Hepatobiliary Surgery Practice Questions

Q: A 45-year-old woman undergoes laparoscopic cholecystectomy. On postoperative day 3, she develops right upper quadrant pain, fever, and jaundice. Her bilirubin rises from 1.2 to 8.5 mg/dL. ERCP shows extravasation of contrast from the common bile duct. What is the most likely cause of this complication?

Iatrogenic bile duct injury during dissection. ***Iatrogenic bile duct injury during dissection*** - The combination of **postoperative right upper quadrant pain**, **fever**, **jaundice**, and **rising bilirubin** following laparoscopic cholecystectomy, along with **extravasation of contrast from the common bile duct on ERCP**, is highly indicative of an iatrogenic bile duct injury incurred during the surgery. - This injury can lead to **bile leakage** (causing pain and peritonitis-like symptoms) and **obstruction** (leading to jaundice and hyperbilirubinemia). *Retained common bile duct stone* - While a retained CBD stone can cause **postoperative jaundice** and **pain**, the ERCP finding of **contrast extravasation** strongly points to a structural injury rather than simple obstruction by a calculus. - A retained stone would typically show a **filling deficit** or obstruction, not leakage of contrast. *Cystic artery injury with bleeding* - A **cystic artery injury** would primarily cause **hemorrhage**, leading to symptoms like **anemia**, **hypotension**, and potentially a **hematoma**, but it would not explain the **jaundice** or **contrast extravasation from the common bile duct**. - Internal bleeding would typically manifest differently, without direct evidence of bile duct compromise. *Postoperative sphincter of Oddi dysfunction* - **Sphincter of Oddi dysfunction** can cause **biliary pain** and elevated liver enzymes, but it typically presents as an **obstruction to bile flow**, not as **extravasation of contrast** from the common bile duct. - It would not explain the clear evidence of a **ductal leak** seen on ERCP.

Q: A 65-year-old man with cirrhosis (Child-Pugh B) and hepatocellular carcinoma presents with a 4 cm tumor. He has portal hypertension with esophageal varices and ascites. His MELD score is 18. Evaluate the optimal treatment strategy considering tumor stage, liver function, and available therapies.

Liver transplantation evaluation. ***Liver transplantation evaluation*** - The presence of a 4 cm hepatocellular carcinoma within a background of advanced cirrhosis (Child-Pugh B, MELD 18) and portal hypertension (esophageal varices, ascites) makes **liver transplantation** the optimal treatment strategy. This addresses both the tumor and the underlying liver disease. - According to the **Milan criteria**, a single tumor up to 5 cm (or up to 3 tumors, each 3 cm or less) is within transplant eligibility, offering the best chance for long-term survival for appropriate candidates. *Sorafenib chemotherapy* - **Sorafenib** is a systemic therapy typically reserved for advanced HCC that is **not amenable to locoregional or surgical therapies**, or in cases of metastatic disease. - Given the tumor size and the patient's liver function, a more definitive and potentially curative option like transplantation should be considered first. *Radiofrequency ablation of the tumor* - **Radiofrequency ablation (RFA)** is a locoregional therapy often used for small HCCs, typically **< 3 cm**, in patients with good liver function. - A 4 cm tumor might be less effectively treated by RFA, and the patient's compromised liver function and portal hypertension make even effective local control less beneficial without addressing the underlying liver disease. *Transarterial chemoembolization (TACE)* - **TACE** is a locoregional treatment for intermediate-stage HCC (often multiple tumors or larger tumors not suitable for RFA or surgery). It is **not considered curative**. - While TACE can control tumor growth, it does not treat the underlying advanced liver disease, which is a major factor in this patient's prognosis.

Q: The following procedure is performed for the management of?

Distal cholangiocarcinoma. ***Distal cholangiocarcinoma*** - The image shows a **Pylorus-preserving Whipple procedure (PPPD)**, which involves resection of the pancreatic head, duodenum, gallbladder, and part of the common bile duct, followed by reconstruction. - This procedure is primarily performed for malignancies of the **pancreatic head**, **distal bile duct (cholangiocarcinoma)**, and **ampulla of Vater**, as they often cause obstructive jaundice and are resectable. *Gallbladder carcinoma* - While gallbladder carcinoma can involve the bile ducts, this specific reconstruction (PPPD) is more commonly associated with tumors of the pancreatic head or distal bile duct rather than the gallbladder itself, which might be managed with a **cholecystectomy** and possibly **liver resection**. - The type of resection and reconstruction varies significantly based on the extent and location of gallbladder cancer. *Chronic calcific pancreatitis* - Surgical management for chronic pancreatitis, especially with calcifications, typically involves drainage procedures (e.g., **Puestow procedure** due to dilated pancreatic duct or **Frey procedure**) or resection of the pancreatic head (e.g., **Beger procedure**). - While some resections of the pancreatic head are performed for chronic pancreatitis, the depicted procedure is specifically designed for malignancies of the pancreatic head region, not primarily for the sequelae of chronic calcific pancreatitis unless associated with a mass suspicious for malignancy. *Advanced gastric carcinoma* - Advanced gastric carcinoma is typically managed by **gastrectomy** (partial or total) with lymphadenectomy, not a Whipple procedure. - The image clearly shows an **intact pylorus** and the stomach mostly preserved, which is inconsistent with advanced gastric carcinoma requiring major gastric resection.

Q: All the following are true about acute cholecystitis, except

Preferential visualization of gall bladder in HIDA scan. ***Preferential visualization of gall bladder in HIDA scan*** - In acute cholecystitis, the **cystic duct** becomes obstructed, preventing bile flow into the gallbladder. - A **HIDA scan** (hepatobiliary iminodiacetic acid scan) would show **non-visualization of the gallbladder** due to this obstruction, not preferential visualization. *Gall bladder thickness >3 mm on USG* - An **ultrasound (USG)** finding of gallbladder wall thickening **greater than 3 mm** is a common indicator of inflammation in acute cholecystitis. - This thickening is due to **edema** and inflammation of the gallbladder wall. *Murphy's sign positive* - A **positive Murphy's sign** involves tenderness and an inspiratory arrest upon palpation of the right upper quadrant, specifically over the gallbladder. - This clinical sign is a **classic indicator** of acute cholecystitis. *Leukocytosis* - **Leukocytosis**, an elevated white blood cell count, is a common systemic inflammatory response seen in acute cholecystitis. - It reflects the body's reaction to the **inflammation and possible infection** within the gallbladder.

Q: A 34-year-old patient presents with severe pain in the right upper quadrant that radiates to the right shoulder. During laparoscopic cholecystectomy, which of the following anatomical spaces must be carefully identified to prevent bile duct injury?

Calot's triangle. ***Calot's triangle*** - **Calot's triangle** is the critical anatomical landmark containing the **cystic artery** and **cystic duct**, whose proper identification is essential to prevent injury to the hepatic artery or bile ducts during cholecystectomy. - Its boundaries are the **cystic duct** (lateral), the **common hepatic duct** (medial), and the **inferior border of the liver** (superior, sometimes described as the cystic artery). *Foramen of Winslow* - The **Foramen of Winslow** (epiploic foramen) is an opening connecting the **greater and lesser sacs** of the peritoneal cavity. - It is not directly relevant to identifying structures during cholecystectomy, but rather to accessing the lesser sac or for surgical procedures involving structures like the portal triad. *Lesser sac* - The **lesser sac** (omental bursa) is a peritoneal cavity posterior to the stomach and lesser omentum. - It is explored in procedures involving the pancreas, posterior gastric wall, or for assessing fluid collections, but not for direct identification of cystic structures during standard cholecystectomy. *Morrison's pouch* - **Morrison's pouch** is the **hepatorenal recess**, a potential space between the posterior aspect of the liver and the right kidney and adrenal gland. - It is a common site for **fluid accumulation** (e.g., ascites, blood) but is not directly incised or dissected for preventing bile duct injury during cholecystectomy.

Q: A 43-year-old Caucasian woman is admitted to the hospital with acute onset right upper quadrant (RUQ) pain. The pain started 6 hours ago after the patient had a large meal at a birthday party and has progressively worsened. She recalls having similar pain before but not so intense. No significant past medical history. Current medications are only oral contraceptive. Vitals are blood pressure 140/80 mm Hg, heart rate 79/min, respiratory rate 14/min, and temperature 37.6℃ (99.7℉). The patient’s BMI is 36.3 kg/m2. On exam, the patient appears slightly jaundiced. Her cardiac and respiratory examinations are within normal limits. Abdominal palpation reveals tenderness to palpation in the RUQ with no rebound or guarding, and there is an inspiratory arrest on deep palpation in this region. The remainder of the examination is within normal limits. Laboratory tests are significant for the following: RBC count 4.1 million/mm3 Hb 13.4 mg/dL Leukocyte count 11,200/mm3 ESR 22 mm/hr Platelet count 230,000/mm3 Total bilirubin 2 mg/dL Direct bilirubin 1.1 mg/dL ALT 20 IU/L AST 18 IU/L Amylase 33 IU/L Ultrasound of the abdomen shows the following result (see image): The common bile duct (CBD) (not shown in the image) is not dilated. Which of the following procedures is most appropriate for the treatment of this patient?

Laparoscopic cholecystectomy. ***Laparoscopic cholecystectomy*** - This patient presents with acute cholecystitis, characterized by **RUQ pain**, **Murphy's sign**, **leukocytosis**, and ultrasound findings of sludge and **gallstones** without **CBD dilation**. Laparoscopic cholecystectomy is the **definitive treatment** for symptomatic gallstones and acute cholecystitis. - The patient's presentation with **biliary colic** that progressed to acute cholecystitis, along with risk factors like being **female**, **obese (BMI 36.3)**, **multiparity (implied by oral contraceptive use)**, and **fair complexion**, aligns with the "4 F's" (Female, Fat, Forty, Fertile) of gallstone disease. *Shock wave lithotripsy* - **Extracorporeal shock wave lithotripsy** is generally reserved for **single, small, non-calcified gallstones** in patients who are not surgical candidates. - It is **not effective** for multiple gallstones, sludge, or the inflammation associated with acute cholecystitis. *Endoscopic retrograde cholangiopancreatography* - **ERCP** is primarily a therapeutic procedure used to **remove stones from the common bile duct** or to relieve obstruction. - In this case, the **common bile duct is not dilated**, and there is no clear indication of **choledocholithiasis** or **cholangitis**, making ERCP unnecessary as the initial treatment. *Percutaneous cholecystostomy* - **Percutaneous cholecystostomy** involves placing a drainage tube into the gallbladder. - This procedure is usually considered a **bridge to surgery** or a definitive treatment for **critically ill patients** with acute cholecystitis who are not stable enough for a cholecystectomy.

Q: A 52-year-old woman comes to the emergency department because of epigastric abdominal pain that started after her last meal and has become progressively worse over the past 6 hours. She has had intermittent pain similar to this before, but it has never lasted this long. Her temperature is 39°C (102.2°F). Examination shows a soft abdomen with normal bowel sounds. The patient has sudden inspiratory arrest during right upper quadrant palpation. Her alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges. Abdominal imaging is most likely to show which of the following findings?

Gallstone in the cystic duct. ***Gallstone in the cystic duct*** - The patient presents with classic symptoms of **acute cholecystitis**: postprandial epigastric pain worsening over hours, fever (39°C), and a **positive Murphy's sign** (sudden inspiratory arrest during right upper quadrant palpation). In acute cholecystitis, a **gallstone** typically obstructs the **cystic duct**, leading to inflammation of the gallbladder. - The **normal liver enzymes (AST, total bilirubin, alkaline phosphatase)** and **normal amylase** rule out choledocholithiasis, cholangitis, hepatitis, and pancreatitis. Therefore, imaging would confirm the presence of a gallstone in the cystic duct and associated gallbladder inflammation. *Enlargement of the pancreas with peripancreatic fluid* - This finding suggests **acute pancreatitis**, which is unlikely given the **normal amylase levels** in this patient. - While gallstones can cause pancreatitis (gallstone pancreatitis), the specific obstructive symptoms and normal amylase point away from an active pancreatic inflammation. *Fistula formation between the gallbladder and bowel* - **Fistula formation** between the gallbladder and bowel (e.g., cholecystoenteric fistula) is a complication of chronic or severe cholecystitis and is usually associated with recurrent infections, not the acute presentation described. - This complication can lead to gallstone ileus, and patients often have a history of chronic cholecystitis rather than a first severe episode of acute pain. *Dilated common bile duct with intrahepatic biliary dilatation* - This finding would suggest **obstructive jaundice** due to a blockage in the common bile duct, such as a **choledocholithiasis** or stricture. - The patient's **normal total bilirubin and alkaline phosphatase levels** make significant common bile duct obstruction highly unlikely.

Q: 32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?

Ultrasound. ***Ultrasound*** - **Ultrasound** is the initial and often definitive investigation for suspected **gallbladder pathology** like cholecystitis, especially given the symptoms of fever and **right upper quadrant pain post-meals**. - It effectively visualizes **gallstones**, gallbladder wall thickening, and **pericholecystic fluid**, which are key indicators of cholecystitis. *CT scan* - A **CT scan** is generally not the first-line investigation for acute cholecystitis due to **radiation exposure** and its **lower sensitivity** for gallstones compared to ultrasound. - While it can identify complications like abscesses or perforations, it is usually reserved for **ambiguous ultrasound findings** or suspected complications. *ERCP (Endoscopic Retrograde Cholangiopancreatography)* - **ERCP** is an **invasive procedure** primarily used therapeutically for the removal of **bile duct stones** or for stent placement in cases of obstruction. - It carries risks of **pancreatitis** and perforation, making it unsuitable as an initial diagnostic tool for simple cholecystitis. *MRCP (Magnetic Resonance Cholangiopancreatography)* - **MRCP** is a **non-invasive imaging technique** that provides detailed images of the **biliary and pancreatic ducts** without radiation, primarily useful for confirming suspected bile duct stones or strictures. - While excellent for ductal anatomy, it is **not typically the first choice** for acute cholecystitis, as ultrasound is quicker, cheaper, and sufficient for initial diagnosis.

Question 1

A 45-year-old woman undergoes laparoscopic cholecystectomy. On postoperative day 3, she develops right upper quadrant pain, fever, and jaundice. Her bilirubin rises from 1.2 to 8.5 mg/dL. ERCP shows extravasation of contrast from the common bile duct. What is the most likely cause of this complication?

Accepted Answer

Iatrogenic bile duct injury during dissection

Answer

Retained common bile duct stone

Answer

Cystic artery injury with bleeding

Answer

Postoperative sphincter of Oddi dysfunction

Question 2

A 65-year-old man with cirrhosis (Child-Pugh B) and hepatocellular carcinoma presents with a 4 cm tumor. He has portal hypertension with esophageal varices and ascites. His MELD score is 18. Evaluate the optimal treatment strategy considering tumor stage, liver function, and available therapies.

Accepted Answer

Liver transplantation evaluation

Answer

Sorafenib chemotherapy

Answer

Radiofrequency ablation of the tumor

Answer

Transarterial chemoembolization (TACE)

Question 3

A 72-year-old man with severe coronary artery disease, ejection fraction 25%, and recent MI 6 weeks ago presents with acute cholangitis (Charcot's triad). Blood cultures grow E. coli, and ERCP shows choledocholithiasis with biliary obstruction. His surgical risk is prohibitive. Evaluate the best management strategy that balances infection control, biliary drainage, and cardiac risk.

Accepted Answer

ERCP with biliary stent placement and indefinite medical management

Answer

Emergency cholecystectomy with common bile duct exploration

Answer

Percutaneous transhepatic biliary drainage followed by staged procedures

Answer

ERCP with sphincterotomy and stone extraction followed by elective cholecystectomy

Question 4

A patient is found to have an asymptomatic common bile duct (CBD) stone two years after cholecystectomy on routine imaging. What is the most appropriate initial management?

Accepted Answer

ERCP with sphincterotomy and stone extraction

Answer

Keep on active surveillance

Answer

Medical dissolution therapy with ursodeoxycholic acid

Answer

Surgical exploration and choledochotomy

Question 5

The following procedure is performed for the management of?

Accepted Answer

Distal cholangiocarcinoma

Answer

Gallbladder carcinoma

Answer

Chronic calcific pancreatitis

Answer

Advanced gastric carcinoma

Question 6

All the following are true about acute cholecystitis, except

Accepted Answer

Preferential visualization of gall bladder in HIDA scan

Answer

Gall bladder thickness >3 mm on USG

Answer

Murphy's sign positive

Answer

Leukocytosis

Question 7

A 34-year-old patient presents with severe pain in the right upper quadrant that radiates to the right shoulder. During laparoscopic cholecystectomy, which of the following anatomical spaces must be carefully identified to prevent bile duct injury?

Accepted Answer

Calot's triangle

Answer

Foramen of Winslow

Answer

Lesser sac

Answer

Morrison's pouch

Question 8

A 43-year-old Caucasian woman is admitted to the hospital with acute onset right upper quadrant (RUQ) pain. The pain started 6 hours ago after the patient had a large meal at a birthday party and has progressively worsened. She recalls having similar pain before but not so intense. No significant past medical history. Current medications are only oral contraceptive. Vitals are blood pressure 140/80 mm Hg, heart rate 79/min, respiratory rate 14/min, and temperature 37.6℃ (99.7℉). The patient’s BMI is 36.3 kg/m2. On exam, the patient appears slightly jaundiced. Her cardiac and respiratory examinations are within normal limits. Abdominal palpation reveals tenderness to palpation in the RUQ with no rebound or guarding, and there is an inspiratory arrest on deep palpation in this region. The remainder of the examination is within normal limits.
Laboratory tests are significant for the following:
RBC count 4.1 million/mm3
Hb 13.4 mg/dL
Leukocyte count 11,200/mm3
ESR 22 mm/hr
Platelet count 230,000/mm3
Total bilirubin 2 mg/dL
Direct bilirubin 1.1 mg/dL
ALT 20 IU/L
AST 18 IU/L
Amylase 33 IU/L
Ultrasound of the abdomen shows the following result (see image):
The common bile duct (CBD) (not shown in the image) is not dilated. Which of the following procedures is most appropriate for the treatment of this patient?

Accepted Answer

Laparoscopic cholecystectomy

Answer

Shock wave lithotripsy

Answer

Endoscopic retrograde cholangiopancreatography

Answer

Percutaneous cholecystostomy

Question 9

A 52-year-old woman comes to the emergency department because of epigastric abdominal pain that started after her last meal and has become progressively worse over the past 6 hours. She has had intermittent pain similar to this before, but it has never lasted this long. Her temperature is 39°C (102.2°F). Examination shows a soft abdomen with normal bowel sounds. The patient has sudden inspiratory arrest during right upper quadrant palpation. Her alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges. Abdominal imaging is most likely to show which of the following findings?

Accepted Answer

Gallstone in the cystic duct

Answer

Enlargement of the pancreas with peripancreatic fluid

Answer

Fistula formation between the gallbladder and bowel

Answer

Dilated common bile duct with intrahepatic biliary dilatation

Question 10

32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?

Accepted Answer

Ultrasound

Answer

CT scan

Answer

ERCP (Endoscopic Retrograde Cholangiopancreatography)

Answer

MRCP (Magnetic Resonance Cholangiopancreatography)

Hepatobiliary Surgery — MCQs

Hepatobiliary Surgery — MCQs

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