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SU23.1-3,SU24.1-3 | Adrenal and Pancreatic Surgery — PBL Case

CLINICAL SETTING

You are part of the surgical team at a teaching hospital. Over one week, three very different patients with adrenal or pancreatic pathology are admitted under your care. Work through each trigger as a group, building your differential, investigation plan, and management before revealing the next trigger. Reason from pathophysiology to decisions.

Trigger 1: Collapse on the ward round

A 39-year-old woman is admitted for investigation of poorly controlled hypertension. While the team is examining her abdomen, she suddenly becomes flushed, sweaty, and tremulous; her monitored blood pressure spikes to 220/120 mmHg with a heart rate of 140. The episode settles spontaneously over ten minutes. The intern, in a panic, asks whether they should give an urgent IV beta-blocker to bring the heart rate down.

DISCUSSION POINTS

  • What is the unifying diagnosis that links labile hypertension, an adrenal lesion, and these paroxysmal episodes?
  • Why is giving a beta-blocker first potentially dangerous in this patient, and what must be established before any beta-blockade?
  • Which biochemical test would you order and why is it preferred over measuring catecholamines directly?
  • Once biochemically confirmed, what imaging and what definitive treatment would you plan, and how does preparation prevent intraoperative crises?
Click to reveal Trigger 2: The painful epigastrium at midnight (discuss previous trigger first!)

Trigger 2: The painful epigastrium at midnight

A 52-year-old man arrives in the emergency department with severe constant epigastric pain boring through to his back, repeated vomiting, and an inability to lie still. He admits to heavy weekend alcohol use. His serum amylase is markedly elevated. He is tachycardic with a low-grade fever. The covering doctor wants to start broad-spectrum antibiotics 'to be safe' and is unsure how sick this man really is.

DISCUSSION POINTS

  • What is the diagnosis, and what are the two most common aetiologies you must actively exclude in every case?
  • How would you stratify the severity of his pancreatitis, and which classification defines the disease course?
  • Is routine prophylactic antibiotic therapy justified in mild acute pancreatitis? Defend your answer.
  • What are the cornerstones of supportive management, and what definitive step prevents recurrence if gallstones are found?
Click to reveal Trigger 3: The fasting fainter (discuss previous trigger first!)

Trigger 3: The fasting fainter

A 34-year-old teacher is referred after several months of episodic confusion, sweating, and odd behaviour that occur before meals and resolve quickly once she eats sweets. A colleague once recorded a very low capillary glucose during an episode. She has gained weight from constant snacking to prevent symptoms. During a supervised fast she becomes symptomatic with documented hypoglycaemia; insulin and C-peptide are both inappropriately high.

DISCUSSION POINTS

  • Which clinical triad does her presentation satisfy, and what is the most likely diagnosis?
  • Why is the simultaneously raised C-peptide crucial, and how does it exclude surreptitious exogenous insulin?
  • Following the 'confirm then localise' discipline of endocrine surgery, what is the next step before any operation?
  • What other functioning pancreatic neuroendocrine tumours should you know, and which inherited syndrome groups parathyroid, pituitary and pancreatic tumours together?

Group Task Assignments

  • Produce a one-page comparison table of phaeochromocytoma, Conn's syndrome, and Cushing's syndrome covering the clinical clue, the confirmatory biochemistry, and the key management principle for each.
  • Draft a structured preoperative phaeochromocytoma preparation checklist that a junior doctor could follow safely, making the alpha-before-beta rule explicit.
  • Build a flowchart for acute pancreatitis from presentation through severity stratification to definitive management, including when antibiotics are and are not indicated.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU23.1] What is the pathophysiology of phaeochromocytoma and why must alpha-blockade always precede beta-blockade before surgery?
  2. [SU23.2] How do the biochemical signatures of Conn's syndrome and Cushing's syndrome differ, and how is each confirmed?
  3. [SU24.1] What are the causes, severity classification, and evidence-based management principles (including antibiotic use) of acute pancreatitis?
  4. [SU24.2] How is an insulinoma diagnosed using Whipple's triad and the insulin/C-peptide relationship, and how is it localised?
  5. [SU24.3] What is Zollinger-Ellison syndrome and how do pancreatic neuroendocrine tumours relate to MEN-1?