Transjugular Intrahepatic Portosystemic Shunt — MCQs
The ideal muscle relaxant used for a neonate undergoing porto-enterostomy for biliary atresia is:
What condition is classified using the Milwaukee classification?
Reversal of shunt is not possible in natural history of?
How does 'hepatic vein thrombosis' present on Doppler ultrasound?
What is the best method to treat a large port-wine stain?
Which of the following is an indication of auxiliary partial orthotopic liver transplantation?
Post-hepatic portal hypertension is caused by?
All of the following are complications of cirrhosis, EXCEPT:
Identify the structure shown in CT abdomen section. (Recent NEET Pattern 2018-19)
A dense persistent nephrogram may be seen in all of the following except:
Transjugular Intrahepatic Portosystemic Shunt Indian Medical PG Practice Questions and MCQs
Question 1: The ideal muscle relaxant used for a neonate undergoing porto-enterostomy for biliary atresia is:
- A. Vecuronium
- B. Pancuronium
- C. Atracurium (Correct Answer)
- D. Rocuronium
Explanation: ***Atracurium*** - **Atracurium** undergoes **Hofmann elimination** and **ester hydrolysis**, making its elimination independent of renal or hepatic function. This characteristic is particularly beneficial in neonates, especially those with conditions like biliary atresia where hepatic function may be compromised. - Its **predictable duration of action** and minimal cardiovascular effects make it a safe choice for neonates with potentially unstable physiological systems. *Vecuronium* - **Vecuronium** is primarily metabolized by the **liver** and excreted through the bile and kidneys. - In neonates, especially those with **biliary atresia**, its clearance may be prolonged due to immature or compromised liver function, leading to a prolonged duration of action and potential accumulation. *Pancuronium* - **Pancuronium** is predominantly eliminated by the **kidneys** and, to a lesser extent, by hepatic metabolism. - Neonates have **immature renal function**, which can significantly prolong the elimination half-life of Pancuronium, making its use less predictable and increasing the risk of prolonged paralysis. *Rocuronium* - **Rocuronium** is primarily eliminated by the **liver** and partially cleared by the kidneys. - In neonates, its elimination can be **prolonged due to immature hepatic function**, leading to a longer duration of block and potential for accumulation, especially in cases of compromised liver function.
Question 2: What condition is classified using the Milwaukee classification?
- A. Sphincter of Oddi dysfunction (Correct Answer)
- B. Pancreaticobiliary duct junction abnormalities
- C. Pancreatitis due to sphincter dysfunction
- D. Chronic pancreatitis due to sphincter dysfunction
Explanation: ***Sphincter of Oddi dysfunction*** - The **Milwaukee classification** is specifically used to categorize **sphincter of Oddi dysfunction (SOD)** into different types based on clinical, laboratory, and manometric findings. - This classification helps in guiding treatment decisions and predicting outcomes for patients with SOD [1]. *Pancreaticobiliary duct junction abnormalities* - These are **structural anomalies** of the junction between the pancreatic and bile ducts, not directly classified by the Milwaukee system. - While they can lead to symptoms similar to SOD, their diagnosis relies on imaging rather than the criteria used in the Milwaukee classification. *Pancreatitis due to sphincter dysfunction* - This describes a potential **consequence** of sphincter of Oddi dysfunction, particularly Type I and Type II SOD, but it is not the condition itself that the Milwaukee classification categorizes [1]. - The classification assesses the dysfunction of the sphincter, which *can* lead to pancreatitis, but the pancreatitis itself is a complication. *Chronic pancreatitis due to sphincter dysfunction* - This is a **long-term outcome** or complication that can arise from sustained sphincter of Oddi dysfunction. - The Milwaukee classification is used to define the nature of the sphincter dysfunction, not the resulting chronic pancreatitis itself.
Question 3: Reversal of shunt is not possible in natural history of?
- A. TOF (Correct Answer)
- B. PDA
- C. VSD
- D. ASD
Explanation: ***TOF*** - In **Tetralogy of Fallot (TOF)**, the shunt is typically right-to-left from birth due to **pulmonary stenosis** and a large **VSD** [1]. - This fixed **right-to-left shunt** means that reversal to a left-to-right shunt does not occur naturally [1]. *PDA* - A **patent ductus arteriosus (PDA)** typically features an initial **left-to-right shunt**. - However, if **pulmonary hypertension** develops, the shunt can reverse to become **right-to-left** (Eisenmenger syndrome), meaning reversal *is* possible. *VSD* - A **ventricular septal defect (VSD)** initially presents with a **left-to-right shunt** [2]. - Prolonged systemic-level pressures in the pulmonary arteries can lead to **pulmonary vascular disease** and eventual shunt reversal to **right-to-left** (Eisenmenger syndrome) [2]. *ASD* - An **atrial septal defect (ASD)** typically causes an initial **left-to-right shunt**. - Over time, significant **pulmonary hypertension** can develop, leading to shunt reversal to **right-to-left** (Eisenmenger syndrome), indicating reversal is possible.
Question 4: How does 'hepatic vein thrombosis' present on Doppler ultrasound?
- A. Absent or reversed flow (Correct Answer)
- B. Anechoic appearance
- C. Increased flow
- D. Normal triphasic flow
Explanation: ***Absent or reversed flow*** - **Hepatic vein thrombosis** directly obstructs blood flow, leading to either an absence of detectable flow or, in some cases, reversal of flow due to high downstream pressure and collateral formation. - This finding on **Doppler ultrasound** is a key indicator of **Budd-Chiari syndrome**, caused by the obstruction of hepatic venous outflow. *Anechoic appearance* - An **anechoic appearance** on ultrasound typically refers to a fluid-filled structure, such as a cyst or gallbladder, which allows sound waves to pass through without reflection. - While thrombosis can affect the lumen of a vessel, the thrombus itself often has some echogenicity, and the primary Doppler finding relates to flow dynamics, not simply the anechoic nature of the vessel. *Increased flow* - **Increased flow** in the hepatic veins would suggest a hyperdynamic state or shunting, which is not characteristic of venous thrombosis. - Thrombosis causes obstruction, leading to a reduction or cessation of flow, not an increase. *Normal triphasic flow* - **Normal triphasic flow** in the hepatic veins is characterized by three distinct phases corresponding to cardiac cycles: antegrade flow during systole and diastole, and a brief period of reversed flow during atrial contraction. - The presence of thrombosis would disrupt this normal pattern, making it an unlikely finding in **hepatic vein thrombosis**.
Question 5: What is the best method to treat a large port-wine stain?
- A. Radiotherapy
- B. Excision with skin grafting
- C. Pulsed dye laser (Correct Answer)
- D. Tattooing
Explanation: ***Pulsed dye laser*** - The **pulsed dye laser (PDL)** is considered the **gold standard** for treating port-wine stains due to its specific targeting of hemoglobin in the dilated capillaries without damaging surrounding tissue. - This treatment involves multiple sessions to progressively lighten the stain and prevent complications such as **nodularity** and **tissue hypertrophy**. *Radiotherapy* - **Radiotherapy** is generally not recommended for port-wine stains due to its potential for **scarring**, **pigment changes**, and risk of **malignancy**. - It is an aggressive treatment typically reserved for **cancerous conditions** or severe proliferative vascular lesions not amenable to other treatments. *Tattooing* - **Tattooing** involves injecting skin-colored pigments into the lesion to camouflage it, but it does not treat the underlying vascular abnormality. - This method can result in an **artificial appearance**, **uneven coverage**, and potential for **allergic reactions** or infections. *Excision with skin grafting* - **Surgical excision** of a large port-wine stain would result in a **significant scar** and require **skin grafting**, which carries risks of graft failure, poor aesthetic outcome, and color mismatch. - This method is generally reserved for very small, localized lesions or those with significant **nodular hypertrophy** that cannot be effectively managed by laser therapy.
Question 6: Which of the following is an indication of auxiliary partial orthotopic liver transplantation?
- A. As a standby procedure till a suitable donor is found
- B. Metabolic liver disease (Correct Answer)
- C. Drug induced hepatic failure
- D. All irreversible causes of fulminant liver failure
Explanation: ***Metabolic liver disease*** - **Auxiliary partial orthotopic liver transplantation (APOLT)** is indicated for metabolic liver diseases to provide the necessary enzyme or protein function while potentially allowing the native liver to regenerate. - This procedure involves transplanting a portion of a healthy liver and leaving a portion of the diseased native liver in place. This is especially useful in conditions like **Crigler-Najjar syndrome** or **urea cycle disorders**. *As a standby procedure till a suitable donor is found* - While temporary support can be crucial in acute liver failure, APOLT is a complex surgical procedure, not a simple standby. - **Bridge to transplant** often involves less invasive measures like extracorporeal liver assist devices rather than a partial transplant. *Drug induced hepatic failure* - Drug-induced hepatic failure, if reversible, typically managed with supportive care, and the native liver may recover. - While severe cases might require transplantation, APOLT is generally reserved for conditions requiring ongoing metabolic support where the native liver may eventually recover some function. *All irreversible causes of fulminant liver failure* - For irreversible **fulminant liver failure**, a **full orthotopic liver transplantation** is usually required because the entire native liver needs to be replaced due to extensive and irreversible damage. - APOLT aims to allow the native liver to recover, which is unlikely in cases of irreversible fulminant failure, making a complete replacement necessary.
Question 7: Post-hepatic portal hypertension is caused by?
- A. Congenital hepatic fibrosis
- B. Banti Syndrome
- C. Portal vein thrombosis
- D. Budd-Chiari Syndrome (Correct Answer)
Explanation: ***Budd-Chiari Syndrome*** - **Budd-Chiari Syndrome** is characterized by obstruction of the **hepatic veins** or **inferior vena cava**, leading to blood backing up into the liver and causing **post-hepatic portal hypertension** [1]. - This obstruction prevents proper blood outflow from the liver, increasing pressure in the **hepatic sinusoids** and consequently the **portal venous system** [1]. *Congenital hepatic fibrosis* - This is a **pre-sinusoidal cause** of portal hypertension, often associated with developmental abnormalities of the **bile ducts**. - It leads to increased resistance to blood flow within the **portal tracts** before the sinusoids. *Banti Syndrome* - **Banti Syndrome** is an older term for **splenomegaly** with associated **pancytopenia** and **portal hypertension**, primarily caused by splenic vein thrombosis or increased splenic blood flow. - While it involves portal hypertension, the primary site of obstruction is typically **pre-hepatic** or **intra-hepatic sinusoidal**, not post-hepatic. *Portal vein thrombosis* - **Portal vein thrombosis** causes **pre-hepatic portal hypertension** due to obstruction of the **portal vein** before it enters the liver [2]. - This blockage prevents normal blood flow into the liver, increasing pressure in the **splenic** and **mesenteric venous systems**.
Question 8: All of the following are complications of cirrhosis, EXCEPT:
- A. Spontaneous bacterial peritonitis
- B. Portal hypertension
- C. Hepatic encephalopathy
- D. Hypercalcemia (Correct Answer)
Explanation: ***Hypercalcemia*** - While liver disease can lead to **metabolic derangements**, severe hypercalcemia is not a direct or typical complication of **cirrhosis** itself. - Causes of hypercalcemia are usually related to **parathyroid dysfunction**, **malignancy**, or specific drug effects. *Spontaneous bacterial peritonitis* - This is a common and serious infection of the **ascitic fluid** that occurs in patients with cirrhosis, often without an obvious source of infection. - It is a direct consequence of impaired immune function and bacterial translocation in **advanced liver disease**. *Portal hypertension* - This condition is a hallmark of cirrhosis, resulting from increased resistance to blood flow through the fibrotic liver [1]. - It leads to many other complications such as **ascites**, **esophageal varices**, and **splenomegaly** [1]. *Hepatic encephalopathy* - This is a neuropsychiatric syndrome caused by the accumulation of toxins normally cleared by the liver, such as **ammonia**, in the systemic circulation [1]. - It is a significant complication of **cirrhosis** and often indicates advanced liver failure [1].
Question 9: Identify the structure shown in CT abdomen section. (Recent NEET Pattern 2018-19)
- A. Inferior vena cava
- B. Portal vein (Correct Answer)
- C. Splenic vein
- D. Superior mesenteric vein
Explanation: ***Portal vein*** - The arrow points to a vessel receiving blood from the splenic and superior mesenteric veins, which is characteristic of the **portal vein** entering the **liver parenchyma**. - The portal vein is typically seen anterior to the **inferior vena cava** and posterior to the **common hepatic artery** at this level. *Inferior vena cava* - The **inferior vena cava (IVC)** is a large, retroperitoneal vessel located posterior to the liver and to the right of the aorta. - The structure indicated by the arrow is clearly within the liver substance, not in the typical position of the IVC. *Splenic vein* - The **splenic vein** runs horizontally behind the body of the pancreas and joins with the superior mesenteric vein to form the portal vein. - The vessel shown is within the liver, distal to the formation of the portal vein. *Superior mesenteric vein* - The **superior mesenteric vein (SMV)** typically runs vertically in the mesentery and joins the splenic vein to form the portal vein. - The indicated structure is within the liver hilum, not in the anatomical location of the SMV.
Question 10: A dense persistent nephrogram may be seen in all of the following except:
- A. Severe hydronephrosis
- B. Dehydration
- C. Acute ureteral obstruction
- D. Systemic hypertension (Correct Answer)
Explanation: ***Systemic hypertension*** - **Systemic hypertension** is not typically associated with a dense, persistent nephrogram on imaging. While chronic hypertension can cause renal damage, it does not directly lead to the characteristic prolonged parenchymal enhancement. - A dense, persistent nephrogram suggests impaired contrast excretion or increased reabsorption, neither of which is a primary manifestation of systemic hypertension itself. *Severe hydronephrosis* - **Severe hydronephrosis** leads to impaired urine flow and delayed transit of contrast medium through the renal tubules, resulting in a persistent nephrogram. - The dilated collecting system and compressed parenchyma can retain contrast for an extended period due to reduced glomerular filtration rate (GFR) in the affected kidney. *Dehydration* - In cases of **dehydration**, the kidneys attempt to conserve water, leading to increased reabsorption of water from the renal tubules. - This process can concentrate the contrast medium within the tubules, resulting in a denser and more persistent nephrogram as it slowly transits through the kidney. *Acute ureteral obstruction* - **Acute ureteral obstruction** causes a build-up of pressure within the renal collecting system, impairing glomerular filtration and slowing the passage of contrast. - The contrast medium remains within the renal parenchyma for a prolonged period due to the blockage, leading to a dense and persistent nephrogram and delayed excretion.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free