Mirizzi syndrome, all are true except -Gallstone ulcerating into common ductImpacted in cystic ductSevere pericholecystic inflammationObsturctive jaundiceAns: None > CSolution:Ans. is None > 'c' i.e., None > Severe pericholecystic inflammation * Options A, B, D are definitely true.* One can also expect pericholecystic inflammation if the stone ulcerates in Mirizzi SyndromeMirizzi syndrome'common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann's pouch of the gallbladder'Type I mirizzi syndromeType II mirizzi syndromeAn impacted stone in the gallbladder infundibulum or cystic duct can compress the bile duct, usually at the level of the common hepatic duct.A stone can erode from the gallbladder or cystic duct into the common hepatic duct, resulting in a cholecystochole- dochal fistula.ClinicalPatients are seen with symptoms of acute cholecystitis but with the additional finding of hyperbilirubinemia and elevated alkaline phosphatase.ManagementLaproscopic approach is not recommended as it results in high conversion rate and high complication rates.Open cholecystectomy is the gold standard for treatment when this condition is identified preoperatively.In the acute setting, the biliary obstruction often resolves after cholecystectomy and resolution of the inflammatory process.If inflammation has obliterated the triangle of Calot, a partial cholecystectomy with removal of any stones may be all that is possible and usually resolves the condition.Best initial test for achalasia cardia -
High-Yield Explanation
Ans. is 'd' i.e., Barium swallow Diagnosis of achalasia* Chest x-ray - shows absence of gastric air bubble, an air-fluid level in the mediastinum in the upright position representing retained food in oesophagus.* Barium swallow - shows dilated esophagus with tapering narrowing in the terminal end of esophagus described as 'birds' beak' appearance. Fluoroscopy shows loss of normal peristalsis in the lower two thirds of esophagus.* Endoscopy may be done to rule out any secondary cause of achlasia eg. carcinoma, stricture at LES.* Manometry It's the most confrmatory investigation. It is able to distinguish between various forms of motor disorders of esophagus manometric characteristics of Achlasia# Incomplete lower esophageal sphincter relaxation (< 75% relaxation)# Elevated LES pressure# Loss of primary peristaltic waves in the esophageal body, but disorganized muscular activity may be present.# Increased intraesophageal baseline pressure relative to gastric baseline.* Cholecystokinin (CCK) which normally causes a fall in the sphincter pressure, paradoxically causes contraction of the LES (the CCK test). This paradoxical response occurs because, in achlasia the neurally transmitted inhibitory effect of CCK is absent owing to the loss of inhibitory neurons.