Hepatobiliary Surgery Practice Questions

Q: Which of the following is the classical triad of acute cholangitis?

Pain, jaundice, fever. ***Correct: Pain, jaundice, fever*** - This is **Charcot's triad**, the classical presentation of acute cholangitis - Represents the three cardinal clinical features: **RUQ abdominal pain**, **jaundice** (from biliary obstruction), and **fever with rigors** (from ascending infection) - Acute cholangitis is a bacterial infection of the bile ducts, typically occurring due to biliary obstruction (most commonly from choledocholithiasis) - When hypotension and altered mental status are added to Charcot's triad, it becomes **Reynolds pentad** (indicating severe/suppurative cholangitis) *Incorrect: Pain, ↑ WBC, ↑ Bilirubin* - While these findings may be present in acute cholangitis, this is not the classical **clinical triad** - Laboratory findings are supportive but not part of the classical triad definition *Incorrect: Fever, jaundice, ↑ WBC* - Missing the key clinical feature of **RUQ pain** - Includes laboratory finding (↑ WBC) rather than clinical presentation *Incorrect: Pain, jaundice, shock* - This combination represents part of **Reynolds pentad** but is missing fever - Reynolds pentad = Charcot's triad + hypotension + altered mental status - Not the classical triad being asked in the question

Q: A 55-year-old diabetic male develops sudden-onset severe abdominal pain 3 days after an uncomplicated laparoscopic cholecystectomy. Examination reveals peritonitis with guarding and rigidity. Abdominal X-ray shows free air under the diaphragm. What is the most likely diagnosis?

Duodenal perforation. ***Duodenal perforation*** - The combination of **sudden, severe peritonitis** (guarding and rigidity) and **free air under the diaphragm** 3 days post-surgery is pathognomonic for a **perforated hollow viscus**. - Iatrogenic injury to adjacent structures, particularly the **duodenum** (first part is near the gallbladder bed), is a recognized complication during laparoscopic cholecystectomy that can lead to delayed presentation of perforation. - **Free intraperitoneal air** on X-ray confirms hollow organ perforation and mandates urgent surgical exploration. *Bile duct injury with bile peritonitis* - Bile leaks (e.g., from the cystic duct stump or duct of Luschka) cause **bile peritonitis**, resulting in inflammatory pain and signs of peritonitis, but they **do not introduce gas** into the peritoneal cavity. - Diagnosis is typically confirmed by high drainage fluid bilirubin or HIDA scan, and **free air under the diaphragm is characteristically absent**. - The presence of pneumoperitoneum rules this out as the primary diagnosis. *Normal post-laparoscopic pneumoperitoneum* - Residual CO₂ from laparoscopic insufflation can persist for 24-48 hours post-operatively, but it is typically **asymptomatic** and resolves spontaneously. - The presence of **acute peritonitis with guarding and rigidity** 3 days post-surgery indicates a surgical emergency, not benign residual gas. - The clinical picture of sepsis and acute abdomen distinguishes this from normal postoperative pneumoperitoneum. *Retained gallstone causing obstruction* - A retained stone in the common bile duct typically causes symptoms of **biliary colic**, **obstructive jaundice**, or **cholangitis** (Charcot's triad: fever, jaundice, right upper quadrant pain). - Although it can cause pain, a retained stone does not cause acute generalized peritonitis with **free air** under the diaphragm, as it does not breach the integrity of hollow viscera.

Q: Identify the instrument in the image:

Langenbeck retractor. ***Langenbeck retractor*** - The image clearly displays a **Langenbeck retractor**, characterized by its **L-shaped blade** and often a slight curve in the handle. - This instrument is a **small, handheld retractor** commonly used for retracting skin, subcutaneous tissue, or muscle in various surgical procedures, particularly in general surgery and orthopedics.

Q: A splenorenal shunt procedure may be required for treatment of:

Bleeding esophageal varices. ***Bleeding esophageal varices*** - A **splenorenal shunt** (Warren shunt) creates an anastomosis between the **splenic vein** and **left renal vein**, effectively decompressing the **portal venous system** and reducing pressure in esophageal varices. - This procedure is specifically indicated for **portal hypertension** with recurrent variceal bleeding that is refractory to medical management and endoscopic interventions. *Mesenteric ischemia* - Mesenteric ischemia results from **inadequate arterial blood supply** to the bowel, typically due to **atherosclerotic disease** or **embolic occlusion** of mesenteric arteries. - Treatment involves **arterial revascularization** procedures like bypass grafting or angioplasty, not portal venous shunting. *Injury to tail of pancreas* - Pancreatic tail injuries are managed with **distal pancreatectomy** with or without splenectomy, depending on the extent of ductal involvement and tissue viability. - This condition requires **direct surgical repair** of the injured pancreatic tissue, not modification of portal venous drainage. *Liver laceration* - Liver lacerations are treated based on hemodynamic stability with **conservative management**, **surgical repair**, or **angiographic embolization** for active bleeding. - Management focuses on **controlling hemorrhage** and preserving hepatic function, not altering portal venous flow patterns.

Q: A 20-year-old patient presents with fever and tenderness in RUQ. CT abdomen shows a lesion measuring 10 cm × 4 cm. Which is the preferred site for aspiration?

6th intercostal space, midaxillary line. ***6th intercostal space, midaxillary line*** - This approach minimizes the risk of injuring the **pleural cavity** or traversing uninvolved liver parenchyma, as the liver often extends up to this point in the midaxillary line. - The 6th intercostal space in the midaxillary line is typically **above the diaphragm** and offers direct access to the superior aspect of the liver, providing a safe window for percutaneous drainage of a liver abscess. *USG guided from front* - A frontal approach increases the risk of traversing the **peritoneal cavity** and bowel loops, potentially leading to contamination or bowel injury. - While **ultrasound guidance** is crucial, the specific entry site from the front may be less safe due to intervening structures. *6th intercostal space, midclavicular line* - This site is often too anterior and higher, increasing the risk of puncturing the **lung parenchyma** or traversing significant portions of healthy liver. - The liver edge is typically lower at the midclavicular line compared to the midaxillary line, making a 6th intercostal space puncture in this location more likely to hit the lung. *8th intercostal space, midaxillary line* - The 8th intercostal space in the midaxillary line is typically **below the diaphragm**, making it a less optimal entry point for a superior liver lesion. - This approach may risk damaging the **diaphragm** or traversing the base of the lung and pleural space, which is still quite close at this level.

Q: Which classification is used to evaluate the condition shown in the image below?

Todani classification. ***Todani classification*** - The image provided shows an **ERCP (Endoscopic Retrograde Cholangiopancreatography)** with contrast in the biliary tree, demonstrating a dilated common bile duct (CBD) marked with an arrow. This appearance is characteristic of a **choledochal cyst**. - The **Todani classification** is a widely used system for categorizing choledochal cysts, which are congenital dilations of the biliary tree. *Bismuth classification* - The Bismuth classification is used to categorize **cholangiocarcinomas** (cancers of the bile ducts), particularly those affecting the hepatic confluence (Klatskin tumors). - It describes the extent of involvement of the hepatic duct bifurcation, which is distinct from the diffuse or localized dilations seen in choledochal cysts. *Johnson classification* - The Johnson classification is used for categorizing **duodenal ulcers**, specifically related to their location within the duodenum (e.g., gastric acid hypersecretion vs. normal acid production). - This classification is entirely unrelated to biliary tree pathologies. *Maastricht classification* - The Maastricht classification is used for grading **hepatic encephalopathy**, which is a neuropsychiatric complication of liver failure. - It describes the severity of neurological symptoms in patients with liver disease and has no relevance to imaging findings of biliary anomalies.

Q: A patient with chronic cholelithiasis develops the complication shown in the image below. This leads to development of:

Bouveret syndrome. ***Bouveret syndrome*** - The image shows gallstones in the gallbladder (GB) moving into the duodenum through a **cholecystoenteric fistula**, specifically into the stomach and duodenum, which is the mechanism leading to **Bouveret syndrome** [3]. - **Bouveret syndrome** is a rare form of gastric outlet obstruction caused by a large gallstone eroding through the gallbladder wall into the duodenum or stomach [3]. *Emphysematous cholecystitis* - This condition is characterized by the presence of **gas in the gallbladder wall or lumen** due to infection by gas-forming organisms, which is not depicted in the image. - It's a severe form of acute cholecystitis, often seen in diabetics or immunocompromised patients, and does not involve stone migration into the gut as shown. *Cholesterolosis* - **Cholesterolosis** (also known as "strawberry gallbladder") is a benign condition characterized by an accumulation of cholesterol esters in the macrophages of the gallbladder wall. - It does not involve the migration of gallstones into the gastrointestinal tract or the formation of fistulas and is not represented by the stones shown entering the duodenum. *Carcinoma of gallbladder* - **Gallbladder carcinoma** is a malignant tumor arising from the epithelial lining of the gallbladder [1]. - While chronic gallstones can be a risk factor for gallbladder cancer, the image specifically illustrates a mechanical complication of gallstone migration, not a neoplastic process [1][2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 886. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 883-884. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 404-405.

Q: What type of choledochal cyst is shown in the image?

2. ***2*** - The image displays a **diverticulum** protruding from the side of the **common bile duct (CBD)**, which is characteristic of a **Type II choledochal cyst**. - Type II choledochal cysts are rare, focal diverticula of the CBD, typically managed by excision. *1* - Type I choledochal cysts involve **fusiform or cystic dilation** of the extrahepatic bile duct, not a diverticulum protruding from the side. - They are the most common type and are usually treated with cyst excision and Roux-en-Y hepaticojejunostomy. *3* - Type III choledochal cysts, also known as **choledochoceles**, involve **dilation of the intraduodenal portion** of the CBD. - This typically appears as an intraduodenal cyst, which is not depicted in the image. *4* - Type IV choledochal cysts involve **multiple dilations** of the intrahepatic and/or extrahepatic bile ducts. - The image shows a single diverticular outpouching, not multiple dilations.

Q: The image shows: (DNB Pattern 2018)

Postoperative T- Tube cholangiogram. ***Postoperative T- Tube cholangiogram*** - This image clearly shows a **T-tube** in place, which is typically inserted into the **common bile duct** during surgery to allow for drainage and subsequent imaging of the biliary tree. - The contrast material delineates the bile ducts, consistent with a **postoperative cholangiogram** performed via the T-tube to check for patency and stones. *ERCP* - **ERCP (Endoscopic Retrograde Cholangiopancreatography)** involves passing an endoscope down the throat and introducing contrast into the bile ducts via the papilla of Vater, but it does not involve an external T-tube. - The image lacks the characteristic endoscopic view or equipment associated with ERCP performed from within the gastrointestinal tract. *HIDA scan* - A **HIDA scan** (Hepatobiliary Iminodiacetic Acid scan) is a nuclear medicine study that uses a radioactive tracer to evaluate gallbladder function and bile duct patency. - The image shown is a contrast-filled X-ray radiograph, not a nuclear medicine scan, which would typically show radioactivity uptake and excretion over time. *Oral cholecystography* - **Oral cholecystography** involves taking oral contrast tablets that are absorbed and concentrated by the liver, then excreted into the bile and stored in the gallbladder. - This method visualizes the gallbladder and bile ducts but does not involve an external T-tube or direct injection into the biliary system as seen in the image.

Question 1

Which of the following is the classical triad of acute cholangitis?

Accepted Answer

Pain, jaundice, fever

Answer

Pain, $\uparrow$ WBC, $\uparrow$ Bilirubin

Answer

Fever, jaundice, $\uparrow$ WBC

Answer

Pain, jaundice, shock

Question 2

A 55-year-old diabetic male develops sudden-onset severe abdominal pain 3 days after an uncomplicated laparoscopic cholecystectomy. Examination reveals peritonitis with guarding and rigidity. Abdominal X-ray shows free air under the diaphragm. What is the most likely diagnosis?

Accepted Answer

Duodenal perforation

Answer

Normal post-laparoscopic pneumoperitoneum

Answer

Retained gallstone causing obstruction

Answer

Bile duct injury with bile peritonitis

Question 3

Identify the instrument in the image:

Accepted Answer

Langenbeck retractor

Answer

Deaver retractor

Answer

Army-Navy retractor

Answer

Richardson retractor

Question 4

A splenorenal shunt procedure may be required for treatment of:

Accepted Answer

Bleeding esophageal varices

Answer

Mesenteric ischemia

Answer

Injury to tail of pancreas

Answer

Liver laceration

Question 5

A 25-year-old shepherd presents with dragging discomfort in right hypochondrium and on examination shows presence of enlarged liver 5 cm below costal margins. The probable diagnosis is:

Accepted Answer

Hydatid cyst

Answer

Amoebic liver abscess

Answer

Pyogenic liver abscess

Answer

Hepatic adenoma

Question 6

A 20-year-old patient presents with fever and tenderness in RUQ. CT abdomen shows a lesion measuring 10 cm × 4 cm. Which is the preferred site for aspiration?

Accepted Answer

6th intercostal space, midaxillary line

Answer

USG guided from front

Answer

6th intercostal space, midclavicular line

Answer

8th intercostal space, midaxillary line

Question 7

Which classification is used to evaluate the condition shown in the image below?

Accepted Answer

Todani classification

Answer

Bismuth classification

Answer

Johnson classification

Answer

Maastricht classification

Question 8

A patient with chronic cholelithiasis develops the complication shown in the image below. This leads to development of:

Accepted Answer

Bouveret syndrome

Answer

Emphysematous cholecystitis

Answer

Cholesterolosis

Answer

Carcinoma of gallbladder

Question 9

What type of choledochal cyst is shown in the image?

Accepted Answer

2

Answer

1

Answer

3

Answer

4

Question 10

The image shows: (DNB Pattern 2018)

Accepted Answer

Postoperative T- Tube cholangiogram

Answer

ERCP

Answer

HIDA scan

Answer

Oral cholecystography

Hepatobiliary Surgery — MCQs

Hepatobiliary Surgery — MCQs

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