Hepatobiliary Surgery Practice Questions

Q: Referred pain to the inferior angle of the right scapula in acute cholecystitis is known as

Boa's sign. ***Boa's sign*** - This sign is characterized by **referred pain** to the **inferior angle of the right scapula** due to irritation of the **phrenic nerve** (C3-C5 dermatomes) by an inflamed gallbladder [1]. - The pain is typically felt unilaterally on the right side and is a classic presentation in **acute cholecystitis** [1]. *Murphy's sign* - This is a test for acute cholecystitis, characterized by **inspiratory arrest** upon deep palpation of the right upper quadrant under the costal margin [1]. - It indicates **visceral tenderness** of the gallbladder itself, rather than referred pain to the scapula. *Naunyn's sign* - This sign is not a recognized clinical sign associated with acute cholecystitis or referred pain patterns in common medical practice. - There might be confusion with other eponymous signs that are not directly related to gallbladder pathology and referred scapular pain. *Cullen's sign* - This sign refers to **periumbilical ecchymosis** (bruising around the umbilicus). - It is indicative of **retroperitoneal hemorrhage**, such as in acute pancreatitis [2] or ruptured ectopic pregnancy, not acute cholecystitis.

Q: Pringle's manoeuvre may be required for treatment of

Liver laceration. ***Liver laceration*** - **Pringle's manoeuvre** involves clamping the **hepatoduodenal ligament** to control blood flow to the liver, effectively managing bleeding from **liver lacerations**. - This maneuver helps to differentiate between hepatic and non-hepatic bleeding sources during abdominal surgery. *Injury to tail of pancreas* - An injury to the **tail of the pancreas** is usually managed by surgical resection or repair of the damaged pancreatic tissue, and Pringle's manoeuvre does not directly address this. - The pancreas is supplied by branches of the **celiac axis** and **superior mesenteric artery**, which are not occluded by Pringle's manoeuvre. *Mesenteric ischemia* - **Mesenteric ischemia** is a condition involving reduced blood flow to the intestines via the **mesenteric arteries**; Pringle's manoeuvre would not be an appropriate treatment. - Treatment for mesenteric ischemia typically involves revascularization of the affected mesenteric vessels. *Bleeding esophageal varices* - **Bleeding esophageal varices** are managed by therapies like **endoscopic band ligation**, sclerotherapy, or octreotide infusion. - Pringle's manoeuvre is not indicated for treating bleeding from esophageal varices, as these are related to portal hypertension and not direct hepatic artery/portal vein bleeds.

Q: Which of the following is not true about hydatid cysts of the liver?

Mostly in left lobe. ***Mostly in left lobe*** - **Hydatid cysts** (Echinococcosis) caused by the parasite **Echinococcus granulosus** are most commonly found in the **right lobe of the liver** (75%), followed by the left lobe (15-20%), and then other sites. - The liver is the **primary site** of involvement in around 75% of cases because it is the **first capillary bed** encountered by the swallowed eggs. *Surgical management is done* - **Surgical removal** is often the definitive treatment for **hydatid cysts**, particularly for large, symptomatic, or complicated cysts. - Procedures can range from **cystectomy** (removal of the cyst wall) to **radical resections** depending on the cyst's location and size. *Conservative treatment is effective in elderly with small cyst* - **Conservative management** or "watch and wait" is a viable option for **asymptomatic, small cysts**, especially in **elderly patients** or those with significant comorbidities where surgery might pose a high risk. - **Antiparasitic medications** like **albendazole** are also used, sometimes alone for smaller cysts, or in conjunction with other treatments. *CT shows pathognomonic ring-like calcification* - **Computed tomography (CT)** scans can show characteristic features such as a **"daughter cyst" formation** within the mother cyst or **ring-like calcification** of the cyst wall, which are highly suggestive of a **hydatid cyst**. - While not universally present, the presence of **calcification** is a strong indicator, though the diagnostic gold standard often involves serology and imaging.

Q: A 60-year-old patient with air in the biliary tree, colicky abdominal pain, and hyper-peristaltic abdominal sounds. What is the diagnosis?

Gallstone ileus. ***Gallstone ileus*** - This condition presents with the classic triad of **pneumobilia** (air in the biliary tree), symptoms of **small bowel obstruction** (colicky abdominal pain, hyper-peristaltic sounds), and evidence of a **gallstone in the ileum**. - The gallstone typically erodes through the gallbladder wall into the small intestine, causing obstruction, often at the **ileocecal valve**. *Hemobilia* - Characterized by **bleeding into the biliary tree**, which presents with upper gastrointestinal bleeding, biliary colic, and jaundice. - It does not cause bowel obstruction or pneumobilia and is often associated with trauma, iatrogenic injury, or vascular malformations. *Cholangitis* - An **infection of the bile ducts**, typically presenting with **Charcot's triad**: fever, right upper quadrant pain, and jaundice. - While it involves the biliary tree, it does not typically cause air in the biliary tree or small bowel obstruction. *Pneumobilia* - Refers specifically to the presence of **air in the biliary tree** and is a sign, not a diagnosis for the entire clinical picture. - While present in this case, pneumobilia alone does not explain the colicky abdominal pain, hyper-peristaltic sounds, and bowel obstruction.

Q: Which of the following is not a common symptom associated with common bile duct (CBD) stones?

Septic shock. ***Septic shock*** - While **sepsis** can occur as a complication of **cholangitis** due to CBD stones, **septic shock** itself is a severe, life-threatening systemic response and not a *common symptom* directly associated with the presence of uncomplicated CBD stones. - It represents a late, severe complication of infection rather than an initial or typical presentation. *Pain* - **Biliary colic** due to obstruction of the **cystic duct** or **common bile duct** (CBD) by stones is a very common symptom, manifesting as acute, intense pain in the upper abdomen. - This pain is often felt in the **right upper quadrant** or epigastrium and can radiate to the back or shoulder. *Fever* - **Fever** is a common symptom, particularly when **CBD stones** lead to **cholangitis**, an infection of the bile duct. - The obstruction caused by the stone allows bacterial proliferation, leading to inflammation and systemic symptoms like fever. *Jaundice* - **Jaundice** due to **hyperbilirubinemia** is a frequent symptom when a CBD stone obstructs the flow of bile from the liver into the intestine. - This obstruction prevents the excretion of **conjugated bilirubin**, leading to its build-up in the blood and deposition in tissues, causing yellowing of the skin and eyes.

Q: In choledochal cyst, the most common type is:

Type 1. ***Type 1*** - **Type 1 choledochal cysts** account for the vast majority, approximately **80-90%**, of all choledochal cyst cases. - This type is characterized by a **fusiform or cystic dilation** of the common bile duct. *Type 2* - **Type 2 choledochal cysts** are relatively rare, presenting as a **diverticulum** arising from the common bile duct. - This morphology is distinctly different from the more common diffuse or localized enlargements. *Type 4* - The classification of Type 4 includes both **intrahepatic** and **extrahepatic** duct dilations. - While it represents a significant proportion of the remaining cases, it is less common than Type 1. *Type 4A* - **Type 4A** is a specific subtype within the Type 4 classification, involving **multiple intrahepatic and extrahepatic cysts**. - Its incidence is lower than the overall Type 4 category, making it far less common than Type 1.

Q: What is the treatment for asymptomatic gallstones greater than 3 cm?

Laparoscopic cholecystectomy. ***Laparoscopic cholecystectomy*** - For **asymptomatic gallstones ≥3 cm**, prophylactic cholecystectomy is **recommended** due to significantly increased risk of gallbladder carcinoma - **Large stone size (≥3 cm)** is an established risk factor for malignant transformation of the gallbladder epithelium - Current guidelines recommend **prophylactic surgery** for high-risk features including stones >3 cm, porcelain gallbladder, and gallbladder polyps >10 mm - **Laparoscopic approach** is preferred as it offers minimal morbidity with excellent outcomes *Observation/watchful waiting* - This approach is appropriate for **small to medium-sized asymptomatic gallstones** (<3 cm) where risk of complications is low - However, for stones **≥3 cm**, the increased malignancy risk makes observation inappropriate - Patient should not be left with untreated large gallstones given the oncological risk *Dissolution therapy* - Ursodeoxycholic acid therapy is only effective for **small cholesterol stones** ( 1.5 cm) and has high recurrence rates - Not a viable option for 3 cm stones *ERCP* - **Endoscopic retrograde cholangiopancreatography** is used for **common bile duct stones** or biliary obstruction - **Not indicated** for gallstones confined to the gallbladder - Does not address gallbladder pathology or malignancy risk

Q: Hemolytic anemia is associated with which gallstones?

Pigmented. ***Pigmented*** - **Pigmented gallstones** (specifically black pigment stones) are associated with hemolytic anemia due to increased **unconjugated bilirubin** production [1]. - The excess bilirubin is excreted into bile, where it polymerizes with calcium to form insoluble calcium bilirubinate, leading to stone formation [1]. *Cholesterol* - **Cholesterol gallstones** are the most common type and are primarily formed from supersaturated cholesterol in bile [1]. - Their formation is not directly linked to conditions causing increased bilirubin production, such as **hemolytic anemia**. *Mixed* - **Mixed gallstones** contain both cholesterol and calcium bilirubinate but are predominantly cholesterol [1]. - While they may contain some pigment, their primary etiology is related to gallbladder stasis and cholesterol supersaturation, not typically **hemolysis**. *None of the options* - This option is incorrect because **pigmented gallstones** are strongly associated with hemolytic anemia.

Q: According to the latest AJCC 8th edition TNM classification of carcinoma of the gallbladder, what is the minimum number of lymph nodes involved in N2?

4. ***4*** - According to the **AJCC 8th edition TNM classification** for gallbladder carcinoma, **N2** is defined by the involvement of **4 or more regional lymph nodes**. - This classification specifically groups patients with extensive lymph node involvement, which carries a worse prognosis. *3* - The involvement of **1 to 3 regional lymph nodes** in gallbladder carcinoma corresponds to **N1** stage in the **AJCC 8th edition**. - This option incorrectly identifies the threshold for N2 as it falls within the N1 criteria. *5* - While 5 lymph nodes would qualify as N2 (**4 or more regional lymph nodes**), it is not the *minimum* number required for the classification. - The classification of N2 begins at 4 involved lymph nodes, not 5. *6* - Similar to 5, 6 involved lymph nodes would also be classified as N2, but it is not the *minimum* number required. - The definition for **N2** stage starts at **4 regional lymph nodes**.

Q: What is the medical term for the surgical procedure to remove the gallbladder?

Cholecystectomy. ***Cholecystectomy*** - This term directly translates to the **surgical removal of the gallbladder**, with "cholecyst-" referring to the gallbladder and "-ectomy" meaning surgical excision. - It is a common procedure performed for conditions like **gallstones (cholelithiasis)** or gallbladder inflammation (cholecystitis). *Appendectomy* - This procedure involves the **surgical removal of the appendix**, typically due to inflammation or infection (appendicitis). - It does not involve the gallbladder. *Hernia repair* - This is a surgical procedure to **correct a hernia** by repairing a weakness in the abdominal wall or other muscle layer. - It involves restoring displaced tissue to its proper position and reinforcing the weakened area, not removing an organ like the gallbladder. *Laparotomy* - This is a general surgical procedure involving a **large incision through the abdominal wall** to gain access to the abdominal organs. - It is an exploratory surgery or a preliminary step to perform other procedures, rather than the name of a specific organ removal.

Question 1

Referred pain to the inferior angle of the right scapula in acute cholecystitis is known as

Accepted Answer

Boa's sign

Answer

Murphy's sign

Answer

Naunyn's sign

Answer

Cullen's sign

Question 2

Pringle's manoeuvre may be required for treatment of

Accepted Answer

Liver laceration

Answer

Injury to tail of pancreas

Answer

Bleeding esophageal varices

Answer

Mesenteric ischemia

Question 3

Which of the following is not true about hydatid cysts of the liver?

Accepted Answer

Mostly in left lobe

Answer

Conservative treatment is effective in elderly with small cyst

Answer

Surgical management is done

Answer

CT shows pathognomonic ring-like calcification

Question 4

A 60-year-old patient with air in the biliary tree, colicky abdominal pain, and hyper-peristaltic abdominal sounds. What is the diagnosis?

Accepted Answer

Gallstone ileus

Answer

Hemobilia

Answer

Cholangitis

Answer

Pneumobilia

Question 5

Which of the following is not a common symptom associated with common bile duct (CBD) stones?

Accepted Answer

Septic shock

Answer

Fever

Answer

Jaundice

Answer

Pain

Question 6

In choledochal cyst, the most common type is:

Accepted Answer

Type 1

Answer

Type 2

Answer

Type 4

Answer

Type 4A

Question 7

What is the treatment for asymptomatic gallstones greater than 3 cm?

Accepted Answer

Laparoscopic cholecystectomy

Answer

Dissolution therapy

Answer

ERCP

Answer

Observation/watchful waiting

Question 8

Hemolytic anemia is associated with which gallstones?

Accepted Answer

Pigmented

Answer

Cholesterol

Answer

Mixed

Answer

None of the options

Question 9

According to the latest AJCC 8th edition TNM classification of carcinoma of the gallbladder, what is the minimum number of lymph nodes involved in N2?

Accepted Answer

4

Answer

3

Answer

5

Answer

6

Question 10

What is the medical term for the surgical procedure to remove the gallbladder?

Accepted Answer

Cholecystectomy

Answer

Hernia repair

Answer

Laparotomy

Answer

Appendectomy

Hepatobiliary Surgery — MCQs

Hepatobiliary Surgery — MCQs

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