A 59-year-old man presented with acute severe central abdominal pain and vomiting. He rarely consumed alcohol and had no signi cant past medical history. A clinical diagnosis of acute pancreatitis was made. He was treated with intravenous uid resuscitation and analgesia. A day after initial presentation he had blood tests performed. 



Investigations:



white cell count                              8.3 x 109/L (4.0–11.0) 

serum urea                                    7.2 mmol/L (2.5–7.0) 

serum creatinine                            103 μmol/L (60–110) 

serum albumin                                34 g/L (37–49) 

serum total bilirubin                        20 μmol/L (1–22)

serum alanine aminotransferase       55 U/L (5–35)



serum alkaline phosphatase             140 U/L (45–105)



serum amylase                                829 U/L (60–180)

pH                                                  7.40 (7.35–7.45)

PCO2                                              5.0 kPa (4.7–6.0)

PO2                                                11.7 kPa (11.3–12.6)

bicarbonate                                     24 mmol/L (21–29)

base excess                                     + 1.8 mmol/L (±2)

serum C-reactive protein                   22 mg/L (< 10)



abdominal ultrasound                        several gallstones < 5 mm in size in a 

                                                       thin walled gallbladder; the common 

                                                       bile duct (CBD) measured 0.6 cm in   

                                                       diameter 



His symptoms improved with uid and analgesia. What is the most appropriate management plan for this patient? 

A 74-year-old woman presented with a fever of 38°C, jaundice, and 4 kg

weight loss in the previous 4 months. 



Investigations:

serum albumin                                    33 g/L (37–49)     

serum total bilirubin                             89 μmol/L (1–22)

serum alanine aminotransferase            75 U/L (5–35)



serum alkaline phosphatase                  210 U/L (45–105)



serum CA 19–9                                   27 000 U/mL (< 33)

abdominal ultrasound                        mass lesion in the common hepatic  

                                                       duct with proximal dilatation. Four 

                                                       peripheral liver lesions suspicious



                                                       for metastatic deposits in segments I,

                                                       I, III, and VII of the liver

CT thorax, abdomen, and pelvis        no other abnormality 



She was treated with intravenous antibiotics and her fever settled. 

What is the next step in the management of her mass lesion? 

A 42-year-old woman presented to your clinic with an incidental nding of gallstones in a thin walled gallbladder on ultrasound scanning undertaken for another reason. She denied fever, rigors, or pain, and was slightly overweight. She had a moderate alcohol intake but denied any other medical problems.



Investigations:



serum albumin                                     39 g/L (37–49)

serum total bilirubin                             17 μmol/L (1–22)

serum alanine aminotransferase            42 U/L (5–35)



serum alkaline phosphatase                  104 U/L (45–105)



serum C-reactive protein                      6 mg/L (< 10)



abdominal ultrasound                           gallstones in a thin walled gallbladder 



Which of the following most accurately re ects her prognosis over the next 10 years? 

A 50-year-old man underwent an abdominal ultrasound examination for upper abdominal pain. The report suggested that although the liver architecture was normal and the common bile duct of normal calibre, there was debris in the gallbladder and one large lesion adjacent to the gallbladder wall which may have been either a gallbladder stone or a polyp.



Which of the following statements about gallbladder polyps is most accurate? 

A 45-year-old man presented with severe sudden onset of epigastric pain associated with vomiting. He drank 38 units of alcohol a week and smoked 40 cigarettes a day.



Investigations at 24 hours:

white cell count                                 21 x 109/L (4.0–11.0)

serum urea                                       9 mmol/L (2.5–7.0)

serum calcium                                  1.8 mmol/L (2.20–2.60) 

serum albumin                                  34 g/L (37–49) 

serum alanine aminotransferase         84 U/L (5–35)



serum lactate dehydrogenase            450 U/L (10–250)



plasma glucose                                8 mmol/L (3.0–6.0) 

serum amylase                                1012 U/L (60–180) 

PO2                                                10.5 kPa (11.3–12.6) 

serum C-reactive protein                  120 mg/L (< 10) 



What is the Glasgow acute pancreatitis score for this patient