Gastrointestinal and Hepatobiliary Surgery
Gastrointestinal and Hepatobiliary Surgery dominates the paper. It tests pattern recognition (painless jaundice, Charcot's triad, Rigler's sign), the anatomy that governs safe resection (Couinaud segments, the critical view of safety) and the correct sequence of resuscitation, investigation and operation.
Oesophagus and stomach
- Achalasia: dysphagia to solids and liquids, 'bird-beak' on barium swallow, manometry is diagnostic; treat with laparoscopic Heller myotomy plus Dor fundoplication, pneumatic dilatation or botulinum toxin.
- Boerhaave perforation: effort-induced vomiting followed by chest pain and subcutaneous emphysema; contrast study then urgent surgery.
- Gastric cancer: D1 dissection removes nodes 3-6; D2 adds nodes along the left gastric, common hepatic, splenic and coeliac arteries.
Colorectal
Right-sided cancer presents with iron-deficiency anaemia, left-sided with obstruction. A mid-rectal tumour staged T3 or node-positive receives neoadjuvant long-course chemoradiotherapy before total mesorectal excision.
Hepatobiliary and pancreas
- Courvoisier's law: a palpable, non-tender gallbladder with painless jaundice is unlikely to be gallstones.
- Acute cholangitis: Charcot's triad (fever, jaundice, right upper quadrant pain); Reynolds' pentad adds hypotension and confusion - resuscitate, give antibiotics, then urgent biliary drainage by ERCP.
- Acute pancreatitis: two of three criteria (typical pain, lipase over 3× upper limit, imaging); early fluid resuscitation and enteral nutrition; early CT does not change management.
Spleen
After splenectomy vaccinate against pneumococcus, meningococcus and Haemophilus influenzae type b, with lifelong penicillin prophylaxis for children and at-risk adults against overwhelming post-splenectomy infection.
Worked example
A 68-year-old with painless jaundice and a palpable gallbladder has a distal bile duct stricture on ultrasound. Courvoisier's law makes gallstone disease improbable; the next steps are pancreatic-protocol CT, CA19-9 and MDT discussion, with a Whipple resection if resectable.
Traps
Attributing painless jaundice to stones; forgetting the 3× lipase threshold; draining cholangitis before resuscitating; omitting post-splenectomy vaccination.