Hepatobiliary Surgery — MCQs
On this page
Which of the following is NOT an indication for cholecystectomy in a patient with asymptomatic gallstones?
What is choledocholithotomy?
A 29-year-old woman on oral contraceptives presents with abdominal pain. A computed tomography (CT) scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of an underlying liver lesion. Her hemoglobin is 6, and she is transfused 2 units of packed red blood cells and 2 units of fresh frozen plasma. Two hours after starting the transfusion, she develops respiratory distress and requires intubation. She is not volume overloaded clinically, but her chest x-ray shows bilateral pulmonary infiltrates. Which of the following is the management strategy of choice?
Which of the following is NOT a complication of gallstones?
A saccular diverticulum of the extrahepatic bile duct in a choledochal cyst is classified as which type?
All of the following are causes of acalculous cholecystitis except?
Which of the following is considered a precancerous lesion of the gall bladder?
Which of the following statements is true regarding hepatocellular carcinoma?
Which of the following investigations is the investigation of choice to diagnose gallstones?
What is an exception to Courvoisier's law?
Hepatobiliary Surgery Indian Medical PG Practice Questions and MCQs
Question 461: Which of the following is NOT an indication for cholecystectomy in a patient with asymptomatic gallstones?
- A. Diabetes mellitus (Correct Answer)
- B. Sickle cell anaemia
- C. Porcelain gallbladder
- D. Gallbladder cancer in high prevalence areas
Explanation: In modern surgical practice, **asymptomatic gallstones** (silent stones) are generally managed with observation ("expectant management") because the risk of developing complications is lower than the risk of surgical intervention. ### Why Diabetes Mellitus is the Correct Answer Historically, **Diabetes Mellitus (Option A)** was considered an indication for prophylactic cholecystectomy due to fears of rapidly progressing gangrenous cholecystitis. However, current evidence shows that diabetics do not have a higher risk of developing symptoms or complications compared to non-diabetics. Therefore, asymptomatic stones in a diabetic patient are **not** an indication for surgery. ### Explanation of Incorrect Options (Indications for Surgery) * **Sickle Cell Anaemia (Option B):** Prophylactic surgery is recommended because it is difficult to differentiate a painful "sickle cell crisis" from "biliary colic/cholecystitis." Removing the gallbladder simplifies future diagnostic dilemmas. * **Porcelain Gallbladder (Option C):** This refers to intramural calcification of the gallbladder wall. It is associated with a significantly increased risk of **Gallbladder Carcinoma** (up to 7–25%), necessitating removal. * **High Prevalence Areas (Option D):** In regions with high rates of gallbladder cancer (e.g., Chile, parts of North India), the threshold for surgery is lower to prevent malignancy. ### NEET-PG High-Yield Pearls Other indications for cholecystectomy in asymptomatic patients include: 1. **Stone size >3 cm:** Increased risk of malignancy. 2. **Gallbladder Polyps >10 mm:** High malignant potential. 3. **Anomalous Pancreaticobiliary Duct Junction (APBDJ):** High risk of cancer. 4. **Patients undergoing Bariatric Surgery:** To prevent rapid weight loss-induced stone complications. 5. **Transplant candidates:** To avoid post-transplant immunosuppressed biliary sepsis.
Question 462: What is choledocholithotomy?
- A. Removal of a ureteric stone
- B. Removal of a gallstone
- C. Removal of the gallbladder
- D. Removal of a common bile duct stone (Correct Answer)
Explanation: **Explanation:** **Choledocholithotomy** is a surgical procedure involving an incision into the **common bile duct (CBD)** to remove stones. The term is derived from "choledocho-" (referring to the CBD), "-lith-" (stone), and "-otomy" (to cut into). 1. **Why Option D is Correct:** The CBD is formed by the union of the common hepatic duct and the cystic duct. When stones migrate from the gallbladder or form de novo in the CBD (choledocholithiasis), they can cause obstructive jaundice or cholangitis. Choledocholithotomy is the definitive surgical intervention to clear these stones, often followed by the placement of a **T-tube** to ensure biliary drainage and allow for post-operative cholangiography. 2. **Why Other Options are Incorrect:** * **Option A:** Removal of a ureteric stone is termed **ureterolithotomy**. * **Option B:** Removal of a gallstone (without removing the gallbladder) is rarely performed today but is historically termed **cholecystolithotomy**. * **Option C:** Surgical removal of the gallbladder is **cholecystectomy**, which is the gold standard for symptomatic cholelithiasis. **NEET-PG High-Yield Clinical Pearls:** * **Gold Standard:** Currently, the preferred management for CBD stones is **ERCP with endoscopic sphincterotomy**, followed by laparoscopic cholecystectomy. * **Indications for T-tube:** After a formal choledocholithotomy, a T-tube is inserted to prevent bile leak and stricture. It is typically removed after **10–14 days** once a "T-tube cholangiogram" confirms no residual stones. * **Primary vs. Secondary Stones:** Secondary stones (migrated from the gallbladder) are usually cholesterol-based, while primary CBD stones are typically **brown pigment stones** associated with stasis or infection.
Question 463: A 29-year-old woman on oral contraceptives presents with abdominal pain. A computed tomography (CT) scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of an underlying liver lesion. Her hemoglobin is 6, and she is transfused 2 units of packed red blood cells and 2 units of fresh frozen plasma. Two hours after starting the transfusion, she develops respiratory distress and requires intubation. She is not volume overloaded clinically, but her chest x-ray shows bilateral pulmonary infiltrates. Which of the following is the management strategy of choice?
- A. Continue the transfusion and administer an antihistamine
- B. Stop the transfusion and administer a diuretic
- C. Stop the transfusion, perform bronchoscopy, and start broad-spectrum empiric antibiotics
- D. Stop the transfusion and continue supportive respiratory care (Correct Answer)
Explanation: ### Explanation **1. Why Option D is Correct: Understanding TRALI** The patient is presenting with **Transfusion-Related Acute Lung Injury (TRALI)**. This is a clinical syndrome characterized by the sudden onset of hypoxemic respiratory failure and non-cardiogenic pulmonary edema (bilateral infiltrates on CXR) within 6 hours of a blood product transfusion. The underlying pathophysiology involves donor antibodies (usually anti-HLA or anti-neutrophil antibodies) reacting against the recipient’s leukocytes, leading to sequestration and activation of neutrophils in the pulmonary microvasculature. This causes capillary leakage. The **management is purely supportive**: immediately stop the transfusion and provide respiratory support (oxygen or mechanical ventilation). Most patients recover within 48–96 hours with supportive care alone. **2. Why Other Options are Incorrect:** * **Option A:** Continuing the transfusion is dangerous as it further exposes the patient to the offending antibodies. Antihistamines are used for simple allergic/urticarial reactions, not TRALI. * **Option B:** Diuretics are the treatment for **TACO** (Transfusion-Associated Circulatory Overload). This patient is "not volume overloaded clinically," making TACO less likely. In TRALI, patients may actually be hypotensive or euvolemic; diuretics can worsen the situation. * **Option C:** While the patient has infiltrates, the timing (2 hours post-transfusion) and sudden onset point to TRALI rather than pneumonia. Bronchoscopy and antibiotics are not indicated for an immune-mediated lung injury. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** TRALI is now the leading cause of transfusion-related fatalities. * **Implicated Products:** Highest risk is associated with **FFP and Platelets** (products with high plasma volume). * **Donor Profile:** Often associated with multiparous female donors (due to HLA sensitization during pregnancy). * **TRALI vs. TACO:** * **TRALI:** Fever, hypotension, non-cardiogenic (normal PCWP/JVP). * **TACO:** Hypertension, signs of fluid overload (raised JVP/S3 gallop), responds to diuretics. * **Surgical Context:** The patient likely has a ruptured **Hepatic Adenoma** (linked to OCP use), which caused the initial hemorrhage.
Question 464: Which of the following is NOT a complication of gallstones?
- A. Mucocele
- B. Diverticulosis (Correct Answer)
- C. Acute cholangitis
- D. Empyema of the gallbladder
Explanation: **Explanation:** The correct answer is **B. Diverticulosis**. Diverticulosis refers to the formation of small, bulging pouches (diverticula) in the digestive tract, most commonly the sigmoid colon. It is a condition of the large intestine caused by high intraluminal pressure and weakened muscular walls; it has no pathophysiological link to gallstones. **Analysis of Options:** * **Mucocele (Option A):** This occurs when a gallstone chronically impacts the cystic duct. The gallbladder becomes distended with clear, sterile mucus (hydrops) because the bile is absorbed and the gallbladder mucosa continues to secrete mucus. * **Acute Cholangitis (Option C):** This is a life-threatening bacterial infection of the biliary tree. It occurs when a gallstone migrates into the common bile duct (choledocholithiasis), causing obstruction and subsequent stasis of bile, which becomes infected. * **Empyema of the Gallbladder (Option D):** This is a complication of acute cholecystitis where the gallbladder becomes filled with purulent material (pus) due to secondary bacterial infection of stagnant bile. **High-Yield Clinical Pearls for NEET-PG:** * **Charcot’s Triad:** Fever, jaundice, and RUQ pain (indicative of Acute Cholangitis). * **Reynold’s Pentad:** Charcot’s triad plus hypotension and altered mental status (indicative of obstructive suppurative cholangitis). * **Mirizzi Syndrome:** Extrinsic compression of the common hepatic duct by a stone impacted in the cystic duct or gallbladder neck. * **Gallstone Ileus:** A late complication where a large stone enters the bowel via a cholecystenteric fistula, typically causing obstruction at the **ileocecal valve**.
Question 465: A saccular diverticulum of the extrahepatic bile duct in a choledochal cyst is classified as which type?
- A. Type I
- B. Type II (Correct Answer)
- C. Type III
- D. Type IV
Explanation: This question refers to the **Todani Classification**, which is the standard system used to categorize choledochal cysts based on their anatomical location and morphology. ### **Explanation of the Correct Answer** **Type II** choledochal cysts are characterized as a **true diverticulum** of the extrahepatic bile duct. They appear as a saccular outgrowth protruding from the wall of the common bile duct (CBD), while the rest of the duct remains normal in diameter. They are rare, accounting for only about 2–3% of all cases. ### **Analysis of Incorrect Options** * **Type I (Most Common):** Involves cystic or fusiform dilatation of the **entire extrahepatic bile duct**. It is the most frequently encountered type (75–85%). * **Type III (Choledochocele):** This is a cystic dilatation of the **intraduodenal portion** of the common bile duct. It is often managed endoscopically. * **Type IV:** Characterized by **multiple cysts**. * **IVa:** Both intrahepatic and extrahepatic dilatations. * **IVb:** Multiple extrahepatic dilatations only. ### **Clinical Pearls for NEET-PG** * **Type V (Caroli’s Disease):** Dilatation involves only the **intrahepatic** bile ducts. If associated with congenital hepatic fibrosis, it is called Caroli’s Syndrome. * **Classic Triad:** Jaundice, right upper quadrant pain, and a palpable mass (present in only <20% of patients, more common in children). * **Gold Standard Investigation:** MRCP (Magnetic Resonance Cholangiopancreatography). * **Surgical Management:** For Types I, II, and IV, the treatment of choice is **complete cyst excision** with Roux-en-Y hepaticojejunostomy to prevent the high risk of cholangiocarcinoma.
Question 466: All of the following are causes of acalculous cholecystitis except?
- A. Bile duct stricture
- B. Schistosomiasis (Correct Answer)
- C. Prolonged TPN
- D. Major operations
Explanation: **Explanation:** Acalculous cholecystitis refers to acute inflammation of the gallbladder in the absence of gallstones. It typically occurs in critically ill patients due to a combination of **bile stasis** and **gallbladder wall ischemia**. **Why Schistosomiasis is the Correct Answer:** Schistosomiasis (specifically *S. haematobium*) is classically associated with **Squamous Cell Carcinoma of the urinary bladder**. While some parasitic infections like *Clonorchis sinensis* or *Ascaris lumbricoides* are linked to biliary disease and stone formation, Schistosomiasis is not a recognized cause of acute acalculous cholecystitis. **Analysis of Incorrect Options:** * **Bile duct stricture:** Causes mechanical obstruction to bile flow, leading to significant bile stasis, which is a primary trigger for acalculous inflammation. * **Prolonged Total Parenteral Nutrition (TPN):** TPN leads to a lack of enteral stimulation, resulting in decreased Cholecystokinin (CCK) release. This causes gallbladder stasis and the formation of biliary sludge, a high-risk factor for acalculous cholecystitis. * **Major operations:** Severe physiological stress, dehydration, and prolonged fasting post-surgery lead to increased bile viscosity and ischemia of the gallbladder (supplied by the end-arterial cystic artery), triggering inflammation. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Burns, trauma, sepsis, prolonged mechanical ventilation, and diabetes. * **Pathogenesis:** Increased bile viscosity + Ischemia = Gallbladder gangrene (more common in acalculous than calculous types). * **Diagnosis:** Ultrasound is the initial test (showing wall thickening >4mm and pericholecystic fluid), but **HIDA scan** (showing non-visualization of the gallbladder) is the most sensitive. * **Management:** Percutaneous cholecystostomy is often the preferred initial treatment in unstable, critically ill patients.
Question 467: Which of the following is considered a precancerous lesion of the gall bladder?
- A. Porcelain gall bladder (Correct Answer)
- B. Mirrizi syndrome
- C. Cholesterosis
- D. Acalculous Cholecystitis
Explanation: **Explanation:** **1. Why Porcelain Gallbladder is Correct:** A **Porcelain Gallbladder** refers to the intramural calcification of the gallbladder wall, often resulting from chronic cholecystitis. It is classically considered a **premalignant condition**. While recent studies suggest the risk of progression to Gallbladder Carcinoma (GBC) is lower than previously thought (approx. 7–15%), it remains a high-yield surgical indication for **prophylactic cholecystectomy**, especially when the calcification is "stippled" or "patchy" rather than a continuous broad band. **2. Analysis of Incorrect Options:** * **Mirizzi Syndrome:** This is an extrinsic compression of the common hepatic duct by a stone impacted in the cystic duct or Hartmann’s pouch. While it causes obstructive jaundice and recurrent cholangitis, it is an inflammatory complication, not a direct precancerous lesion. * **Cholesterosis (Strawberry Gallbladder):** This involves the deposition of cholesterol esters in the lamina propria (submucosa) of the gallbladder wall. It is a benign condition and carries no increased risk of malignancy. * **Acalculous Cholecystitis:** This is acute inflammation of the gallbladder in the absence of stones, typically seen in critically ill patients (burns, sepsis, TPN). It is an acute surgical emergency but does not lead to cancer. **3. High-Yield Clinical Pearls for NEET-PG:** * **Other Precancerous Lesions:** Gallbladder polyps (>10 mm), Adenomyomatosis (specifically the segmental type), and Anomalous Pancreaticobiliary Duct Junction (APBDJ). * **Risk Factors for GBC:** Cholelithiasis (stones >3 cm), Salmonella typhi carrier state, and "Indian" ethnicity (highest incidence in North India). * **Imaging:** Porcelain gallbladder is easily identified on a plain X-ray or CT scan as a rim of calcification in the right upper quadrant.
Question 468: Which of the following statements is true regarding hepatocellular carcinoma?
- A. It is associated with Hepatitis B virus (HBV) and Hepatitis C virus (HCV).
- B. Cirrhosis is a predisposing factor.
- C. The fibrolamellar variety is not associated with cirrhosis.
- D. All of the above. (Correct Answer)
Explanation: Hepatocellular Carcinoma (HCC) is the most common primary malignancy of the liver, and its pathogenesis is closely linked to chronic liver injury and regeneration. **Explanation of Options:** * **Option A:** Chronic viral hepatitis is the leading global cause of HCC. **HBV** can cause HCC even without cirrhosis due to its ability to integrate into the host genome (insertional mutagenesis). **HCV** causes HCC primarily through the pathway of chronic inflammation and cirrhosis. * **Option B:** Approximately **80-90% of HCC cases** occur in the background of **cirrhosis**. Any condition leading to cirrhosis (Alcoholic Liver Disease, NAFLD/NASH, Hemochromatosis, Alpha-1 antitrypsin deficiency) significantly increases the risk of malignant transformation. * **Option C:** The **Fibrolamellar variant** is a distinct subtype of HCC typically seen in **younger patients (teens to 20s)**. Crucially, it occurs in **non-cirrhotic livers**, has no association with HBV/HCV, and usually presents with normal Alpha-fetoprotein (AFP) levels. It carries a better prognosis compared to conventional HCC. Since all statements are medically accurate, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Alpha-fetoprotein (AFP) is the most common marker; however, **PIVKA-II** (Protein Induced by Vitamin K Absence) is more specific. * **Radiology:** The classic triad on Triphasic CT is **Intense arterial enhancement** followed by **portal venous washout**. * **Screening:** High-risk patients (cirrhotics) should undergo screening every 6 months with **USG + AFP**. * **Metastasis:** The most common site of extrahepatic spread is the **Lungs**.
Question 469: Which of the following investigations is the investigation of choice to diagnose gallstones?
- A. X-ray abdomen
- B. Ultrasound abdomen (Correct Answer)
- C. ERCP
- D. MRCP
Explanation: **Explanation:** **Ultrasound (USG) Abdomen** is the investigation of choice (IOC) for diagnosing gallstones (cholelithiasis). It is highly sensitive (>95%) and specific. The characteristic findings include an echogenic focus within the gallbladder lumen that casts a **posterior acoustic shadow** and moves with changes in the patient's position. It is preferred because it is non-invasive, cost-effective, lacks ionizing radiation, and can simultaneously evaluate gallbladder wall thickness and the biliary tree. **Analysis of Incorrect Options:** * **X-ray Abdomen:** Only 10–15% of gallstones are radiopaque (contain enough calcium to be seen). Most stones are cholesterol-based and radiolucent, making X-ray an unreliable screening tool. * **ERCP (Endoscopic Retrograde Cholangiopancreatography):** This is an invasive procedure primarily used for the **management** (stone extraction) of Common Bile Duct (CBD) stones, not for diagnosing simple gallstones. * **MRCP (Magnetic Resonance Cholangiopancreatography):** While highly accurate for visualizing the biliary anatomy and detecting CBD stones (choledocholithiasis), it is expensive and unnecessary for diagnosing stones localized to the gallbladder. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Cholecystitis:** HIDA Scan (Radionuclide scan) is the most accurate test for acute cholecystitis (shows non-visualization of the gallbladder). * **IOC for Choledocholithiasis:** MRCP (Diagnostic); ERCP (Therapeutic). * **WES Triad:** (Wall-Echo-Shadow) A USG finding seen when the gallbladder is completely filled with stones. * **Most common type of stone:** Cholesterol stones (Western world); Pigment stones are more common in certain Asian populations or hemolytic states.
Question 470: What is an exception to Courvoisier's law?
- A. Double impaction (Correct Answer)
- B. Portal lymphadenopathy
- C. Periampullary carcinoma
- D. None of the above
Explanation: ### Explanation **Courvoisier’s Law** states that in a patient with obstructive jaundice, if the gallbladder is palpable, the cause is unlikely to be a gallstone. This is because stones cause chronic inflammation and fibrosis, resulting in a shrunken, non-distensible gallbladder. Instead, a palpable gallbladder usually indicates malignant obstruction (e.g., pancreatic head cancer). #### Why "Double Impaction" is the Correct Answer Double impaction is a classic exception to this law. It occurs when one gallstone is impacted in the **cystic duct** (causing the gallbladder to distend with mucus, known as mucocele) and another stone is impacted in the **common bile duct (CBD)** (causing obstructive jaundice). In this specific scenario, despite the presence of stones, the gallbladder is palpable in a jaundiced patient. #### Analysis of Other Options * **B. Portal Lymphadenopathy:** This is not an exception; it is a cause of extrinsic compression of the bile duct. If the gallbladder is healthy (not fibrotic), it will distend, thus following Courvoisier’s Law. * **C. Periampullary Carcinoma:** This is the most common condition that **follows** Courvoisier’s Law. Malignant obstruction below the cystic duct junction leads to a distended, palpable gallbladder. #### High-Yield Clinical Pearls for NEET-PG * **Other Exceptions to Courvoisier’s Law:** 1. **Oriental Cholangiohepatitis:** Recurrent pyogenic cholangitis where stones form in the ducts but the gallbladder remains distensible. 2. **Pancreatic Calculi:** Can obstruct the ampulla while the gallbladder remains healthy. 3. **Mucocele of the Gallbladder:** If jaundice co-exists due to a separate pathology (like viral hepatitis). * **Modified Courvoisier’s Law:** In a jaundiced patient, a palpable gallbladder is usually due to malignancy, **unless** proven otherwise. * **Terrier's Sign:** The clinical finding of a palpable, non-tender gallbladder in a jaundiced patient.
Practice by Chapter
Liver Anatomy and Physiology
Practice Questions
Benign Liver Lesions
Practice Questions
Liver Abscess
Practice Questions
Hepatocellular Carcinoma
Practice Questions
Metastatic Liver Disease
Practice Questions
Cirrhosis and Portal Hypertension
Practice Questions
Liver Trauma
Practice Questions
Cholelithiasis and Cholecystitis
Practice Questions
Choledocholithiasis
Practice Questions
Biliary Tract Tumors
Practice Questions
ERCP and Its Complications
Practice Questions
Liver Transplantation Basics
Practice Questions
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free