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SU28.10-12 | Hepatobiliary and Splenic Surgery — Practice Quiz
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A 38-year-old man returning from a rural posting presents with high fever, right upper quadrant pain and tender hepatomegaly. Ultrasound shows a single solitary cystic lesion in the right lobe with no daughter cysts. Aspiration yields odourless reddish-brown 'anchovy-sauce' fluid. Which is the most appropriate management?
Anchovy-sauce aspirate is pathognomonic of an amoebic liver abscess, which is fundamentally a medical disease responding to metronidazole; aspiration is reserved for large, left-lobe, or non-responding lesions.
Amoebic liver abscess: metronidazole (then a luminal amoebicide) is first-line; aspirate only if large/left-lobe/failing to respond. Anchovy-sauce pus is the classic descriptor.
The 'anchovy-sauce' aspirate identifies an amoebic abscess — a medical, not a primarily surgical, disease.
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A 45-year-old sheep-farmer has an incidental 8 cm right-lobe liver cyst with a laminated membrane and internal daughter cysts on ultrasound; serology for Echinococcus is positive. Why is blind percutaneous needle aspiration for diagnosis specifically contraindicated?
Hydatid cyst contents are highly antigenic; leakage during blind aspiration risks anaphylactic shock and seeds daughter cysts throughout the peritoneum.
A cystic liver lesion is hydatid until proven otherwise — do not needle it blindly. Diagnose on imaging (daughter cysts, laminated membrane) and serology; treat with albendazole + PAIR or surgery under cover.
The danger of aspirating a hydatid cyst is spillage of antigenic fluid causing anaphylaxis and dissemination.
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A confirmed hepatic hydatid cyst is to be managed with the PAIR technique (Puncture, Aspiration, Injection, Re-aspiration). Which adjunct most directly reduces the risk of recurrence and peri-procedural complications?
Albendazole given around the procedure reduces cyst viability and the risk of recurrence from any spilled protoscolices; the injected scolicidal agent is re-aspirated in the 'I' and 'R' steps.
Hydatid management combines albendazole with PAIR or surgery; metronidazole treats amoebae, not Echinococcus.
Hydatid disease is parasitic — albendazole (not metronidazole, which is for amoebae) provides the chemotherapeutic cover for PAIR.
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A 60-year-old man with known cirrhosis from chronic hepatitis B develops weight loss and a rising serum alpha-fetoprotein. A triple-phase CT shows a 5 cm lesion with arterial enhancement and venous washout. What is the most likely diagnosis?
Cirrhosis plus a rising AFP and the classic arterial-enhancement/venous-washout pattern is diagnostic of hepatocellular carcinoma.
HCC arises on a background of chronic liver disease/cirrhosis; AFP and dynamic CT/MRI (arterial enhancement, washout) underpin diagnosis; resection needs adequate future liver remnant.
The combination of cirrhosis, raised AFP and arterial enhancement with washout points to hepatocellular carcinoma.
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A 24-year-old man is brought in after a motorbike crash with left-sided lower rib fractures, left upper quadrant pain and pain referred to the left shoulder tip. His blood pressure is 90/60 mmHg and rising heart rate; he does not respond to fluids. CT confirms a high-grade splenic injury. What is the most appropriate management?
Management is led by haemodynamic stability, not CT grade. A patient who remains shocked despite resuscitation needs urgent laparotomy; with a high-grade bleeding injury this means splenectomy. Left shoulder-tip pain is Kehr's sign.
Splenic injury: stability decides management, not the CT grade. Stable → non-operative/angioembolisation; haemodynamically unstable → urgent laparotomy ± splenectomy. Kehr's sign = referred left shoulder-tip pain.
The decisive factor is haemodynamic stability. A persistently shocked patient cannot be observed and needs urgent operative control.
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A patient is scheduled for an elective splenectomy. To minimise the risk of overwhelming post-splenectomy infection (OPSI), when should the recommended vaccinations ideally be given?
For an elective splenectomy, vaccinate at least two weeks BEFORE surgery, while the spleen is still present to mount the immune response. (For emergency splenectomy, vaccinate post-operatively, classically around two weeks after.)
OPSI prophylaxis: vaccinate ≥2 weeks pre-op for elective splenectomy; post-op (~2 weeks) for emergency. Plus penicillin prophylaxis and a patient alert card.
The timing rule: vaccinate the elective patient at least two weeks BEFORE surgery, while the spleen can still respond.
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Overwhelming post-splenectomy infection is driven by loss of the spleen's role in clearing a particular class of organisms. Against which group of pathogens is the asplenic patient most characteristically at risk?
The spleen filters and opsonises encapsulated organisms; its loss leaves the patient vulnerable to Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b — hence vaccination against these three.
Asplenia → risk from encapsulated bacteria → vaccinate against pneumococcus, meningococcus and Hib, plus penicillin prophylaxis.
OPSI is caused by encapsulated organisms (pneumococcus, meningococcus, Hib) that the spleen normally clears.
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A 55-year-old woman has fever with rigors, right upper quadrant pain and jaundice (Charcot's triad). She then becomes hypotensive and confused. Which diagnosis does the development of this pentad indicate, and what is the underlying problem?
Charcot's triad (fever + RUQ pain + jaundice) signals ascending cholangitis; adding hypotension and confusion makes Reynolds pentad — a surgical emergency requiring resuscitation, antibiotics and urgent biliary drainage (usually ERCP).
Charcot's triad → cholangitis; Reynolds pentad (add shock + confusion) → severe cholangitis. Treat with antibiotics and urgent biliary drainage (ERCP).
Triad + hypotension + confusion = Reynolds pentad = severe ascending cholangitis needing urgent decompression.
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