Hepatobiliary and Pancreatic Surgery
What the exam tests
This domain covers gallstone disease, acute pancreatitis, obstructive jaundice, liver masses and perioperative decisions in pancreatic and hepatic resection.
Core rules
- Right upper quadrant pain with a positive Murphy sign suggests acute cholecystitis; perform ultrasound, give antibiotics and plan cholecystectomy.
- Cholangitis: Charcot triad (fever, jaundice, right upper quadrant pain); Reynolds pentad adds shock and confusion. Give antibiotics and obtain biliary drainage.
- Acute pancreatitis is diagnosed by two of: characteristic pain, amylase or lipase above three times normal, and imaging. Early care is fluids, analgesia and enteral feeding; prophylactic antibiotics are not routine.
- Painless jaundice with a palpable gallbladder suggests a periampullary or pancreatic head cancer until proven otherwise.
- Resectability is judged on pancreatic-protocol CT and MDT review; drain the biliary tree for cholangitis or before neoadjuvant therapy, not routinely.
Worked example
A 62-year-old has painless jaundice, weight loss and a palpable gallbladder. Ultrasound shows dilated intrahepatic and common bile ducts. CT shows a mass in the pancreatic head without vascular invasion or metastases. EUS-guided FNA confirms adenocarcinoma. After MDT review, a Whipple resection is planned; a stent relieves pruritus while staging is completed.
Traps
Labelling painless jaundice as hepatitis; missing cholangitis; performing ERCP in severe coagulopathy without correction; and ignoring portal vein or caudate lobe involvement when assessing resectability.