Hepatobiliary Surgery Practice Questions

Q: The following image shows: (DNB Pattern 2018)

ERCP. ***ERCP*** - The image shows a **cannula** within the **bile duct**, indicating the injection of contrast medium directly into the biliary tree via the **ampulla of Vater** during an endoscopic procedure. - The presence of the endoscope clearly visible alongside the opacified bile ducts confirms that this is an **Endoscopic Retrograde Cholangiopancreatography (ERCP)**. *Percutaneous cholangiography* - This procedure involves inserting a needle directly through the skin and liver into a bile duct to inject contrast. - There is no visible **endoscope** or evidence of a **transhepatic** approach in the image. *Oral cholecystography* - This is an older, non-invasive method where oral contrast agents are absorbed and concentrated in the gallbladder. - The image clearly displays the **ductal system** and an **endoscope**, which are not typical features of oral cholecystography. *T-Tube cholangiogram* - A T-tube cholangiogram is performed through a surgically placed **T-tube drain** in the common bile duct, usually post-cholecystectomy. - The image does not show a T-tube in place; instead, it shows an **endoscopic instrument** at the ampulla.

Q: A 35-year-old shepherd presents with painless enlarged liver. CT abdomen shows presence of:

Hydatid cyst. ***Hydatid cyst*** - The patient's profession as a **shepherd** points towards exposure to dogs, which are primary hosts for *Echinococcus granulosus*, the parasite causing hydatid disease. - The CT scan shows a large, **multiloculated cystic lesion** in the liver, often referred to as "daughter cysts" or "water lily sign" due to undulating membranes within a mother cyst, characteristic of a hydatid cyst. *Amoebic liver abscess* - An amoebic liver abscess is typically a **solitary lesion**, often with a thick, enhancing rim. - It's usually associated with a history of travel to **endemic areas** and symptoms like fever, right upper quadrant pain, and elevated inflammatory markers. *Pyogenic liver abscess* - Pyogenic abscesses often present with **fever, chills, and right upper quadrant pain**, which are absent in this case. - They can be multiloculated but typically appear as **rim-enhancing fluid collections** with gas foci in some instances, not generally organized "daughter cysts." *Cavernous hemangioma* - Cavernous hemangiomas are **benign vascular tumors** that typically appear as well-defined, homogeneous hyperechoic lesions on ultrasound or enhance characteristically on dynamic CT/MRI with **peripheral nodular enhancement** followed by centripetal fill-in. - They are solid or partially cystic, but do not exhibit the **multiloculated appearance with internal septations** or daughter cysts seen in the image.

Q: A Sengstaken-Blakemore tube is used for the management of :

Variceal bleeding. ***Variceal bleeding*** - A **Sengstaken-Blakemore tube** is specifically designed with gastric and esophageal balloons to apply direct pressure and tamponade **bleeding esophageal varices**, a common complication of portal hypertension. - It is utilized as a temporary measure to control severe hemorrhage when endoscopic interventions fail or are unavailable. *Corrosive poisoning* - Management of corrosive poisoning focuses on **supportive care**, pain management, and preventing further injury; a Sengstaken-Blakemore tube is not indicated. - Using such a tube could potentially worsen esophageal damage or perforation in corrosive injuries. *Tension pneumothorax* - A tension pneumothorax is a **thoracic emergency** requiring immediate **needle decompression** or chest tube insertion. - A Sengstaken-Blakemore tube is an upper gastrointestinal device and has no role in managing pulmonary conditions. *Asphyxia* - Asphyxia involves a lack of oxygen and is managed by establishing an **open airway**, providing ventilation, and addressing the underlying cause. - A Sengstaken-Blakemore tube is irrelevant to the treatment of asphyxia.

Q: Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'? 1. Elevated white cell count (> 18000/mm3) 2. Renal dysfunction 3. Duration > 72 hours 4. Marked local inflammation

2. Renal dysfunction. ***2. Renal dysfunction*** - **Renal dysfunction** is a criterion for **Grade III (severe)** acute cholecystitis, NOT Grade II, indicating systemic organ failure. - This represents a critical systemic complication requiring intensive care, distinct from the moderate severity markers of Grade II. *1. Elevated white cell count (> 18000/mm3)* - An elevated white blood cell count *greater than 18,000/mm³* **IS** a criterion for **Grade II (moderate)** acute cholecystitis. - This reflects a substantial systemic inflammatory response, categorizing it as a moderate severity finding. *3. Duration > 72 hours* - A duration of symptoms *greater than 72 hours* **IS** a defining criterion for **Grade II (moderate)** acute cholecystitis according to the **Tokyo Guidelines for severity assessment**. - This indicates a more prolonged inflammatory process, often associated with increased local complications. *4. Marked local inflammation* - **Marked local inflammation** **IS** a characteristic of **Grade II (moderate)** acute cholecystitis. - This criterion includes conditions such as pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, or biliary peritonitis, indicating significant local complications.

Q: A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by

Early surgery. ***Early surgery*** - **Diabetic patients** with gallstones, especially those over 3 cm, have a higher risk of complications like **cholecystitis**, **cholangitis**, and even **gallbladder cancer**, justifying prophylactic cholecystectomy. - The risk of perioperative complications is lower than the risk associated with an acute gallstone event in a diabetic patient. *Bile-salt treatment* - This treatment is primarily used for **small cholesterol gallstones** in patients who are not surgical candidates. - It is ineffective for large gallstones (>3 cm) and calcified stones, and it carries a high recurrence rate. *Waiting till it becomes symptomatic* - In diabetic patients, waiting for symptoms can lead to more severe and **atypical presentations** of complications, which may be harder to manage. - Larger gallstones in diabetic patients pose a significantly increased risk of developing **gallbladder cancer**, making prophylactic removal beneficial. *ESWL (Extracorporeal Shock Wave Lithotripsy)* - **ESWL** is generally reserved for solitary, small ( 3 cm) and carries risks of stone recurrence and fragmentation complications.

Q: Which one of the following is not a common feature of bile duct stone ?

Distended gall bladder. ***Distended gall bladder*** - A distended gallbladder is **less common** when the obstruction is caused by a stone in the **common bile duct (CBD)** because the gallbladder can often decompress through the cystic duct if it is patent. [1] - Furthermore, **Mirizzi syndrome**, which can cause gallbladder distension due to an impacted stone in the cystic duct compressing the CBD, is a specific and less frequent scenario than simple choledocholithiasis. [2] *Clay colored stools* - **Clay-colored stools** (acholic stools) are a common feature of bile duct obstruction as it prevents bilirubin from reaching the intestines to be converted into **stercobilin**, which gives stool its normal brown color. - The absence of bilirubin in the gut results in stools appearing pale or gray. *Itching* - **Pruritus (itching)** is a very common symptom of bile duct obstruction due to the systemic accumulation of **bile salts** and other pruritic substances that are normally excreted in bile. [3] - These substances deposit in the skin, irritating nerve endings. *Obstructive jaundice* - **Obstructive jaundice** is a hallmark feature of bile duct stones. The obstruction prevents the flow of conjugated bilirubin into the intestine, leading to its reabsorption into the bloodstream. [1] - This results in elevated **conjugated bilirubin** and **icterus**, causing yellow discoloration of the skin and sclera.

Q: A retained stone in CBD (common bile duct) diagnosed by T-tube cholangiogram is best treated by :

Endoscopic papillotomy. ***Endoscopic papillotomy*** - This procedure, typically performed via an **ERCP**, allows for the removal of **retained common bile duct stones** in a less invasive manner than re-exploration. - It involves incising the **sphincter of Oddi** to facilitate stone extraction or spontaneous passage, especially when a **T-tube** is already in place, making access easier. *Re-exploration of common bile duct* - This is a more invasive surgical procedure with higher risks compared to endoscopic approaches. - Re-exploration is generally reserved for cases where **endoscopic techniques fail** or where there are specific contraindications to endoscopy. *Extra corporeal shock wave lithotripsy* - **ESWL** is primarily used for **kidney stones** and sometimes for large pancreatic or gallbladder stones that are difficult to access endoscopically. - Its effectiveness in fragmenting **CBD stones**, especially when a T-tube is present, is limited, and fragments may still obstruct the duct. *Dissolution therapy* - This therapy involves administering **ursodeoxycholic acid** to dissolve cholesterol stones. - It is a **slow process** and is generally ineffective for pigmented stones or for promptly resolving symptomatic or **obstructive retained CBD stones**.

Q: The scolicidal agents used in the surgery of a hydatid cyst include all of the following except

15% glutaraldehyde. ***15% glutaraldehyde*** - **15% glutaraldehyde** is NOT a standard scolicidal agent used during hydatid cyst surgery. - While glutaraldehyde is an effective disinfectant and sterilizing agent, it is **not routinely used as a scolicidal agent** in hydatid cyst surgery. - It is **highly toxic to tissues** and can cause severe local damage, making it unsuitable for intraoperative use in the peritoneal cavity. - Standard scolicidal agents are safer and more established for this specific purpose. *Absolute alcohol* - **Absolute alcohol (95-100% ethanol)** is an effective scolicidal agent used in hydatid cyst surgery. - It kills protoscolices rapidly and has documented efficacy in preventing **secondary hydatidosis**. - While it can be irritating to tissues, it is still employed clinically with appropriate precautions to minimize spillage. *0.5% silver nitrate* - **0.5% silver nitrate** solution is an effective scolicidal agent that causes disruption of the scolex membranes. - It has been shown to kill scolices and reduce the risk of **secondary hydatidosis**. - It is one of the established agents used in hydatid cyst surgery. *20% (hypertonic) saline* - **Hypertonic saline (20%)** is the **most widely used** scolicidal agent due to its osmotic effect, which causes scolices to rupture. - It is **relatively safe** and highly effective, making it the preferred choice in most surgical protocols. - Spillage should still be minimized to avoid complications like hypernatremia or electrolyte imbalance.

Question 1

The following image shows: (DNB Pattern 2018)

Accepted Answer

ERCP

Answer

Percutaneous cholangiography

Answer

Oral cholecystography

Answer

T-Tube cholangiogram

Question 2

A 35-year-old shepherd presents with painless enlarged liver. CT abdomen shows presence of:

Accepted Answer

Hydatid cyst

Answer

Amoebic liver abscess

Answer

Pyogenic liver abscess

Answer

Cavernous hemangioma

Question 3

A Sengstaken-Blakemore tube is used for the management of :

Accepted Answer

Variceal bleeding

Answer

Corrosive poisoning

Answer

Tension pneumothorax

Answer

Asphyxia

Question 4

Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'?

1. Elevated white cell count (> 18000/mm3)
2. Renal dysfunction
3. Duration > 72 hours
4. Marked local inflammation

Accepted Answer

2. Renal dysfunction

Answer

4. Marked local inflammation

Answer

3. Duration > 72 hours

Answer

1. Elevated white cell count (> 18000/mm3)

Question 5

A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by

Accepted Answer

Early surgery

Answer

Bile-salt treatment

Answer

Waiting till it becomes symptomatic

Answer

ESWL

Question 6

A young patient develops high grade fever with chills and rigors, mild jaundice and acute pain in the upper abdomen following cholecystectomy. On examination she was jaundiced, toxic, haemodynamically stable and having vague fullness upper abdomen. What is the most probable diagnosis ?

Accepted Answer

Localised collection of bile in peritoneal cavity

Answer

Duodenal injury

Answer

Acute Pancreatitis

Answer

Iatrogenic ligation of common bile duct

Question 7

Which one of the following is not a common feature of bile duct stone ?

Accepted Answer

Distended gall bladder

Answer

Clay colored stools

Answer

Itching

Answer

Obstructive jaundice

Question 8

A retained stone in CBD (common bile duct) diagnosed by T-tube cholangiogram is best treated by :

Accepted Answer

Endoscopic papillotomy

Answer

Re-exploration of common bile duct

Answer

Extra corporeal shock wave lithotripsy

Answer

Dissolution therapy

Question 9

A 25-year-old patient has 5 x 5 cm amoebic abscess in right lobe of liver. He is febrile and has pain in right hypochondrium. His primary management would include:

Accepted Answer

Ultra-sound guided placement of pigtail catheter

Answer

Laparotomy and drainage

Answer

Administration of antibiotic and observation

Answer

Ultra-sound guided aspiration

Question 10

The scolicidal agents used in the surgery of a hydatid cyst include all of the following except

Accepted Answer

15% glutaraldehyde

Answer

Absolute alcohol

Answer

0.5% silver nitrate

Answer

20% (hypertonic) saline

Hepatobiliary Surgery — MCQs

Hepatobiliary Surgery — MCQs

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