Hepatobiliary Surgery Practice Questions

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: 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: Which is correct about hematemesis (upper GI bleeding) in this patient?

Rockall scoring is used for risk stratification. ***Rockall scoring is used for risk stratification*** - The image shows a patient with significant **hematemesis**, indicating an upper gastrointestinal bleed. The **Rockall score** is a validated tool used to assess the risk of rebleeding and mortality in patients with upper GI bleeding. - This scoring system considers factors such as **age**, **shock**, **comorbidity**, and endoscopic findings to guide management. *Most common is variceal bleeding* - While variceal bleeding is a serious cause of upper GI hemorrhage, **peptic ulcer disease** (gastric or duodenal ulcers) is the most common cause of non-variceal upper GI bleeding, accounting for 40-50% of cases. - Variceal bleeding is common in patients with **portal hypertension**, often due to liver cirrhosis. *Occurs only if bleeding occurs proximal to ampulla of Vater* - **Hematemesis** (vomiting blood) specifically indicates bleeding **proximal to the ligament of Treitz**, which is superior to the ampulla of Vater. - Bleeding from the small intestine distal to the ligament of Treitz or the colon typically results in **melena** or **hematochezia**, not hematemesis. *MC management is endoscopic banding* - **Endoscopic banding** is the primary treatment for **esophageal variceal bleeding**. - For non-variceal bleeding, such as from **peptic ulcers**, the most common endoscopic management is **epinephrine injection** followed by **thermal coagulation** or **clip placement**.

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.

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: The percutaneous PAIR therapy used in the treatment of uncomplicated hepatic hydatid cyst can be associated with the following complications, except

bradycardia. ***bradycardia*** - **Bradycardia is not a recognized primary complication** of percutaneous aspiration, injection, and re-aspiration (PAIR) therapy for hydatid cysts. - While bradycardia can occur as a **vasovagal response during any invasive procedure**, it is not specifically listed among the complications of PAIR therapy in standard medical literature. - The typical cardiovascular manifestation of anaphylaxis (a known PAIR complication) is **tachycardia**, not bradycardia. *hypotension* - **Hypotension** is a well-documented complication of PAIR therapy, occurring due to **anaphylactic reaction** from leakage of antigenic hydatid fluid into the circulation. - It can also result from **intra-abdominal hemorrhage** if a major vessel is inadvertently punctured during the procedure. *vomiting* - **Vomiting** can occur as part of a **systemic allergic reaction or anaphylaxis** triggered by the release of hydatid cyst contents. - It may also be a manifestation of peritoneal irritation if cyst contents leak into the peritoneal cavity. *anaphylaxis* - **Anaphylaxis** is the most feared and well-documented complication of PAIR therapy, caused by the release of **highly antigenic hydatid cyst fluid** (containing protoscolices and hydatid antigens) into the host's system. - This severe Type I hypersensitivity reaction can manifest with **hypotension, tachycardia, bronchospasm, urticaria, angioedema**, and in severe cases, cardiovascular collapse. - Prophylactic antihistamines and corticosteroids are often administered to minimize this risk.

Q: Pringle's manoeuvre is done to stop bleeding at:

Hepatoduodenal ligament. ***Hepatoduodenal ligament*** - **Pringle's manoeuvre** involves clamping the **hepatoduodenal ligament** to temporarily occlude the hepatic artery and portal vein, which are the main blood supply to the liver. - This maneuver is used during **liver surgery** to control or prevent bleeding from the liver parenchyma. *Splenic artery* - The **splenic artery** supplies the spleen and is not directly occluded by Pringle's manoeuvre. - Bleeding from the splenic artery would require direct clamping or **ligation** of that vessel, not compression of the hepatoduodenal ligament. *Renal artery* - The **renal artery** supplies the kidney and is located in the retroperitoneum, far from the liver and the hepatoduodenal ligament. - Pringle's manoeuvre has no effect on blood flow to the kidneys. *Left gastric artery* - The **left gastric artery** supplies the stomach and is a branch of the celiac trunk, which is proximal to the points of compression in Pringle's manoeuvre. - While it is part of the systemic circulation, Pringle's manoeuvre is specific to the blood supply entering the liver via the hepatoduodenal ligament, not individual gastric vessels.

Q: Regarding carcinoma gall bladder following features are true except:

Squamous cell carcinoma is 40% of all cases. ***Squamous cell carcinoma is 40% of all cases*** - This statement is incorrect because **adenocarcinoma** accounts for approximately 90% of all gallbladder carcinomas, while squamous cell carcinoma is rare, representing only about 1-5% of cases. - The vast majority of gallbladder cancers are of glandular origin, reflecting the epithelial lining of the organ. *One can have similar presentation with benign biliary disease* - This is true because symptoms of gallbladder carcinoma such as **right upper quadrant pain**, nausea, and jaundice can mimic those of **gallstones** or cholecystitis, leading to delayed diagnosis. - The **non-specific nature** of early symptoms makes differentiation from benign conditions challenging without further investigation. *Most patients present with advanced disease* - This is true due to the gallbladder's deep anatomical location and the **non-specific nature** of early symptoms, leading to late detection. - Consequently, by the time symptoms become significant enough for diagnosis, the cancer has often **metastasized** or invaded surrounding structures. *Prognosis is poor* - This is true, largely because the disease is typically diagnosed at an **advanced stage** with regional or distant metastasis. - The **aggressive biological behavior** of gallbladder cancer and its resistance to conventional therapies also contribute to a poor prognosis.

Question 1

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 2

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 3

What type of choledochal cyst is shown in the image?

Accepted Answer

2

Answer

1

Answer

3

Answer

4

Question 4

Which is correct about hematemesis (upper GI bleeding) in this patient?

Accepted Answer

Rockall scoring is used for risk stratification

Answer

Most common is variceal bleeding

Answer

Occurs only if bleeding occurs proximal to ligament of Treitz

Answer

MC management is endoscopic banding

Question 5

The image shows: (DNB Pattern 2018)

Accepted Answer

Postoperative T- Tube cholangiogram

Answer

ERCP

Answer

HIDA scan

Answer

Oral cholecystography

Question 6

The following image shows: (DNB Pattern 2018)

Accepted Answer

ERCP

Answer

Percutaneous cholangiography

Answer

Oral cholecystography

Answer

T-Tube cholangiogram

Question 7

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 8

The percutaneous PAIR therapy used in the treatment of uncomplicated hepatic hydatid cyst can be associated with the following complications, except

Accepted Answer

bradycardia

Answer

hypotension

Answer

vomiting

Answer

anaphylaxis

Question 9

Pringle's manoeuvre is done to stop bleeding at:

Accepted Answer

Hepatoduodenal ligament

Answer

Splenic artery

Answer

Renal artery

Answer

Left gastric artery

Question 10

Regarding carcinoma gall bladder following features are true except:

Accepted Answer

Squamous cell carcinoma is 40% of all cases

Answer

One can have similar presentation with benign biliary disease

Answer

Most patients present with advanced disease

Answer

Prognosis is poor

Hepatobiliary Surgery — MCQs

Hepatobiliary Surgery — MCQs

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