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SU28.10-12 | Hepatobiliary and Splenic Surgery — PBL Case

CLINICAL SETTING

It is a busy evening in a district general surgical unit. Over a single shift, the on-call team meets three very different patients whose problems all converge on the upper abdomen. The registrar uses the shift as a teaching opportunity, asking the group to reason from anatomy and physiology to a safe plan for each. Work through the triggers in order; for each, decide what you would do next and, crucially, WHY.

Trigger 1: The febrile traveller with a tender liver

A 35-year-old man, recently returned from a rural area, presents with a swinging fever, rigors and constant right upper quadrant pain. He looks unwell. On examination there is tender hepatomegaly. Ultrasound shows a single solitary lesion in the right lobe of the liver. The intern asks whether they should aspirate it for diagnosis straight away.

DISCUSSION POINTS

  • What is your differential for a febrile patient with a focal liver lesion, and how do amoebic and pyogenic abscesses differ in source and management?
  • If aspiration yielded odourless reddish-brown 'anchovy-sauce' fluid, what is the diagnosis and what is the first-line treatment?
  • Before reaching for a needle, what single feature of the lesion on ultrasound would make you stop and reconsider aspiration entirely, and why?
Click to reveal Trigger 2: The cyclist who hit the handlebars (discuss previous trigger first!)

Trigger 2: The cyclist who hit the handlebars

A 22-year-old cyclist is wheeled in after a fall, gripping his left upper abdomen; he reports pain spreading to his left shoulder. His lower-left ribs are bruised. His pulse is 120/min and blood pressure 88/58 mmHg; after two litres of fluid he improves only briefly before deteriorating again. CT shows a high-grade splenic laceration. The team debates whether to observe or operate.

DISCUSSION POINTS

  • Why does splenic injury cause left shoulder-tip pain, and what is this sign called?
  • What single clinical parameter — not the CT grade — should lead the decision to operate, and what operation is indicated here?
  • If he proceeds to emergency splenectomy, what lifelong risk does he now carry, which organisms are responsible, and what prophylaxis (including vaccination timing) does he need?
Click to reveal Trigger 3: The woman who turned yellow (discuss previous trigger first!)

Trigger 3: The woman who turned yellow

A 62-year-old woman presents with fever and rigors, right upper quadrant pain and jaundice. Shortly after admission she becomes hypotensive and confused. Blood tests show an obstructive picture and a raised inflammatory marker; ultrasound shows a dilated common bile duct with a stone at its lower end.

DISCUSSION POINTS

  • Name the triad and then the pentad of signs she displays, and state what each indicates about the severity of her biliary disease.
  • What is the underlying problem (an obstructed, infected biliary tree), and what are the first priorities of management?
  • Compare MRCP and ERCP in her management — which is diagnostic, which is therapeutic, and why does the distinction matter here?

Group Task Assignments

  • Construct a single comparison table distinguishing amoebic abscess, pyogenic abscess and hydatid cyst by source, key imaging/aspirate feature, and first-line management.
  • Draw a decision flowchart for blunt splenic trauma that puts haemodynamic stability — not CT grade — at the top, branching to non-operative management, angioembolisation and splenectomy.
  • Write a one-page patient-safety summary on overwhelming post-splenectomy infection covering the organisms, vaccination timing for elective versus emergency splenectomy, penicillin prophylaxis and the alert card.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU28.10] What are the applied anatomy, clinical features, investigations and principles of management of liver abscess (amoebic and pyogenic), hydatid disease, liver injuries and liver tumours?
  2. [SU28.11] What is the applied anatomy of the spleen, how are splenic injuries assessed and managed, and how is post-splenectomy sepsis prevented?
  3. [SU28.12] What are the applied anatomy, clinical features, investigations and principles of management of diseases of the biliary system, including the eponymous bedside signs?