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SU23.1-3,SU24.1-3 | Adrenal and Pancreatic Surgery — Graded Quiz
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During an adrenalectomy for phaeochromocytoma, the anaesthetist reports a sudden surge in blood pressure as the surgeon manipulates the tumour. Which preoperative measure, if properly completed, most reduces the risk of these intraoperative haemodynamic swings?
Correct. Catecholamine surges during tumour handling are minimised by adequate preoperative alpha-blockade (controlling vasoconstriction) WITH volume re-expansion, before beta-blockade is added. This restores the contracted intravascular volume and blunts the swings.
Adequate alpha-blockade + volume re-expansion (then beta-blockade) is what stabilises the phaeochromocytoma patient for surgery.
The protective measure is full alpha-blockade plus volume expansion before surgery, with beta-blockade added afterward. Fluid restriction and beta-blockade alone worsen instability.
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A 30-year-old man has central obesity, purple abdominal striae, proximal muscle weakness, easy bruising, and hypertension. Overnight dexamethasone fails to suppress his serum cortisol. What does this confirm?
Correct. The clinical picture (central obesity, striae, proximal myopathy, bruising, hypertension) with failure of cortisol suppression on dexamethasone confirms Cushing's syndrome (endogenous hypercortisolism). Further testing then localises the source (pituitary vs adrenal vs ectopic ACTH).
Cushing's syndrome: cushingoid features + non-suppression of cortisol on dexamethasone. Next step is to localise the source.
Failure of cortisol to suppress with dexamethasone, plus the cushingoid phenotype, confirms hypercortisolism (Cushing's syndrome), not aldosterone or catecholamine excess.
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A 55-year-old presents with a rapidly enlarging 9 cm heterogeneous adrenal mass with irregular margins, local invasion on CT, and mixed hormonal hypersecretion. Which diagnosis is most concerning and dictates urgent surgical referral?
Correct. Large size (>4-6 cm), rapid growth, heterogeneity, irregular margins, local invasion and mixed hormone excess are red flags for adrenocortical carcinoma, which requires urgent specialist surgical management and complete (en bloc) resection.
Adrenocortical carcinoma: large (>4-6 cm), heterogeneous, invasive, often multi-hormone secreting; needs urgent en bloc resection.
Large, rapidly growing, heterogeneous, invasive masses with mixed hormone secretion strongly suggest adrenocortical carcinoma — the malignant diagnosis that mandates urgent surgery.
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A 60-year-old with acute pancreatitis is being stratified for severity. Which combination is used in contemporary practice to assess severity and define the disease course?
Correct. The Glasgow (Imrie) score is a validated prognostic scoring system for acute pancreatitis severity, and the revised (modified) Atlanta classification defines severity as mild, moderately severe, or severe based on organ failure and local complications.
Glasgow (Imrie) prognostic score + revised Atlanta classification (mild / moderately severe / severe) frame acute pancreatitis.
Acute pancreatitis severity is assessed with prognostic scores such as Glasgow/Imrie and classified by the revised Atlanta classification. Child-Pugh/TNM and the other pairs belong to liver disease, cancer staging, and other conditions.
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A patient with gallstone pancreatitis has now settled clinically. Imaging confirms gallbladder stones with no retained common bile duct stone. What is the recommended definitive management to prevent recurrence?
Correct. After mild gallstone pancreatitis, cholecystectomy is the definitive treatment to prevent recurrence and is recommended during the same admission or shortly after recovery. Leaving the gallbladder in situ carries a high risk of recurrent attacks.
Mild gallstone pancreatitis: definitive treatment is cholecystectomy, ideally during the index admission or soon after recovery.
The way to prevent recurrent gallstone pancreatitis is to remove the gallbladder. Cholecystectomy after recovery (ideally same admission for mild disease) is the definitive management.
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An insulinoma is biochemically confirmed in a young woman. Following the confirm-then-localise discipline of endocrine surgery, what is the correct next step?
Correct. Endocrine surgery follows a two-step discipline: confirm the hormonal syndrome biochemically FIRST (done here), THEN localise the tumour with cross-sectional imaging and/or endoscopic ultrasound to plan an enucleation or limited resection. Blind surgery is not appropriate.
Endocrine surgery rule: confirm the syndrome biochemically, THEN localise with imaging before any operation.
After biochemical confirmation, the next step is localisation with imaging (CT/MRI, EUS), not blind surgery or medical therapy. Confirm first, then localise, then operate.
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A 45-year-old man presents with a gastrinoma, primary hyperparathyroidism, and a pituitary adenoma. Which inherited syndrome should be suspected, and what is the implication for his family?
Correct. The combination of parathyroid (hyperparathyroidism), pituitary, and pancreatic (gastrinoma) tumours — the 'three Ps' — defines MEN-1. It is autosomal dominant, so first-degree relatives should be offered genetic counselling and surveillance.
MEN-1 = parathyroid + pituitary + pancreatic tumours (three Ps), autosomal dominant; offer family genetic counselling and screening.
Parathyroid + pituitary + pancreatic tumours is MEN-1 (the three Ps), an autosomal dominant condition. Relatives warrant genetic counselling and screening; this is not MEN-2 or sporadic.
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A patient with severe acute pancreatitis develops a persistent fluid collection at six weeks that is encapsulated by a defined wall on imaging, with ongoing pain and early satiety. Which local complication is this?
Correct. A persistent, encapsulated (well-defined non-epithelialised wall) peripancreatic fluid collection maturing around 4+ weeks after acute pancreatitis is a pancreatic pseudocyst. Symptomatic or enlarging pseudocysts may need drainage.
Pancreatic pseudocyst = encapsulated peripancreatic fluid collection maturing ~4 weeks after acute pancreatitis; drain if symptomatic/complicated.
An encapsulated fluid collection developing weeks after acute pancreatitis, causing pain and early satiety, is a pancreatic pseudocyst — a recognised local complication of pancreatitis.
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