’s letter states that he has been suffering from epigastric pain for the past 6 months. The pain typically occurs about an hour after eating and is associated with nausea and belching. He has had some relief from a proton pump inhibitor, but the symptoms have not entirely settled, despite a 2-month course. Blood tests were arranged by the GP and the results are shown below.
examination
General examination is normal. A picture taken at endoscopy is shown in Figure 34.1.
Figure 34.1 Finding on endoscopy.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
11.9 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
10 × 109/l |
4.0–11.0 × 109/l |
platelets |
252 × 109/l |
150–400 × 109/l |
Sodium |
137 mmol/l |
135–145 mmol/l |
potassium |
4.2 mmol/l |
3.5–5.0 mmol/l |
urea |
5.0 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
72 μmol/l |
44–80 μmol/l |
amylase |
32 iu/dl |
0–100 iu/dl |
aSt |
30 iu/l |
5–35 iu/l |
ggt |
46 iu/l |
11–51 iu/l |
albumin |
46 g/l |
35–50 g/l |
bilirubin |
12 mmol/l |
3–17 mmol/l |
glucose |
5.0 mmol/l |
3.5–5.5 mmol/l |
QuESTIONS
•What is the diagnosis?
•Which common organism is commonly implicated?
•Which other factors are thought to be important?
•Which tests can be used to detect the organism?
•What are the current treatments?
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100 Cases in Surgery
ANSWER 34
Figure 34.1 shows peptic ulceration (arrow). A peptic ulcer is a dissolution in the mucosa, 3 mm or greater in size, of the stomach or duodenum. Epigastric pain is the most common presenting symptom, which often occurs 1–3 h after meals. It can occur at night and is relieved by food or antacids. Nausea is common and vomiting may occur where there is partial or complete gastric outlet obstruction. Patients may also present with haematemesis or melaena resulting from gastrointestinal bleeding. Symptoms do not correlate well with clinical findings, as only 20–25 per cent of patients with symptoms suggestive of peptic ulceration are found to have a peptic ulcer.
Helicobacter pylori is now known to be an important contributory factor in the development of peptic ulceration. It is a Gram-negative spiral flagellated bacterium which is found in approximately 90 per cent of patients with duodenal ulceration, 70 per cent of patients with gastric ulceration and 60 per cent of patients with gastric cancer. Normal mucosal production of mucus, bicarbonate and prostaglandins are important in preventing ulceration. A disturbance in this physiological barrier can lead to ulceration. This may be attributed to factors such as smoking, NSAIDs, ethanol, bile acids, aspirin, steroids or stress.
H. pylori can be detected by biopsies taken at the time of the oesophagogastroduodenoscopy, using a rapid urease test, or by blood serology or a urea breath test. The majority of peptic ulcers will heal after 2 months’ treatment with a proton pump inhibitor. There is low recurrence with long-term maintenance therapy. If H. pylori is detected, the patient should have triple therapy, consisting of a course of antibiotics and acid suppression.
Patients should be advised to stop smoking, avoid NSAIDs and aspirin use, avoid excessive alcohol and reduce stress.
KEY POINTS
•Most peptic ulcers will heal after 2 months of a high-dose proton pump inhibitor.
•H. pylori is found in 90 per cent of patients with duodenal ulceration.
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Upper Gastrointestinal
CASE 35: leFt upper QuaDrant maSS
history
The GP has referred a 63-year-old man to the surgical outpatients. The patient had gone to his GP after becoming lethargic and short of breath on minimal exertion. The GP palpated a mass in the left upper quadrant and noticed multiple bruises on the upper arms and chest. The patient denied any recent injuries.
examination
On examination, there was no palpable lymphadenopathy, pallor or jaundice. The chest was clear and heart sounds normal. His blood pressure was 136/70 mmHg with a pulse rate of 78/ min. Examination of the abdomen revealed a mass in the left upper quadrant. The superior border of the mass could not be reached and a notch was felt on the medial side. The mass was non-pulsatile and dull to percussion. No other masses were palpable and the rest of the examination was unremarkable.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
11.2 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
4.2 × 109/l |
4.0–11.0 × 109/l |
platelets |
110 × 109/l |
150–400 × 109/l |
Sodium |
137 mmol/l |
135–145 mmol/l |
potassium |
4.2 mmol/l |
3.5–5.0 mmol/l |
urea |
5 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
72 μmol/l |
44–80 μmol/l |
international normalized ratio (inr) |
1.0 |
0.9–1.2 |
activated partial thromboplastin time (aptt) |
32 s |
29–41 s |
examination of the blood film showed teardrop-shaped red blood cells.
Questions
•What is the mass likely to be?
•What are its normal functions?
•What are the causes of enlargement?
•Which condition is this patient likely to have?
•How would the diagnosis be confirmed?
•What are the treatment options?
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