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Case A: Upper Abdominal Mass with Projectile Vomiting

i. Diagnosis (3 marks)

• Visible gastric peristalsis — distended stomach showing peristaltic waves moving left to right across the epigastrium
• Succussion splash — audible splashing on shaking the patient, indicating a fluid-filled, dilated stomach with retained contents
• Projectile vomiting immediately after food — vomitus contains undigested/digested food, NO bile (obstruction is proximal to ampulla of Vater)
• Upper abdominal mass = palpable distended stomach

• Carcinoma of the pylorus / antrum (must be excluded — as per Bailey & Love's, p.1189: "gastric outlet obstruction should be considered malignant until proven otherwise")
• Congenital hypertrophic pyloric stenosis (in adults, rare)
• Extrinsic compression (lymph nodes, pancreatic head mass)

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ii. Investigations (3 marks)

• Serum electrolytes: Hypokalaemia, hyponatraemia, hypochloraemia
• ABG / Serum bicarbonate: Hypochloraemic, hypokalaemic metabolic alkalosis (classic — due to repeated vomiting of HCl)
• Urea & creatinine: Elevated (dehydration, pre-renal)
• CBC: Anaemia (if malignancy or chronic blood loss)

• Plain X-ray abdomen (erect): Large gastric bubble with fluid level
• Barium meal (UGI series): Dilated stomach, delayed gastric emptying, narrow pyloric canal ("string sign"); shows site and nature of obstruction
• CT scan abdomen with contrast: Investigation of choice to delineate cause (benign vs malignant), assess extent, lymphadenopathy, liver metastases

• Most important investigation — directly visualises the pylorus/antrum, determines cause (ulcer vs tumour), allows biopsy for histopathology (to differentiate benign peptic stricture from malignancy)

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iii. Management (4 marks)

A. Resuscitation & Correction of Metabolic Derangement (Pre-operative)

• IV fluid resuscitation — Normal saline + KCl supplementation to correct hypochloraemic, hypokalaemic alkalosis
• Urinary catheter — target urine output >0.5 mL/kg/hr
• NG tube insertion — gastric decompression and lavage (remove retained food)
• Correct anaemia, nutritional deficiencies (TPN/enteral nutrition if severely malnourished)
• Monitor electrolytes daily until normal

B. Definitive Management

• Endoscopic balloon dilation — first-line for benign strictures; may be repeated
• Surgical options (if endoscopic dilation fails or recurs):
  • Truncal vagotomy + gastrojejunostomy (drainage procedure)
  • Pyloroplasty (widening of pylorus)
  • Highly selective vagotomy (HSV) + drainage
• H. pylori eradication (if H. pylori +ve): Triple therapy (PPI + amoxicillin + clarithromycin for 14 days)
• PPI therapy long term

• Staging → resectable: radical gastrectomy (Billroth II / Roux-en-Y)
• Unresectable/palliative: gastrojejunostomy (bypass) or endoscopic stenting

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Case B: Acute Pancreatitis in a Chronic Alcoholic

i. Probable Diagnosis (2 marks)

• Alcoholic for 20 years (major etiological factor)
• Severe epigastric pain relieved by leaning forward (reduces stretch on retroperitoneal pancreas)
• Significantly raised serum amylase (>3× upper limit of normal) and serum lipase (more specific — >3× ULN; lipase remains elevated longer than amylase)

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ii. Etiological Factors (2 marks)

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iii. Clinical Features (2 marks)

• Severe, sudden-onset epigastric pain radiating to the back (band-like)
• Pain relieved by leaning forward / sitting up (classic)
• Nausea and persistent vomiting (does not relieve pain — distinguishing from other causes)
• Abdominal distension (ileus)
• Fever (low grade initially; high fever suggests infected necrosis)

• Epigastric tenderness and guarding
• Tachycardia, hypotension (if severe — hypovolaemia, third-space losses)
• Reduced or absent bowel sounds (paralytic ileus)
• Cullen's sign — periumbilical ecchymosis (haemoperitoneum; poor prognosis)
• Grey Turner's sign — flank ecchymosis (retroperitoneal haemorrhage; poor prognosis)
• Jaundice (if biliary obstruction due to oedematous head)
• In severe cases: features of SIRS/MODS (ARDS, AKI, DIC)

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iv. Management of Acute Pancreatitis

Step 1 — Immediate Assessment & Severity Scoring

• Ranson's criteria (at admission and 48 hours): ≥3 = severe
• APACHE II score ≥8 = severe
• CT Severity Index (Balthazar) — done at 48–72 hrs
• CRP >150 mg/L at 48 hrs = predictor of severity

Step 2 — Supportive / Conservative Management (Cornerstone)

Step 3 — Specific Interventions

• NOT routinely recommended in mild-moderate sterile pancreatitis
• Indicated in infected pancreatic necrosis (confirmed by CT-guided FNA or clinical suspicion) — use Imipenem/Meropenem or Ciprofloxacin + Metronidazole

• Indicated within 24–72 hrs if acute pancreatitis is due to gallstones with cholangitis/biliary obstruction

• Infected pancreatic necrosis: Step-up approach:
  1. CT/US-guided percutaneous drainage (first step)
  2. Video-assisted retroperitoneal debridement (VARD) or minimally invasive necrosectomy
  3. Open necrosectomy — only if above fail (high morbidity)
• Pseudocyst: If symptomatic → endoscopic cystogastrostomy or percutaneous drainage
• Interval cholecystectomy: Performed 4–6 weeks after resolution if gallstones were the cause

Step 4 — Treatment of Underlying Cause

• Alcohol cessation — counselling, referral to de-addiction services (this patient)
• Correct hyperlipidaemia, hypercalcaemia if present

Step 5 — Monitoring for Complications