Upper GI & Hepatobiliary Surgery

A gallstone impacts persistently at the cystic duct, so unlike transient biliary colic the gallbladder wall distends, becomes ischaemic and secondarily infected, producing continuous pain, fever and a positive Murphy's sign.

A stone or stricture obstructing the common bile duct lets bacteria ascend and multiply in stagnant, pressurised bile, producing a life-threatening triad of obstruction and infection that demands urgent drainage, not antibiotics alone.

Cholesterol or pigment stones form in a supersaturated gallbladder, and pain occurs only when a stone transiently obstructs the cystic duct against a contracting gallbladder: no sustained obstruction, no inflammation, no pain.

Chronic Helicobacter pylori infection drives atrophic gastritis and intestinal metaplasia, and it is this field of pre-malignant change accumulating over years (not a single event) that eventually gives rise to adenocarcinoma, which is why early disease is silent and presentation is often late.

Widening of the diaphragmatic oesophageal hiatus lets part of the stomach migrate into the thorax, and whether it drags the gastro-oesophageal junction upward with it (sliding, disrupting the reflux barrier) or herniates alongside a normally sited junction (rolling, risking obstruction and strangulation) determines both the symptoms and the urgency.

Squamous cell carcinoma arises from chronic mucosal irritation of the upper/mid oesophagus, while adenocarcinoma arises from Barrett's metaplasia driven by chronic acid reflux in the lower oesophagus, and both narrow the lumen from within to produce progressive dysphagia, solids before liquids.