General Surgery
Stomach, Liver, Spleen and Biliary Tract
MBBS surgery notes on stomach, liver, spleen and biliary tract: peptic ulcer, gastric cancer, gallstones and cholangitis, mapped to NMC codes SU28.7 to SU28.12.
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Stomach, Liver, Spleen and Biliary Tract
MBBS surgery notes on stomach, liver, spleen and biliary tract: peptic ulcer, gastric cancer, gallstones and cholangitis, mapped to NMC codes SU28.7 to SU28.12.
This chapter covers surgical disease of the stomach, liver, spleen and biliary tract. It spans peptic ulcer complications and gastric cancer, gallstone disease and its complications, liver tumours and abscess, and the consequences of splenectomy.
High-yield: Stomach, Liver, Spleen and Biliary Tract
- Peptic ulcer disease is chiefly caused by Helicobacter pylori infection and non-steroidal anti-inflammatory drugs.
- A perforated peptic ulcer causes sudden severe upper abdominal pain, board-like rigidity and free gas under the diaphragm on an erect chest radiograph.
- A bleeding peptic ulcer presents with haematemesis or melaena and is treated first by endoscopic haemostasis.
- Gastric outlet obstruction from chronic ulceration causes projectile vomiting of undigested food and a hypochloraemic hypokalaemic metabolic alkalosis.
- Gastric cancer often presents late with weight loss, anaemia and a mass, and signet ring adenocarcinoma is a common histology.
- Virchow node, an enlarged left supraclavicular lymph node, can be a sign of metastatic gastric cancer.
- Gallstones are common and most are cholesterol or mixed stones; many are asymptomatic.
- Biliary colic is right upper quadrant pain after a fatty meal without fever, while acute cholecystitis adds fever and a positive Murphy sign.
- Choledocholithiasis is a stone in the common bile duct causing obstructive jaundice and risking cholangitis and pancreatitis.
- Ascending cholangitis presents with the Charcot triad of fever with rigors, right upper quadrant pain and jaundice.
- Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstones.
- A liver abscess in India is commonly amoebic, classically in the right lobe, and responds to metronidazole with drainage if large.
- Hepatocellular carcinoma usually arises in a cirrhotic liver and is associated with a raised alpha fetoprotein.
- The spleen is the commonest solid organ injured in blunt abdominal trauma.
- After splenectomy, patients are at risk of overwhelming infection by encapsulated organisms and need vaccination and prophylaxis.
Gallstone disease spectrum
- **Biliary colic:** Right upper quadrant pain after fatty food; no fever; stone in the gallbladder or neck.
- **Acute cholecystitis:** Pain with fever and a positive Murphy sign; inflamed obstructed gallbladder.
- **Choledocholithiasis:** Stone in the common bile duct; obstructive jaundice; risk of pancreatitis.
- **Cholangitis:** Charcot triad of fever with rigors, right upper quadrant pain and jaundice; a surgical emergency.
NMC competencies in this chapter
- **SU28.7:** Peptic ulcer disease and its complications
- **SU28.8:** Gastric cancer
- **SU28.9:** Gallstone disease and its complications
- **SU28.10:** Biliary tract disease and obstructive jaundice
- **SU28.11:** Liver tumours and abscess
- **SU28.12:** Splenic disease, trauma and splenectomy
Frequently Asked Questions
How does a perforated peptic ulcer present?
With sudden, severe generalised upper abdominal pain, board-like abdominal rigidity and free gas under the diaphragm on an erect chest radiograph, indicating a surgical emergency.
What is the Charcot triad?
Fever with rigors, right upper quadrant pain and jaundice, the classic presentation of ascending cholangitis from an obstructed, infected common bile duct.
What is the treatment of symptomatic gallstones?
Laparoscopic cholecystectomy is the standard treatment. A stone in the common bile duct may first be cleared endoscopically before the gallbladder is removed.
Why do splenectomy patients need vaccination?
The spleen clears encapsulated bacteria, so after splenectomy patients are at risk of overwhelming post-splenectomy infection and need vaccination against pneumococcus, meningococcus and Haemophilus, plus prophylaxis.
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