1. MRCS PART A: Upper GI surgery
Mr Bhaskar Kumar
Cons Upper GI Surgeon
Norfolk & Norwich NHS Trust

2. A 32 year old man presents to the acute surgical unit with acute pancreatitis. Over the next few days he becomes dyspnoeic and his saturations are 89% on air. A CXR shows bilateral pulmonary infiltrates. His CVP pressure is 16mmHg. What is the most likely diagnosis?
A. Cardiac failure
B. Pneumococcal pneumonia
C. Staphylococcal pneumonia
D. Pneumocystis carinii
E. Adult respiratory distress syndrome

3. Group Discussion Points:
What is the definition of ARDS ?
Defined as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia (PaO2/FiO2 ratio < 200) in the absence of evidence for cardiogenic pulmonary oedema (clinically or pulmonary capillary wedge pressure of less than 18 mm Hg).
What are the causes of ARDS ?
Causes
Sepsis
Direct lung injury
Trauma
Acute pancreatitis
Long bone fracture or multiple fractures (through fat embolism)
Head injury (causes sympathetic nervous stimulation which leads to acute pulmonary hypertension)

4. What is the management of ARDS ?
Treat the underlying cause
Antibiotics (if signs of sepsis)
Negative fluid balance i.e. Diuretics
Recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure
Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes may cause lung injury (only treatment found to improve survival rates)

5. A 63 year old man who smokes heavily presents with dyspepsia
A 63 year old man who smokes heavily presents with dyspepsia. He is tested and found to be positive for helicobacter pylori infection. One evening he has an episode of haematemesis and collapses. What is the most likely vessel to be responsible?
A. Portal vein
B. Short gastric arteries
C. Superior mesenteric artery
D. Gastroduodenal artery
E. None of the above

6. Group Discussion Points:
Applied anatomy of how posterior DU erodes gastroduodenal artery
H pylori and peptic ulcer disease
Endoscopic management of peptic ulcer bleed
Show endoscopic image of peptic ulcer etc.

7. Talks:
Applied anatomy of how posterior DU erodes gastroduodenal artery
H pylori and peptic ulcer disease
Endoscopic management of peptic ulcer bleed
Show endoscopic image of peptic ulcer etc.

8. Session Summary:
Topics covered:
Acute Pancreatitis
Surgical anatomy of peptic ulcer disease