(a) A 40 year old lady came to casualty with pain in the right upper abdomen associated with vomitings for 5 days. On…

(a)(i) Diagnosis and management

Diagnosis: acute calculous cholecystitis (Tokyo Guidelines 2018: local signs of right hypochondrial pain and tenderness or Murphy’s sign, systemic signs, and ultrasound showing a thick wall, gallstones and pericholecystic fluid). Grade by severity (I mild, II moderate, III with organ dysfunction).

Management:

• Admit, nil by mouth, IV fluids, analgesics (NSAIDs, opioids), antiemetics, nasogastric tube if vomiting persists.
• IV antibiotics (ceftriaxone with metronidazole, or piperacillin-tazobactam for severe disease).
• Investigations: CBC, LFT, amylase or lipase, blood culture, renal function, and MRCP if bilirubin or ductal dilatation suggests a CBD stone (then ERCP clearance).
• Laparoscopic cholecystectomy is definitive: early (ideally within 72 hours, and even later in experienced hands) for grade I-II, or interval cholecystectomy after 6-8 weeks if inflammation is advanced.
• High-risk or grade III patients: percutaneous cholecystostomy, then delayed surgery. Histopathology of the specimen.

(a)(ii) Complications of gallstones

1. In the gallbladder: biliary colic, acute and chronic cholecystitis, mucocele, empyema, gangrene and perforation, porcelain gallbladder, carcinoma gallbladder.
2. In the bile ducts: choledocholithiasis with obstructive jaundice, acute cholangitis, Mirizzi syndrome, secondary biliary cirrhosis.
3. Pancreas: acute gallstone pancreatitis.
4. Fistula: cholecystoduodenal or cholecystocolic fistula, gallstone ileus, Bouveret syndrome (gastric outlet obstruction).
5. Peritoneal: pericholecystic abscess, bile peritonitis.

(a)(iii) Mirizzi syndrome

Definition: obstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmann’s pouch, by external compression or by erosion into the duct, causing obstructive jaundice.

Csendes classification:

• Type I: external compression of the common hepatic duct.
• Type II: cholecystobiliary fistula involving under one-third of the duct circumference.
• Type III: fistula involving up to two-thirds.
• Type IV: complete destruction of the duct wall.
• Type V: any of the above with a cholecystoenteric fistula (Vb with gallstone ileus).

Investigation:

• LFT: raised bilirubin and alkaline phosphatase.
• Ultrasound: contracted gallbladder with impacted stone, dilated ducts above the stone, normal CBD below.
• MRCP is the investigation of choice, ERCP for diagnosis with stenting of the duct, CT to exclude carcinoma gallbladder (associated).

Management (open or experienced laparoscopic surgery):

• Type I: cholecystectomy, usually subtotal (fundus-first).
• Type II: subtotal cholecystectomy with repair of the fistula using the gallbladder remnant, T-tube.
• Type III: choledochoplasty with a gallbladder flap or bilioenteric anastomosis.
• Type IV: Roux-en-Y hepaticojejunostomy.
• Type V: in addition, closure of the enteric fistula and enterolithotomy for gallstone ileus.
• Preoperative ERCP stenting reduces bile duct injury.

(b)(i) Total body iron

About 3-5 g (around 4 g in an adult man, 2.5-3 g in a woman). Nearly two-thirds is in haemoglobin, about a quarter stored as ferritin and haemosiderin (liver, marrow, spleen), and the rest in myoglobin, enzymes and transferrin. About 20-25 mg is recycled daily from old red cells.

(b)(ii) Functions of iron

1. Oxygen transport (haemoglobin) and storage in muscle (myoglobin).
2. Electron transport and ATP generation (cytochromes, iron-sulphur proteins).
3. Enzymes: catalase, peroxidase, cytochrome P450 (drug metabolism).
4. DNA synthesis and cell division (ribonucleotide reductase).
5. Brain development, neurotransmitter synthesis and cognition.
6. Immunity: lymphocyte proliferation and killing of microbes.

(b)(iii) Anaemia Mukt Bharat interventions

Launched in 2018 under POSHAN Abhiyaan with a 6x6x6 strategy, aiming at a 3 percentage point fall in anaemia every year.

Six target groups: children 6-59 months, children 5-9 years, adolescents 10-19 years, women of reproductive age, pregnant women and lactating mothers.

Six interventions:

1. Prophylactic iron-folic acid: biweekly syrup (6-59 months), weekly pink tablet (5-9 years), weekly blue tablet (adolescents), weekly red tablet (women), daily IFA for 180 days in pregnancy and 180 days postpartum.
2. Biannual deworming with albendazole (National Deworming Day).
3. Intensified year-round behaviour change communication, including delayed cord clamping and iron-rich diet.
4. Testing with digital haemoglobinometers and treatment (Test, Treat and Talk).
5. Mandatory use of iron-fortified foods (rice, wheat flour, salt) in government programmes.
6. Addressing non-nutritional causes in endemic pockets: malaria, haemoglobinopathies, fluorosis.

(c)(i) Current consensus on HRT

• Indication: the most effective treatment for moderate to severe vasomotor symptoms and for prevention of bone loss in women at risk of fracture.
• Window of opportunity: in women under 60 or within 10 years of menopause without contraindications, benefits outweigh risks. Starting after 60 or 10 years carries higher coronary, stroke, VTE and dementia risk.
• Regimen: oestrogen alone after hysterectomy, oestrogen with progestogen (or micronised progesterone, LNG-IUS) if the uterus is intact. Transdermal route preferred where VTE risk exists.
• Individualised dose and duration with yearly review, no fixed stopping age if benefits continue.
• Local vaginal oestrogen for genitourinary syndrome of menopause.
• Not to be used for prevention of heart disease or dementia.
• Contraindications: breast or endometrial cancer, VTE, active coronary disease or stroke, active liver disease, undiagnosed vaginal bleeding.
• Premature ovarian insufficiency: HRT until the natural age of menopause.
• In 2025 the US FDA removed most boxed warnings on menopausal hormone therapy, reflecting this age-based view.

(c)(ii) Merits and demerits

Merits: relief of hot flushes, night sweats and sleep disturbance, prevention of osteoporosis and fractures, relief of vaginal dryness and urinary symptoms, better mood and quality of life, lower colorectal cancer risk.

Demerits: VTE and stroke (mainly oral), small rise in breast cancer risk with combined therapy beyond 5 years, endometrial cancer with unopposed oestrogen, gallbladder disease, breakthrough bleeding, breast tenderness, need for follow-up.