Hepatobiliary And Pancreatic Surgery (100q).1
Questions and Answers
- 1.
Which of the following statements about the segmental anatomy of the liver are not true?
- A.
Segments are subdivisions in both the French and American systems.
- B.
Segments are determined primarily by the hepatic venous drainage
- C.
The French anatomic system is more applicable than the American system to clinical hepatic resection
- D.
Segments are important to the understanding of the topographic anatomy of the liver
Correct Answer
D. Segments are important to the understanding of the topographic anatomy of the liverExplanation
Segments are the major subdivision of the right and left lobes of the liver. In either the classic lobar (American) or the segmental (French) system, the most variable aspect is the biliary system. Therefore the hepatic venous or portal system defines most segments. The French system depicts eight segments, with the caudate lobe as segment I and the other seven segments defined primarily by the hepatic venous system. Segments are not well-depicted by topography.Rate this question:
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- 2.
Which of the following statements most accurately describes the current therapy for pyogenic hepatic abscess?
- A.
Antibiotics alone are adequate for the treatment of most cases.
- B.
All patients require open surgical drainage for optimal management
- C.
Optimal treatment involves treatment of not only the abscess but the underlying source as well.
- D.
Percutaneous drainage is more successful for multiple lesions than for solitary ones
Correct Answer
C. Optimal treatment involves treatment of not only the abscess but the underlying source as well.Explanation
The development of ultrasonography and computed tomography (CT) in the past two decades has enabled earlier diagnosis and advances in treatment of hepatic abscess. Formerly, open surgical drainage was considered necessary in essentially all cases of pyogenic abscess. Numerous recent series, however, have reported high success rates and low mortality from the percutaneous catheter drainage of abscesses under CT or ultrasonographic guidance. Optimal management of pyogenic abscess, however, involves not only treatment of the abscess, whether by percutaneous or surgical methods, but correction of the underlying source as well. All modes of therapy are more successful in treating solitary lesions than multiple ones.Rate this question:
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- 3.
Which of the following statement(s) is/are true about benign lesions of the liver?
- A.
Adenomas are true neoplasms with a predisposition for complications and should usually be resected
- B.
Focal nodular hyperplasia (FNH) is a neoplasm related to birth control pills (BCPs) and usually requires resection
- C.
Hemangiomas are the most common benign lesions of the liver that come to the surgeon's attention
- D.
Nodular regenerative hyperplasia does not usually accompany cirrhosis.
Correct Answer
A. Adenomas are true neoplasms with a predisposition for complications and should usually be resectedExplanation
Adenomas typically enlarge and cause symptoms, may rupture, and have a definite malignant potential. Therefore they should generally be resected when found. FNH is not a true neoplasm and generally has an uneventful course. Both are related to BCPs, although the relationship of adenoma is more firmly established. While small bile duct hamartomas are much more common, hemangiomas are the most common lesion to come to the attention of surgeons. They should not generally be biopsied because of possible hemorrhage. By definition, nodular regenerative hyperplasia occurs in the absence of cirrhosis.Rate this question:
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- 4.
Which of the following statement(s) is/are true about bile duct cancers?
- A.
If resected, proximal lesions are usually curable
- B.
The more proximal the lesion, the more likely is resection to be curative.
- C.
Radiation clearly prolongs survival
- D.
Transplantation is usually successful if the lesion seems confined to the liver
- E.
None of the above is true.
Correct Answer
E. None of the above is true.Explanation
Most bile duct cancers are discovered after they are incurable, and only a tiny subset of resected proximal lesions are cured. The more distal the lesion, the more likely is resection to achieve cure (e.g., approximately 30% 5-year survival for periampullary lesions as compared with 0% to 10% for hilar lesions). The use of adjuvant or primary radiation remains controversial because of the heterogeneity of the patient populations on which this modality has been used. Because of the localized nature of this disease it would seem that transplantation would produce favorable results; however, this has not been the case.Rate this question:
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- 5.
Which of the following statements about hemobilia are true?
- A.
Tumors are the most common cause.
- B.
The primary treatment of severe hemobilia is an operation.
- C.
Percutaneous cholangiographic hemobilia is usually minor
- D.
Ultrasonography usually reveals a specific diagnosis
Correct Answer
C. Percutaneous cholangiographic hemobilia is usually minorExplanation
By far the most common cause of hemobilia is trauma. Tumors also may cause the syndrome but are relatively uncommon causes. For severe hemobilia the best therapy is arteriographic embolization. Usually the site of bleeding or a false aneurysm can be identified. Operation should be reserved as a last resort or when the condition is recognized intraoperatively. Percutaneous cholangiography–associated intrabiliary hemorrhage is usually, but not always, minor and self-limiting. Ultrasonography is a very nonspecific diagnostic technique for hemobilia. Arteriography remains the best diagnostic method.Rate this question:
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- 6.
Ligation of all of the following arteries usually causes significant hepatic enzyme abnormalities except:
- A.
Ligation of the right hepatic artery
- B.
Ligation of the left hepatic artery
- C.
Ligation of the hepatic artery distal to the gastroduodenal branch
- D.
Ligation of the hepatic artery proximal to the gastroduodenal artery
Correct Answer
D. Ligation of the hepatic artery proximal to the gastroduodenal arteryExplanation
Ligation of the right or left hepatic artery frequently causes enzyme elevation but is usually tolerated by the patient, particularly when this is a life-saving maneuver. Ligation of the hepatic artery distal to the gastroduodenal branch is more risky but is also usually tolerated. Ligation of the hepatic artery proximal to the gastroduodenal one does not normally cause enzyme abnormalities because of abundant collateral flow through that branch.Rate this question:
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- 7.
Which of the following is the most common acid-base disturbance in patients with cirrhosis and portal hypertension?
- A.
Metabolic acidosis.
- B.
Respiratory alkalosis.
- C.
Metabolic alkalosis
- D.
Respiratory acidosis.
Correct Answer
C. Metabolic alkalosisExplanation
Metabolic alkalosis and hypokalemia are common in patients with cirrhosis because they often have associated secondary hyperaldosteronism (especially those with ascites), diarrhea, and frequent emesis. Hyperaldosteronism enhances H+ and K+ exchange for Na+ in the distal tubule of the kidney. The cause of diarrhea in patients with cirrhosis is unknown, but malabsorption secondary to splanchnic venous hypertension may be a contributing factor. Emesis is common in alcoholic cirrhotics and patients with tense ascites. Deleterious effects of metabolic alkalosis include impaired tissue oxygen delivery secondary to shift of the oxyhemoglobin dissociation curve to the left and conversion of ammonium chloride to ammonia, which may contribute to encephalopathy.Rate this question:
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- 8.
Which of the following is the most effective definitive therapy for both prevention of recurrent variceal hemorrhage and control of ascites?
- A.
Endoscopic sclerotherapy.
- B.
Distal splenorenal shunt
- C.
Esophagogastric devascularization (Sugiura procedure).
- D.
Side-to-side portacaval shunt
- E.
End-to-side portacaval shunt
Correct Answer
D. Side-to-side portacaval shuntExplanation
Shunt operations are the most effective means of preventing recurrent variceal hemorrhage. Rebleeding rates after endoscopic sclerotherapy range from 40% to 60%. Although extensive esophagogastric devascularization has effectively prevented recurrent bleeding in Japanese series, these operations have been followed by rebleeding rates in excess of 25% in most Western series. Although one controlled trial has shown more frequent recurrent hemorrhage following the distal splenorenal shunt than after the portacaval shunt, most series have reported rebleeding rates of less than 10% for both of these operations. Both the liver and the splanchnic viscera are important sites of ascites formation. Since the distal splenorenal shunt maintains sinusoidal and mesenteric venous hypertension and requires interruption of important retroperitoneal lymphatics, it tends to aggravate rather than relieve ascites. Hepatic sinusoidal pressure may be unchanged or even increased after an end-to-side portacaval shunt. Only side-to-side portal-systemic shunts, such as the side-to-side portacaval shunt, reliably decompress both the liver and splanchnic viscera, thus preventing ascites formation.Rate this question:
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- 9.
Which of the following treatments most effectively preserves hepatic portal perfusion?
- A.
Distal splenorenal shunt.
- B.
Conventional splenorenal shunt
- C.
Endoscopic sclerotherapy.
- D.
Side-to-side portacaval shunt
Correct Answer
C. Endoscopic sclerotherapy.Explanation
The conventional splenorenal shunt and side-to-side portacaval shunts completely divert portal flow away from the liver (nonselective shunts). The distal splenorenal shunt is a selective shunt that preserves hepatic portal perfusion in the majority of patients; however, the magnitude of portal flow is decreased because the gastrosplenic component is diverted into the renal vein. Additionally, many patients (especially alcoholic cirrhotics) develop collaterals between the mesenteric venous circulation and the shunt, resulting in gradual attrition of the remaining portal flow. Although there have been anecdotal reports of portal vein thrombosis after endoscopic sclerotherapy, two controlled trials have demonstrated better preservation of hepatic portal perfusion in sclerotherapy patients than in persons who receive the distal splenorenal shuntRate this question:
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- 10.
Which of the following veins is preserved in performing the extensive esophagogastric devascularization procedure described by Sugiura?
- A.
Left gastric (coronary) vein
- B.
Short gastric vein.
- C.
Splenic vein.
- D.
Left gastroepiploic vein.
Correct Answer
A. Left gastric (coronary) veinExplanation
The Sugiura procedure consists of devascularization of the esophagus to the inferior pulmonary vein and the proximal two thirds of the stomach, splenectomy, and distal esophageal transection. The devascularization component should be done as close to the esophagus and stomach as possible. The coronary vein and paraesophageal collaterals are preserved to maintain an effective portal-systemic collateral pathway and thereby discourage reformation of varices.Rate this question:
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- 11.
Which of the following complications of portal hypertension often require surgical intervention (for more than 25% of patients)?
- A.
Hypersplenism
- B.
Variceal hemorrhage.
- C.
Ascites
- D.
Encephalopathy
Correct Answer
B. Variceal hemorrhage.Explanation
While many patients with portal hypertension develop hypersplenism, it is rarely clinically significant. A splenectomy should not be performed unless platelet counts are persistently less than 20,000 per cu. mm. or white blood cell counts are less than 1200 per cu. mm. Unfortunately, splenectomy is sometimes done for clinically insignificant hypersplenism, thus obviating a distal splenorenal shunt if the patient should subsequently bleed from varices. The initial treatment for most patients with bleeding esophageal varices should be endoscopic sclerotherapy; however, operation is required for the approximately one third of patients who fail sclerotherapy and for noncompliant persons, those living in remote geographic locations, and patients bleeding from gastric varices. Ascites can be controlled by a medical regimen of dietary salt restriction and diuretic therapy in more than 95% of patients. When ascites is intractable to medical management, either intermittent large-volume paracenteses or a surgical peritoneovenous shunt should be done. With rare exceptions, encephalopathy should be treated medically. Most important is elimination of any precipitating factors that led to the neuropsychological disturbance. Lactulose, neomycin, and dietary protein restriction may also be components of the medical treatment regimen.Rate this question:
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- 12.
Which of the following clinical situations are considered good indications for PVS?
- A.
A 50-year-old cirrhotic man had an emergency portacaval shunt for bleeding varices and postoperatively had an ascites leak and mild superficial wound infection.
- B.
A 57-year-old woman with primary biliary cirrhosis (PBC) has difficult to control ascites and diuretic-induced encephalopathy
- C.
A 46-year-old resistant alcoholic has chronic ascites uncontrolled by diuretics combined with repeat paracentesis
- D.
A 34-year-old woman taking BCPs had rapid onset of ascites and is found to have hepatic vein thrombosis causing the Budd-Chiari syndrome
Correct Answer
C. A 46-year-old resistant alcoholic has chronic ascites uncontrolled by diuretics combined with repeat paracentesisExplanation
Because of the high complication rate and the long-term failure rate, the PVS is used only when other, more lasting options for therapy either are not available or are contraindicated. The chronic alcoholic patient may benefit from a peritoneovenous shunt because his ascites is the dominant problem related to his chronic liver disease, and persistent alcoholism is a contraindication to liver replacement in most centers. PVS may be quite effective for the temporary management of acute intractable postoperative ascites, such as in patient A; however, it is absolutely contraindicated in the presence of infection. Patient B has ascites as her dominant problem as well; however, with PBC as the underlying liver disease, she is an excellent candidate for transplantation. Patient D also has ascites as the major problem; however, the side-to-side portosystemic shunt is a far better long-term treatment option than PVS.Rate this question:
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- 13.
Which of the following statements about biliary tract problems are correct?
- A.
Choledochal cyst should be treated by Roux-en-Y cystojejunostomy
- B.
Sclerosing cholangitis is characterized by long, narrow strictures in the extrahepatic biliary duct system
- C.
Operative (needle) cholangiography is indicated in patients who at operation appear to have no gallbladder
- D.
The long cystic duct, which appears to be fused with the common duct and enters it distally, should be dissected free and ligated at its entrance into the common duct.
Correct Answer
C. Operative (needle) cholangiography is indicated in patients who at operation appear to have no gallbladderExplanation
In the past, choledochal cyst was treated by Roux-en-Y cystojejunostomy, but long-term results were poor. Excision of the cyst is essential to prevent recurrent pancreatitis. In addition, the development of carcinoma in about 25% of patients mandates cyst excision. Accordingly, excision of the cyst with biliary reconstruction by Roux-en-Y hepaticojejunostomy and diversion of the flow of pancreatic juice through the ampulla of Vater is currently the standard treatment. Sclerosing cholangitis causes fibrosis of bile ducts both within and outside the liver. This process, which is poorly understood, causes strictures in the duct system, characteristically with normal or dilated segments between strictures. Unfortunately, this anatomic arrangement does not lend itself to biliary reconstructive procedures. Each case must be analyzed, however, because in some patients the anatomic situation may lend itself to balloon dilatation or reconstruction. When the gallbladder appears to be absent, a search should be made for an ectopically located organ in the retroduodenal area, within the falciform ligament, and within the substance of the right lobe of the liver. With true gallbladder agenesis the common duct may be dilated, and choledocholithiasis is present in about one fourth of those who undergo operation. Therefore, operative needle cholangiography should always be done. Dissection of a long, fused cystic duct is fraught with hazard because the cystic and common ducts may share a common wall and serious duct damage may occur. The cystic duct should be ligated and divided immediately proximal to the area of fusion.Rate this question:
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- 14.
Which of the following are indications for cholecystectomy?
- A.
The presence of gallstones in a patient with intermittent episodes of right-side upper quadrant pain
- B.
The presence of gallstones in an asymptomatic patient
- C.
The presence of symptomatic gallstones in a patient with angina pectoris.
- D.
The presence of asymptomatic gallstones in a patient who has insulin-dependent diabetes.
Correct Answer
A. The presence of gallstones in a patient with intermittent episodes of right-side upper quadrant painExplanation
Cholecystectomy (and concomitant operative cholangiography) are indicated for symptomatic patients to relieve pain and to prevent the development of acute cholecystitis and its complications. Morbidity and expense are not as great for elective cholecystectomy as they are for cholecystectomy for acute cholelithiasis. The risk of the development of symptoms in patients who have asymptomatic stones is approximately 2% per year, a rate associated with mortality and morbidity that do not exceed those of elective cholecystectomy. Therefore, cholecystectomy is not indicated for asymptomatic patients. Patients who have angina pectoris should not have cholecystectomy until their coronary artery disease has been treated adequately, even if this requires a coronary artery bypass procedure. Heart disease is the most frequent cause of death after cholecystectomy. Prophylactic cholecystectomy, formerly recommended for insulin-dependent diabetics, is not indicated because several studies have shown that the mortality rate from acute cholecystitis is no higher for diabetics than for nondiabetics.Rate this question:
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- 15.
The initial goal of therapy for acute toxic cholangitis is to:
- A.
Prevent cholangiovenous reflux by decompressing the duct system.
- B.
Remove the obstructing stone, if one is present
- C.
Alleviate jaundice and prevent permanent liver damage.
- D.
Prevent the development of gallstone pancreatitis
Correct Answer
A. Prevent cholangiovenous reflux by decompressing the duct system.Explanation
Uncontrolled sepsis and the consequent multisystem organ failure are the life-threatening sequelae of acute toxic cholangitis. Thus, the initial goal of treatment is to decompress the biliary duct system to prevent reflux of bacteria and their toxic products into the circulation. This can be done by intubating the duct system through the percutaneous, transhepatic, or the endoscopic route or by insertion of a T tube in the common duct at operation. Removal of the stone causing the obstruction is not necessary to stabilize the patient. Only after the duct is decompressed should the cause of the obstruction be addressed. When transhepatic biliary drainage has been used, endoscopic or surgical removal of the stone can be carried out after the patient has recovered completely. When initial therapy is sphincterotomy, the stone should be removed as part of the procedure. Often the stone falls out without manipulation. If surgical placement of a T tube is the initial treatment, the stone should be removed only if it is convenient to do so. The long-range goal of treatment of patients with bile duct obstruction is to prevent cirrhosis, ascites, portal hypertension, and hemorrhage from esophageal varices; however, death from sepsis is the immediate threat in acute toxic cholangitis. Gallstone pancreatitis may occur in patients who have an impacted stone in the distal duct, independent of the presence or absence of acute toxic cholangitis; however, gallstone pancreatitis is more often associated with the passage of a stone into the duodenum.Rate this question:
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- 16.
Which of the following statement(s) about gallstone ileus is/are not true?
- A.
The condition is seen most frequently in women older than 70.
- B.
Concomitant with the bowel obstruction, air is seen in the biliary tree
- C.
The usual fistula underlying the problem is between the gallbladder and the ileum.
- D.
When possible, relief of small bowel obstruction should be accompanied by definitive repair of the fistula since there is a significant incidence of recurrence if the fistula is left in place.
- E.
Ultrasound studies may be of help in identifying a gallstone as the obstructing agent
Correct Answer
C. The usual fistula underlying the problem is between the gallbladder and the ileum.Explanation
It is true that gallstone ileus occurs mostly in elderly women and should always be suspect when small bowel obstruction presents in this age group. The great majority of cases of gallstone ileus are preceded by a spontaneous fistula occurring between the gallbladder and duodenum, allowing gallstones to enter the intestinal tract, which can potentially block the terminal ileum. Finding air within the biliary tree should always arouse suspicion of the possibility of this diagnosis when it is associated with a radiographic pattern of small bowel obstruction. The initial part of the operative approach to this disease is to relieve the bowel obstruction by performing an enterotomy just proximal to the point of obstruction to remove the stone. Where possible, definitive repair of the fistula should be undertaken to avoid recurrent obstruction and to obviate the possible recurring complications of cholangitis. Percutaneous drainage of bile collections combined with endoscopic papillotomy may be sufficient treatment for external and internal biliary fistulas but is never an allowable approach in the presence of gallstone ileus with small bowel obstruction. Relief of the obstruction is mandated in this setting.Rate this question:
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- 17.
Which of the following lesions are believed to be associated with the development of carcinoma of the gallbladder?
- A.
Cholecystoenteric fistula.
- B.
A calcified gallbladder.
- C.
Adenoma of the gallbladder
- D.
Xanthogranulomatous cholecystitis
- E.
All of the above.
Correct Answer
E. All of the above.Explanation
The prevalence of carcinoma of the gallbladder in patients who have or have had a cholecystoenteric fistula is believed to be 15%. The prevalence of carcinoma in a calcified, or “porcelain,” gallbladder is reported to range from 12.5% to 61%. It is generally accepted that adenoma of the gallbladder is a precancerous lesion that presents as a polypoid lesion. Xanthogranulomatous cholecystitis is a rare form of chronic cholecystitis believed to be associated with a higher incidence of cancer. This form of cholecystitis is also important because, grossly, it may mimic cancer of the gallbladder.Rate this question:
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- 18.
The preferred treatment for carcinoma of the gallbladder is:
- A.
Radical resection that includes gallbladder in continuity with the right hepatic lobe and regional lymph node dissection
- B.
Radiation therapy.
- C.
Chemotherapy
- D.
Combined treatment involving surgical therapy, chemotherapy, and radiation.
- E.
None of the above
Correct Answer
E. None of the aboveExplanation
Radical resection, radiation therapy, and chemotherapy have been effective only anecdotally. Most believe that the dismal prognosis of carcinoma of the gallbladder does not justify anything more than palliative treatment. About 88% of patients are dead within a year of diagnosis, and only about 4% are alive after 5 years, regardless of the type of treatment. Those whose surgeon was unaware of the presence of the tumor at the time of cholecystectomy (approximately 12% of cases) are most likely to survive long term. There are insufficient data to support conclusively the proposition that the patient with unexpected carcinoma found on histologic examination should undergo reoperation with intent for radical excision. There also are indirect suggestions that the prognosis of gallbladder carcinoma may be improving, but it is not clear if this is spontaneous or due to either earlier diagnosis or surgical management.Rate this question:
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- 19.
Standard supportive measures for patients with mild pancreatitis include the following:
- A.
Intravenous fluid and electrolyte therapy.
- B.
Withholding of analgesics to allow serial abdominal examinations.
- C.
Subcutaneous octreotide therapy
- D.
Nasogastric decompression
- E.
Prophylactic antibiotics
Correct Answer
A. Intravenous fluid and electrolyte therapy.Explanation
Standard therapy for all patients with mild acute pancreatitis should include intravenous fluid resuscitation, electrolyte replacement, and analgesics. Nasogastric decompression is typically reserved for patients with significant ileus who are at risk for emesis and aspiration. Subcutaneous therapy with octreotide, the octapeptide analog of somatostatin, has not been proven to influence the outcome in patients with mild pancreatitis. Prophylactic antibiotics are not used for mild pancreatitis. Antibiotics are reserved for patients with severe pancreatitis (defined as greater than three Ranson prognostic signs with associated CT evidence of pancreatic or peripancreatic necrosis).Rate this question:
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- 20.
Which of the following statements about chronic pancreatitis is/are correct?
- A.
Chronic pancreatitis is the inevitable result after repeated episodes of acute pancreatitis
- B.
Patients with chronic pancreatitis commonly present with jaundice, pruritus, and fever.
- C.
Mesenteric angiography is useful in the evaluation of many patients with chronic pancreatitis
- D.
Total pancreatectomy usually offers the best outcome in patients with chronic pancreatitis
- E.
For patients with disabling chronic pancreatitis and a dilated pancreatic duct with associated stricture formation, a longitudinal pancreaticojejunostomy (Peustow procedure) is an appropriate surgical option.
Correct Answer
E. For patients with disabling chronic pancreatitis and a dilated pancreatic duct with associated stricture formation, a longitudinal pancreaticojejunostomy (Peustow procedure) is an appropriate surgical option.Explanation
Chronic pancreatitis is a clinical entity that includes recurrent or persistent abdominal pain with evidence of exocrine and endocrine pancreatic insufficiency. While chronic pancreatitis may result from repeated episodes of acute pancreatitis, not all patients with recurring acute pancreatitis progress to chronic pancreatitis. The most common causes of chronic pancreatitis include alcohol abuse, hyperparathyroidism, congenital anomalies of the pancreatic duct, pancreatic trauma, and cystic fibrosis. The most useful radiographic tests in patients with suspected chronic pancreatitis are CT and endoscopic retrograde cholangiopancreatography (ERCP). Mesenteric angiography has no role in the evaluation of most patients with chronic pancreatitis. Patients with disabling chronic pancreatitis who require operative intervention are candidates for a longitudinal pancreaticojejunostomy (Peustow procedure) if pancreatography demonstrates a dilated pancreatic duct. Total pancreatectomy is rarely performed because of the significant problems associated with labile insulin sensitivity, steatorrhea, and weight loss.Rate this question:
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- 21.
Which of the following statements about adenocarcinoma of the pancreas is/are correct?
- A.
It is the fifth most common cause of cancer death in the U.S.
- B.
Most cases occur in the body and tail of the pancreas, making distal pancreatectomy the most commonly performed resectional therapy.
- C.
For cancers of the head of the pancreas resected by pancreaticoduodenectomy, prognosis appears to be independent of nodal status, margin status, or tumor diameter.
- D.
The most accurate screening test involves surveillance of stool for carbohydrate antigen (CA 19–9).
Correct Answer
A. It is the fifth most common cause of cancer death in the U.S.Explanation
Adenocarcinoma of the pancreas is newly diagnosed in approximately 28,000 patients in the United States every year. It is the fifth most common cause of cancer death in the United States, exceeded only by lung, colorectal, breast, and prostate cancer. The majority of cases of adenocarcinoma of the pancreas occur in the head of the gland, and if resectable, are treated via pancreaticoduodenectomy. Recent studies have shown that factors favoring long-term survival after pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas include negative nodal status, negative margin status, small tumor diameter, and diploid DNA content. No accurate screening tests for adenocarcinoma of the pancreas are currently available. The best serologic test appears to be the CA 19–9, which is elevated in the majority of patients with adenocarcinoma of the head of the pancreas. Unfortunately, the test is not sufficiently sensitive or specific, and further screening tests are needed.Rate this question:
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- 22.
A 35-year-old woman presents with episodes of obtundation, somnolence, and tachycardia. An insulinoma is suspected based on a random serum glucose test value of 38 mg. per dl. Which of the following statements is/are true?
- A.
The most important diagnostic study for insulinoma is an oral glucose tolerance test.
- B.
It may be helpful to perform ERCP in an effort to localize the tumor
- C.
Most patients with insulinoma present with extensive disease, rendering them only rarely resectable or curable
- D.
An important component of the preoperative evaluation in patients with presumed insulinoma involves confirming elevated C-peptide or proinsulin levels and screening for anti-insulin antibodies.
Correct Answer
D. An important component of the preoperative evaluation in patients with presumed insulinoma involves confirming elevated C-peptide or proinsulin levels and screening for anti-insulin antibodies.Explanation
Insulinoma is the most common endocrine tumor of the pancreas. Insulinoma is associated with Whipple's triad, which consists of (1) symptoms of hypoglycemia at fasting; (2) documentation of blood glucose levels of less than 50 mg. per dl.; and (3) relief of symptoms following administration of glucose. The most reliable method for diagnosing insulinomas is a monitored fast. Neither an oral or an intravenous glucose tolerance test is indicated in the majority of patients being evaluated for insulinoma. Support for the diagnosis of insulinoma can come from documenting elevated C peptide and proinsulin levels. Screening for anti-insulin antibodies is indicated to rule out the possibility of surreptitious insulin administration. Tumor localization is typically performed with CT, endoscopic ultrasonography, or angiography. ERCP is not indicated for evaluation of most pancreatic endocrine tumors, as the tumors only rarely communicate with the main pancreatic duct system. As many as 90% of patients with insulinoma have benign solitary pancreatic adenomas amenable to surgical cure.Rate this question:
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- 23.
Pancreas divisum results from incomplete fusion of the ventral pancreatic duct with the dorsal pancreatic duct during embryologic development. Which of the following statements correctly describes pancreas divisum?
- A.
The body and tail of the pancreas drain via an accessory ampulla distal to the ampulla of Vater. The uncinate process drains via the ampulla of Vatercorrectly describes pancreas divisum?
- B.
The entire pancreatic ductal system drains via the ampulla of Vater
- C.
The entire pancreatic ductal system drains via an accessory ampulla proximal to the ampulla of Vater
- D.
The body and tail of the pancreas are absent. The uncinate process drains via the ampulla of Vater
Correct Answer
C. The entire pancreatic ductal system drains via an accessory ampulla proximal to the ampulla of VaterExplanation
In 90% of individuals, the main pancreatic duct, or duct of Wirsung, runs the entire length of the pancreas and joins the common bile duct to empty into the duodenum at the ampulla of Vater. The pancreatic duct is 2 to 3.5 mm in diameter and contains 20 secondary branches, which drain the tail, body, and uncinate process. The drainage of the lesser duct, or duct of Santorini, is variable. The lesser duct commonly drains the superior portion of the head of the pancreas. It empties separately into the second portion of the duodenum through the lesser papilla located 2 cm proximal to the ampulla of Vater. Pancreas divisum results from an incomplete fusion of the ventral pancreatic duct with the dorsal duct during fetal development and is present in 5% of patients. In this anomaly, the lesser duct drains the entire pancreas via an accessory ampulla located proximal to the ampulla of Vater. Inadequacy of this pattern of drainage can result in chronic pain.Rate this question:
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- 24.
Orally administered glucose provokes a greater insulin response than an equivalent amount of intravenously administered glucose. The incremental response to ingested glucose is due to the effects of which of the following hormones?
- A.
Gastric inhibitory peptide
- B.
Somatostatin
- C.
Pancreatic polypeptide
- D.
Secretin
Correct Answer
A. Gastric inhibitory peptideExplanation
Orally administered glucose stimulates a greater insulin response than an equivalent amount of intravenous glucose through the release of enteric hormones that potentiate insulin secretion. This effect is known as the enteroinsular axis. Gastric inhibitory polypeptide (GIP) appears to be an important regulator of this effect, although other gut peptides, such as glucagon-like peptide I (GLP-1), may contribute to this effect as well. Nutrients that regulate insulin secretion include amino acids, such as arginine, lysine, and leucine, and free fatty acids. Hormones that stimulate insulin secretion include glucagon, GIP, and cholecystokinin, whereas somatostatin, amylin, and pancreastatin are inhibitory. Insulin is also stimulated by sulfonylurea compounds, which act independently of the glucose concentration and form the basis of treatment of type II, or insulin-independent, diabetes.Rate this question:
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- 25.
The islets of Langerhans contain four major endocrine cell types that secrete which of the following hormones?
- A.
Insulin, somatostatin, glucagon, secretin
- B.
Insulin, somatostatin, cholecystokinin, pancreatic polypeptide
- C.
Insulin, somatostatin, glucagon, pancreatic polypeptide
- D.
Insulin, secretin, glucagon, cholecystokinin
Correct Answer
C. Insulin, somatostatin, glucagon, pancreatic polypeptideExplanation
Within the pancreas are small nests of cells that are responsible for the secretion of hormones that control glucose homeostasis. These nests are called islets of Langerhans and constitute 2% of the pancreatic mass. The islets contain an average of 3000 cells and range in diameter from 40 to 900 mm. The islets are composed of four major cell types—alpha (A), beta (B), delta (D), and PP or F cells, which secrete glucagon, insulin, somatostatin, and pancreatic polypeptide, respectively. The B cells are centrally located within the islet and constitute 70% of the islet mass, whereas the PP, A, and D cells are located at the periphery of the islet. They constitute roughly 15%, 10%, and 5% of the islet cell mass, respectively.Rate this question:
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- 26.
A 50-year-old man develops acute pancreatitis due to alcohol abuse. Hyperamylasemia resolves by the third day after admission. By the eighth hospital day, the patient is noted to have recurrent fever (38.5°C), progressive leukocytosis (18,500 WBC/mm3), and tachypnea. The most appropriate management includes which as the next step?
- A.
Laparotomy with pancreatic debridement
- B.
CT guided aspiration of peripancreatic fluid collections
- C.
ERCP with sphincterotomy and placement of biliary stent
- D.
Intravenous amphotericin B
Correct Answer
B. CT guided aspiration of peripancreatic fluid collectionsExplanation
The common causes of pancreatic abscesses are infected pancreatic pseudocysts and necrotizing pancreatitis. The diagnosis is suggested by persistent fever, leukocytosis, and a palpable abdominal mass. Bacteremia and systemic toxicity are late clinical features. Percutaneous aspiration with positive cultures is the definitive preoperative test, facilitated by CT scanning or ultrasound-guidance to suspicious peripancreatic fluid collections. When diagnosed, the treatment of choice is wide surgical débridement with removal of all infected and revitalized tissues. Generous drainage is mandatory. One of the major sources of morbidity and mortality in this situation is the late development of mycotic visceral pseudoaneurysms, particularly involving the splenic circulation. These may be complex management problems, requiring angiographic embolization or other innovative treatment strategies.Rate this question:
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- 27.
The patient in the above question is treated by observation for 8 weeks. He continues to be symptomatic with epigastric pain. A repeat abdominal CT scan reveals a persistent 6 cm pseudocyst in the region of the body of the pancreas. The pseudocyst is unilocular and demonstrates a well-defined rim of fibrous tissue. The gastric antrum is displaced anteriorly. Using CT guidance, 300 ml of fluid is aspirated from the lesion which is shown to be collapsed radiographically. No further intervention is performed. What is the risk of pseudocyst recurrence after simple aspiration?
- A.
80–85%
- B.
60–65%
- C.
40–45%
- D.
20–25%
Correct Answer
D. 20–25%Explanation
Generally, a pancreatic pseudocyst can be observed for a period of weeks or months in an effort to allow for spontaneous resolution. Percutaneous ultrasound-or CT-directed aspiration or drainage catheter placement is an initial treatment option. Simple aspiration is performed if the initial aspirate is sterile; if the aspirate is infected, a catheter or open drainage procedure is appropriate. Determination of pancreatic ductal anatomy is important. Contrast injection into the pseudocyst at the time of aspiration should be considered to assess the possibility of pancreatic ductal communication and obstruction, or multiple cysts. The pseudocyst recurrence rate after simple aspiration is about 20% to 25%.Rate this question:
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- 28.
In prospective, randomized trials which of the following agents or therapeutic measures has/have been demonstrated to accelerate recovery from acute pancreatitis?
- A.
Peritoneal lavage
- B.
Anticholinergic blockade
- C.
Octreotide
- D.
H2 receptor blockade
- E.
None of the above
Correct Answer
E. None of the aboveExplanation
Peritoneal lavage as a specific therapy for acute pancreatitis was proposed after experimental studies demonstrated improved survival in animals with fulminant pancreatitis. The concept was appealing in that activated proteases and other vasoactive substances identifiable in peritoneal aspirates from patients with pancreatitis would be removed, rather than systemically absorbed. Unfortunately, clinical trials using this approach have produced disappointing results, and the eventual overall mortality rate appears unchanged.Rate this question:
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- 29.
A 36-year-old woman is admitted to a the hospital with upper abdominal pain, hyperamylasemia, elevation of serum alkaline phosphatase and ultrasound evidence of cholelithiasis. With intravenous hydration and analgesia, symptoms rapidly resolved. After 48 hours, serum amylase and alkaline phosphatase values had returned to normal and physical examination revealed lessening tenderness in the right upper quadrant of the abdomen. Appropriate management consists of which of the following as the next step?
- A.
Cholecystectomy and intraoperative cholangiography before hospital discharge
- B.
Elective cholecystectomy at approximately 8 weeks
- C.
Endoscopic sphincterotomy before discharge followed by cholecystectomy at approximately 8 weeks
- D.
Observation
Correct Answer
A. Cholecystectomy and intraoperative cholangiography before hospital dischargeExplanation
A patient who has simple cholelithiasis and an episode of acute pancreatitis is usually treated nonoperatively until clinical resolution of the pancreatitis occurs. The rate of recurrent biliary pancreatitis is as high as 34% to 56% within 6 weeks; therefore, an aggressive operative approach is appropriate. Cholecystectomy is often performed after the resolution of acute pancreatitis but before hospital discharge. Common bile duct instrumentation in this setting has a substantially increased risk of recurrent acute pancreatitis.Rate this question:
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- 30.
For the patient in the preceding question, symptomatic recurrence at 3 weeks after aspiration is confirmed ultrasonographically. Endoscopic retrograde pancreatography does not demonstrate communication of a major pancreatic duct with the pseudocyst. Appropriate management includes which of the following?
- A.
Pancreatectomy to include the pseudocyst
- B.
Cystgastrostomy
- C.
Repeat aspiration followed by injection of sodium morrhuate into the pseudocyst cavity
- D.
Pancreatic debridement followed by external drainage
Correct Answer
B. CystgastrostomyExplanation
The operative treatment for pseudocysts depends on the underlying cause of the cyst, as well as the size, location, and maturity of the pseudocyst wall. Whenever possible, the status of the pancreatic duct should be assessed preoperatively, preferably by ERCP. Operative drainage can be either external or internal. External drainage is chosen in the presence of infection or an immature capsule. The disadvantages of external drainage include the risk of pancreatic fistula formation and a pseudocyst recurrence. External drainage has been associated with a higher mortality rate, probably because it is used in patients at higher risk, especially those with sepsis, pancreatic abscesses, or ruptured pseudocysts.
The type of internal drainage procedure selected depends on the location of the pseudocyst and whether or not there is associated pancreatic ductal pathology. Cystogastrostomy is the simplest and safest alternative if the pseudocyst is appropriately adjacent to the posterior wall of the stomach. Cystojejunostomy using a Roux-en-Y or loop jejunostomy may also be appropriate, depending on the location and specific anatomy of the pseudocyst. Pancreatic resection is associated with the lowest recurrence rate (3%), but is limited to pseudocysts occurring in the tail of the pancreasRate this question:
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- 31.
Which of the following statement(s) relating to chronic pancreatitis is/are correct?
- A.
In the United States, the most common cause of chronic pancreatitis is alcohol abuse
- B.
Approximately 50% of chronic alcoholics develop chronic pancreatitis
- C.
Clinically significant chronic pancreatitis develops on average after five years of alcohol abuse in men
- D.
The risk of alcohol-induced chronic pancreatitis can be decreased by consumption of a high-protein diet
Correct Answer
A. In the United States, the most common cause of chronic pancreatitis is alcohol abuseExplanation
In the United States, alcohol consumption is the major cause of chronic pancreatitis: with approximately 70% of cases attributable to this factor. Most patients with symptomatic chronic pancreatitis have consumed large volumes of alcohol daily for a prolonged period of time. The average daily intake of alcohol is 150 to 175 g with the mean duration of alcoholism before recognition of pancreatitis being 18 years for men and 11 years for women. The incidence of chronic pancreatitis on autopsy studies of chronic alcoholics is 50 times the rate of non-drinking controls. Only 10% of alcoholics develop chronic pancreatitis—suggesting that factors other than long-term alcohol exposure may also influence susceptibility. In both experimental and clinical studies, the risk of alcohol-induced chronic pancreatitis is increased by a high-protein, high-fat diet.Rate this question:
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- 32.
The most appropriate test to confirm a clinical diagnosis of early chronic pancreatitis is which of the following?
- A.
Serum amylase determination
- B.
Calculation of urinary amylase clearance
- C.
Measurement of para-aminobenzoic acid absorption
- D.
Endoscopic retrograde cholangiopancreatography
Correct Answer
D. Endoscopic retrograde cholangiopancreatographyExplanation
Routine tests of blood or serum are not helpful in making a diagnosis of chronic pancreatitis. Although serum amylase levels are almost always elevated in acute pancreatitis—amylase levels may be normal, elevated, or subnormal in chronic pancreatitis. Determination of urinary amylase secretion and calculation of urinary amylase clearance does not improve sensitivity or specificity. Indirect tests of pancreatic function which measure absorption of nutrients that first require pancreatic digestion are not helpful in early cases of chronic pancreatitis. Clinically detectable malabsorption is absent until 90% of exocrine function is lost. Because of this, indirect tests of pancreatic function do not detect early disease. In addition, false positive tests may occur in other disease states associated with malabsorption (Crohn’s disease, sprue, postgastrectomy states, or in association with diabetes mellitus, cirrhosis, or renal disease. ERCP has become widely recognized as the most sensitive and reliable method for diagnosing chronic pancreatitis. Sensitivity approaches 90% with equal specificity.Rate this question:
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- 33.
A 52-year-old male, known to be alcoholic, is evaluated because of chronic abdominal pain. The clinical diagnosis of chronic pancreatitis is supported by ERCP findings of pancreatic ductal ectasia with alternating areas of stricture and dilatation. Several pancreatic ductal stones are also noted. With chronic pain as the operative indication, the most appropriate procedure would be:
- A.
80% distal pancreatectomy with splenectomy
- B.
Longitudinal pancreaticojejunostomy
- C.
Distal pancreatectomy with end pancreaticojejunostomy
- D.
Total pancreatectomy
Correct Answer
B. Longitudinal pancreaticojejunostomyExplanation
When patients with chronic pancreatitis have pancreatic ductal dilatation (greater than 8 mm. ductal decompression using longitudinal pancreaticojejunostomy may be employed for relief of pain. The finding that pancreatic ductal hypertension exists in patients with painful chronic pancreatitis and that surgical decompression reduces intrapancreatic pressure to normal provides the rationale for this operation. The anterior surface of the pancreas is exposed through the lesser sac. The entire pancreatic duct is opened from the pancreatic tail to a point 1 cm from the duodenum. A side-to-side anastomosis is then performed between the opened pancreatic duct and a loop of jejunum. Splenectomy is not necessary. In-hospital mortality rates of less than 5% have been widely reported. Approximately 80% of patients report complete or substantial improvement of pain following longitudinal pancreaticojejunostomyRate this question:
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- 34.
For the patient in the preceding question, the most appropriate long-term management is which of the following?
- A.
Endoscopic stenting of the distal common bile duct
- B.
Choledochoduodenostomy
- C.
Pancreaticoduodenectomy (Whipple procedure)
- D.
Percutaneous transhepatic drainage of the common hepatic duct
Correct Answer
B. CholedochoduodenostomyExplanation
Operative management of patients with stricture of the common bile duct associated with chronic pancreatitis is justified to treat symptoms and to prevent development of biliary cirrhosis. Operative indications include progressive jaundice, cholangitis, liver biopsy evidence of biliary cirrhosis, persistent elevation of alkaline phosphatase at greater than three times normal, and progressive stricture demonstrated by radiologically progressive dilatation of extrahepatic and intrahepatic biliary ducts. Both choledochoduodenostomy and choledochojejunostomy are excellent operative choices.Rate this question:
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- 35.
Which of the following is the most common cause of obstructive jaundice in patients with chronic pancreatitis?
- A.
Adenocarcinoma of the head of the pancreas
- B.
Choledocholithiasis
- C.
Fibrotic stricture of the common bile duct
- D.
Pancreatic pseudocyst formation
Correct Answer
C. Fibrotic stricture of the common bile ductExplanation
Biliary complications involving the common bile duct can occur in chronic pancreatitis because of the intimate association of that structure with the head of the pancreas. In two-thirds of individuals, the common bile duct traverses the pancreatic parenchyma and in an additional 25%, the common bile duct lies within a groove along the posterior surface of the pancreas. Fibrosis associated with chronic pancreatitis can encase and compress the common bile duct. Common bile duct stenosis is relatively common in chronic pancreatitis, occurring in approximately 10% of cases observed long-term. Cholangiography typically reveals a long, gradually tapering stricture conforming to the intrapancreatic portion of the common bile duct. In contrast, malignant strictures usually result in abrupt termination of the biliary duct. The proximal suprapancreatic portion of the bile duct is variably dilatedRate this question:
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- 36.
Alcohol-induced and hereditary chronic pancreatitis are the two most common etiologies observed in North American patients. Most of the remaining patients fall into which of the following categories?
- A.
Chronic pancreatitis secondary to hyperparathyroidism
- B.
Chronic pancreatitis caused by protein-calorie malnutrition
- C.
Chronic pancreatitis secondary to congenital pancreatic ductal obstruction
- D.
Idiopathic chronic pancreatitis
Correct Answer
D. Idiopathic chronic pancreatitisExplanation
After alcohol-induced and hereditary disease, idiopathic chronic pancreatitis is the most common cause of calcifying pancreatitis in North American patients. This designation is given to those cases without a recognizable cause. Idiopathic pancreatitis accounts for about 15% of the cases and has two peaks in incidence, suggesting that differing underlying causes may exist. The first peak occurs in young adulthood and the second has an occurrence at approximately 60 years of age.Rate this question:
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- 37.
Which of the following is the most common clinical manifestation of chronic pancreatitis?
- A.
Epigastric pain with radiation to the hypogastrium
- B.
Diabetes mellitus
- C.
Steatorrhea
- D.
Epigastric pain with radiation to the upper lumbar vertebrae
Correct Answer
D. Epigastric pain with radiation to the upper lumbar vertebraeExplanation
Pain is a predominant symptom complex in most patients with chronic pancreatitis. Chronic pancreatic pain is usually localized to the epigastrium with radiation to the back in the region of the upper lumbar vertebrae. Discomfort may be exacerbated by eating and is usually alleviated by abstinence from food and by bending forward. Malabsorption and weight loss, clinical manifestations of steatorrhea, are only observed when greater than 90% of exocrine tissue has been destroyed. Clinical signs of malabsorption are a late manifestation of chronic pancreatitis. Although abnormal glucose tests can be demonstrated in 50% to 70% of patients with chronic Pancreatitis: overt diabetes mellitus is present in only 30% to 40%. Endocrine deficits are usually progressive. If individual patients are repetitively tested, progressive deterioration is often observed.Rate this question:
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- 38.
For the patient in the preceding question, appropriate management includes which of the following?
- A.
Distal pancreatectomy
- B.
Cystjejunostomy
- C.
Percutaneous drainage
- D.
Primary radiotherapy and chemotherapy
Correct Answer
A. Distal pancreatectomyExplanation
The proper treatment is surgical removal of the tumor; aggressive pancreatic resection is appropriate. It is crucial to avoid mistaking a mucinous cystic tumor for a pancreatic pseudocyst. Internal drainage of a malignant mucinous cystic tumor results in catastrophic tumor dissemination and should never be performed. With appropriate treatment, all patients with histologically benign tumors should be cured; for tumors demonstrating malignant change, 5-year survival after surgery is about 60%.Rate this question:
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- 39.
A 67-year-old male presents with complaints of itching, dark urine, and epigastric pain. Physical examination reveals jaundice. Initial laboratory tests show total bilirubin of 6.5 mg/dL, alkaline phosphatase elevated at 3 the upper limit of normal, and mild elevations in serum transaminases. Appropriate management includes which diagnostic test next?
- A.
Abdominal ultrasonography
- B.
Computed tomography of the abdomen
- C.
Magnetic resonance imaging of the abdomen
- D.
Endoscopic retrograde cholangiography
Correct Answer
A. Abdominal ultrasonographyExplanation
Standard transcutaneous ultrasonography is the appropriate first test in the evaluation of the patient with jaundice, because the presence of a dilated common bile duct or intrahepatic bile ducts is essentially diagnostic of extrahepatic biliary obstruction. This finding directs the physician to a search for the cause of the obstruction. If the bile ducts are not dilated, mechanical obstruction is unlikely and the diagnostic thrust should move toward hepatocellular disease. Ultrasonography is also the best test to determine whether gallstones are present; this is extremely important because choledocholithiasis is one of the conditions most likely to cause jaundice in the elderly population.Rate this question:
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- 40.
The most common cause of death in the postoperative period following pancreaticoduodenectomy is which of the following?
- A.
Myocardial infarction
- B.
Intraperitoneal hemorrhage
- C.
Pulmonary embolism
- D.
Pneumonia
Correct Answer
B. Intraperitoneal hemorrhageExplanation
Pancreaticoduodenectomy is a formidable operation, and until recently, average operative mortality was reported to approximate 20%. In the past few years, several centers have reported large series with operative mortalities lower than 5%.
The most dreaded complication of pancreaticoduodenectomy is disruption of the pancreaticojejunostomy, which occurs in about 10% of patients. Anastomotic breakdown may lead to the development of an upper abdominal abscess or may present as a external pancreatic fistula. In its most virulent form, disruption leads to necrotizing retroperitoneal infection which may erode major arteries and veins of the upper abdomen, including the portal vein or its branches or the stump of the gastroduodenal artery. Impending catastrophe is often preceded by a small herald bleed from the drain site. Such an event is an indication to return to the operating room to widely drain the pancreaticojejunostomy and to repair the involved blood vessel. Open packing of the wound may be necessary in controlling diffuse necrosis and infection. On rare occasions, completion pancreatectomy is required to control sepsis. Intraperitoneal hemorrhage is the most common cause of death from pancreaticoduodenectomy.Rate this question:
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- 41.
Which of the following surgical procedures has the lowest incidence of recurrent jaundice when used in the context of unresectable carcinoma of the head of the pancreas?
- A.
Choledochoduodenostomy
- B.
Cholecystojejunostomy
- C.
Cholecystoduodenostomy
- D.
Choledochojejunostomy
Correct Answer
D. CholedochojejunostomyExplanation
When jaundiced patients undergo exploration in the hopes of resection but unresectable disease is found, biliary bypass should be performed. The jejunum is typically chosen as a conduit in preference to the duodenum because duodenal obstruction may occur as the tumor becomes more advanced. There has been much discussion over the use of the bile duct or the gallbladder for biliary decompression. Operative mortality and mean survival (about 6 months) do not differ between patients with cholecystojejunostomy and choledochojejunostomy. Recurrent jaundice is more common after cholecystojejunostomy. Because recurrent jaundice constitutes a failure of palliation, the use of the common duct for biliary bypass is preferable in most patients. There are circumstances, however, in which it may be more appropriate to use the gallbladder. Such instances include patients with poor performance status, cases in which the tumor is bulky and invades the porta hepatis, or when periductal varices have developed as a result of portal vein thrombosis. The suitability of the gallbladder as a biliary conduit must be proven intraoperatively. If, on aspiration, the gallbladder contains colorless fluid, the cystic duct may be assumed to be obstructed, and the gallbladder should be removed and not used for bypass. If there is green bile in the gallbladder, patency of the cystic duct should be proved by cholangiography before a bypass is performed.Rate this question:
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- 42.
A 45-year-old woman is evaluated for epigastric and back pain. Physical examination is normal. Computed tomography of the abdomen reveals a 8 cm cystic lesion in the region of the tail of the pancreas. The cyst demonstrates internal septations and papillary projections from its walls. Which of the following diagnoses is most likely in this patient?
- A.
Pancreatic lymphoma
- B.
Retroperitoneal liposarcoma
- C.
Pancreatic pseudocyst
- D.
Pancreatic mucinous cystadenoma
Correct Answer
D. Pancreatic mucinous cystadenomaExplanation
Mucinous cystic neoplasms account for about 2% of pancreatic exocrine tumors. Most patients with mucinous cystic tumors present with abdominal pain or an abdominal mass. There may be associated weight loss, steatorrhea, or diabetes. The diagnosis is best made by CT scanning and ultrasonography, which demonstrate a mass containing fluid-filled structures and internal septations. Occasionally, it is possible to see the papillary tumor excrescences on the cyst walls.
The tumor occurs six times as often in females as in males. About 80% of the tumors are located in the body and tail of the pancreas. They present as large (average, 10 cm), soft, and somewhat irregular tumors. Microscopically, the cysts are lined by columnar epithelium which contains mucin. Although most of the cells may appear benign histologically, most tumors larger than 3 cm contain areas of premalignant or malignant change and all mucinous cystic tumors should be considered to have malignant potential.Rate this question:
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- 43.
For the patient in the preceding question, an insulin/glucose ratio of 0.5 was documented at 28 hours of fasting. Symptoms of mental obtundation developed concurrently and were reversed by oral glucose administration. Endoscopic ultrasonography demonstrated a 1.2 cm mass in the head of the pancreas. Appropriate management consists of which of the following
- A.
Surgical enucleation of the tumor
- B.
Total pancreatectomy
- C.
Long-term octreotide administration
- D.
Primary radiotherapy
Correct Answer
A. Surgical enucleation of the tumorExplanation
The treatment of insulinoma is surgical in nearly all cases. Insulinomas are found evenly distributed within the pancreas, with approximately one-third being located in the head and uncinate process, one-third in the body of the gland, and one-third in the tail of the gland. Ninety percent of patients will be found to have benign solitary adenomas amenable to surgical cure. Small benign insulinomas not in close proximity to the main pancreatic duct may be removed by enucleation, independent of their location within the gland. In the body and tail of the Pancreas: insulinomas greater than 2 cm in diameter, and those in close proximity to the pancreatic duct are most commonly excised by distal pancreatectomy. Large insulinomas deep in the head or uncinate process of the pancreas may not be amenable to local excision, and may require pancreaticoduodenectomy.Rate this question:
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- 44.
Neoplastic hypersecretion of the hormone vasoactive intestinal peptide is associated with which of the following features?
- A.
Hypokalemia, hypochlorhydria, diarrhea
- B.
Hyperglycemia, necrolytic rash, hypoaminoacidemia
- C.
Constipation, gallstones, hyperglycemia
- D.
Hyperkalemia, necrolytic rash, diarrhea
Correct Answer
A. Hypokalemia, hypochlorhydria, diarrheaExplanation
Patients characteristically present with intermittent severe diarrhea, typically of a watery nature, averaging 5 liters/day. Malabsorption and steatorrhea are not common. Hypokalemia results from the fecal loss of large amounts of potassium (up to 400 meq/day), and low serum potassium levels may be associated with muscular weakness, lethargy, and nausea. Most patients are hypochlorhydric or achlorhydric. Half of the patients have some degree of hyperglycemia and hypercalcemia, while cutaneous flushing can be observed in a minority of patients. The diagnosis of VIPoma is typically made after excluding other more common causes of diarrhea. The active agent in the VIPoma syndrome is usually vasoactive intestinal polypeptide (VIP), with a minority of patients having elevations of other candidate mediators such as peptide histidine-isoleucine (PHI) or prostaglandins.Rate this question:
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- 45.
A patient with biochemically confirmed gastrinoma undergoes computed tomography for tumor localization. CT reveals a 2 cm mass in the head of the pancreas and multiple nodules within right and left lobes of the liver. Appropriate management includes which of the following
- A.
Omeprazole administration
- B.
Radiotherapy
- C.
Pancreaticoduodenectomy
- D.
Proximal gastric vagotomy
Correct Answer
A. Omeprazole administrationExplanation
Gastrinoma patients whose localization and staging studies are indicative of unresectable hepatic metastases should undergo percutaneous or laparoscopically-directed liver biopsy for histologic verification. If unresectable gastrinoma is confirmed, then open surgical exploration is not performed and the patient is maintained on long-term omeprazole therapy. Virtually all patients can be rendered achlorhydric with appropriate dose adjustment of omeprazole. Noncompliant patients who refuse to take appropriate doses of omeprazole and who develop complications related to their ulcer diathesis may require total gastrectomy for management. Total gastrectomy removes the end organ (parietal cell mass) and was once the procedure of choice for gastrinoma. Today its use in gastrinoma patients has markedly declined.Rate this question:
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- 46.
In the patient described above, which of the following are important operative steps in the performance of a right hepatic lobectomy?
- A.
The use of an ultrasonic dissector is essential for division of the hepatic parenchyma
- B.
If temporary portal inflow occlusion is used (Pringle maneuver), it is not necessary to reestablish blood flow during the course of the parenchymal division
- C.
The greater omentum may be used to buttress the transected liver edge
- D.
Control of the main right hepatic vein should eliminate all forms of venous drainage
Correct Answer
C. The greater omentum may be used to buttress the transected liver edgeExplanation
The steps involved in a right hepatic lobectomy involve adherence to the tenet of optimal operative exposure and control of vascular inflow and outflow. In select circumstances, control of the vena cava may be desired. Either the individual portal structures can be identified and ligated early in the course of the procedure, or simply the entire portal triad can be circled with an umbilical tape tourniquet in preparation for the Pringle maneuver. If temporary portal inflow occlusion is used, intermittent 10 to 20 minute intervals of clamping with 3 to 5 minutes to reestablish blood flow is recommended. The division of the hepatic parenchyma begins with scoring of Glisson’s capsule with cautery or knife and proceeds with division of the hepatic surface using either blunt dissection by finger fracture, the blunt edge of an instrument or suction tip, or using an ultrasonic dissector. Individual vessels and bile ducts are cauterized, sutured, or clipped in rapid succession from anterior to posterior. The hepatic veins are encountered in the hepatic substance near the vena cava and are carefully clamped and suture ligated to complete the resection. In addition, there are also several posterior accessory veins (up to 10 in number) which drain the medial aspect of the right lobe and empty directly into the right anterior surface of the IVC.Rate this question:
- 47.
Intraoperative ultrasound is now commonly used by the hepatic surgeon. Which of the following statement(s) is/are true concerning intraoperative ultrasound and hepatic surgery?
- A.
An intraoperative ultrasound offers no advantage to conventional transcorporial ultrasound in detection of hepatic lesions
- B.
Portal structures can be differentiated from hepatic veins by the extension of Glisson’s capsule surrounding these structures
- C.
It is difficult on ultrasound to differentiate a vascular structure from a mass
- D.
DThe short hepatic veins are difficult to detect with intraoperative ultrasound
Correct Answer
B. Portal structures can be differentiated from hepatic veins by the extension of Glisson’s capsule surrounding these structuresExplanation
Over the past 10 years, detailed anatomic description of the hepatic veins, portal pedicles, and the inferior vena cava have been possible through the use of intraoperative ultrasound. Cooperation between radiologists and hepatic surgeon with the use of intraoperative ultrasound has allowed the identification of lesions during surgery that were not visible by conventional transcorporial ultrasound or CT scanning. Beginning superiorly at the inferior vena cava, the confluence and course of each of the hepatic veins can easily be determined. More inferiorly, the main right and left portal pedicles can be seen coursing transversely in the transverse scissura. Portal structures can easily be differentiated from hepatic veins by the hyperechoic extensions of Glisson’s capsule which surround these structures. When a circular structure is encountered, a mass or metastasis may be suspected. Scanning away from the mass may reveal a tubulovascular shape which has been imaged and cross sectioned. Flattening of the circular mass by external compression with the ultrasound probe will also differentiate a vascular structure from a solid mass.Rate this question:
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- 48.
The liver plays a vital role in carbohydrate metabolism and regulation of blood glucose. The following statement(s) is/are true concerning carbohydrate metabolism by the liver.
- A.
Glycogen, a complex polymer of glucose, is synthesized by the hepatocyte in a remarkably energy efficient process
- B.
Glucagon stimulates glycogenesis
- C.
Glycolysis, the process by which glucose is converted to two molecules of pyruvate, occurs in the liver mitochondria
- D.
If glycogen stores become depleted, the liver is capable of synthesizing new glucose by the process of gluconeogenesis, which is stimulated by insulin
Correct Answer
A. Glycogen, a complex polymer of glucose, is synthesized by the hepatocyte in a remarkably energy efficient processExplanation
Serum glucose is tightly regulated by the liver despite wide fluctuations in dietary ingestion. The liver can take up as much as 100 g/day of glucose and convert it to glycogen by the process of glycogenesis. The liver can also release glucose into the blood by glycogenolysis, the breakdown of glycogen, or by gluconeogenesis, the formation of new glucose from substrates such as alanine, lactate, glycerol or dietary amino acids. Hormones play a key role in hepatic regulation of glucose metabolism. Insulin, for example, stimulates glycogenesis, and glucagon stimulates glycogenolysis and gluconeogenesis. Gluconeogenesis is also enhanced by fasting, critical illness and periods of anaerobic metabolism.
Glycogen is a complex polymer of glucose. Liver cells can store up to 8% of their weight as glycogen. The first step in glycogen storage is the transport of glucose through the hepatocyte plasma membrane. About 90% of portal venous glucose is removed from the blood by liver cells through carrier-facilitated diffusion. The rate of glucose transport is enhanced by insulin. Once in the hepatocyte, glucose and ATP are converted by the enzyme glucokinase to glucose-6-phosphate (G6P), the first intermediate in the synthesis of glycogen. Because complete oxidation of one molecule of G6P generates 37 molecules of ATP, and storage only uses one molecule of ATP, the overall efficiency of glucose storage in glycogen is a remarkable 97%. Glycolysis is the pathway by which glucose is converted to two molecules of pyruvate and occurs in the cytoplasm in contrast to the citric acid cycle which occurs in the mitochondria.Rate this question:
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- 49.
Which of the following statement(s) is/are true concerning acute, fulminant hepatic failure?
- A.
The most frequent cause of acute hepatic failure world-wide is hepatitis B infection
- B.
Higher grades of encephalopathy are associated with a worse prognosis
- C.
Hypoglycemia is a common complication of all liver diseases
- D.
Liver transplantation would appear indicated in all patients with hepatic coma secondary to acute liver failure
Correct Answer
B. Higher grades of encephalopathy are associated with a worse prognosisExplanation
The diagnosis of acute (fulminant) hepatic failure is based on the development of encephalopathy within eight weeks of the onset of symptoms. The overall prognosis is poor, but the hepatic lesions are potentially reversible, and recovery can lead to restoration of normal liver function. The most frequent cause of acute hepatic failure world-wide is non-A, non-B viral hepatitis. A variety of other viral agents and hepatotoxins can also cause this condition.
No reliable criteria predict outcome and response to treatment. Higher grades of encephalopathy (depth of coma) on admission are associated with the worst prognosis. Management should include general supportive measures and specific treatment for hepatic encephalopathy, cerebral edema, electrolyte and metabolic disturbances, infection, and pain. Hypoglycemia is an unusual complication of most liver diseases except in patients with acute hepatic failure or hepatic neoplasms. The enormous reserve capacity of the liver accounts for the rarity of hypoglycemia except as a preterminal event. Bleeding is also a frequent cause of death in patients with acute hepatic failure secondary to depressed liver synthesis of clotting factors and qualitative or quantitative platelet disorders. The lack of a definitive medical treatment for acute hepatic failure makes liver transplantation seem attractive especially for patients with little or no chance of recovering normal liver function. Perhaps the most significant drawback to widespread acceptance of liver transplantation for acute hepatic failure is the lack of criteria reliability to predict which patients are likely to benefit from operation. Patients with mild to moderate degrees of coma are likely to recovery spontaneously without the need for liver transplantation while rapid deterioration and neurologic status to grade III or grade IV coma are associated in some centers with a mortality of 95%.Rate this question:
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- 50.
The following statement(s) is/are true concerning the management of ascites associated with chronic liver disease
- A.
Spontaneous bacterial peritonitis is an insignificant complication
- B.
Large volume paracentesis is unsafe due to excessive volume loss from the intervascular space
- C.
Peritoneovenous shunting is a trivial surgical procedure with minimal perioperative morbidity and mortality
- D.
Transjugular intrahepatic portosystemic shunts (TIPS) can effectively treat ascites in patients refractory to conventional medical therapy
Correct Answer
D. Transjugular intrahepatic portosystemic shunts (TIPS) can effectively treat ascites in patients refractory to conventional medical therapyExplanation
The onset of ascites usually indicates the presence of advanced liver disease. Cirrhotic ascites is usually straw colored, clear, or greenish. Spontaneous bacterial peritonitis occurs as a complication of cirrhotic ascites in up to 10% of patients. Spontaneous bacterial peritonitis is defined as infected ascitic fluid without a demonstrable other site of infection. This is a serious complication with reported in-hospital mortality rates of 60% to 90%. The rational approach of therapy for ascites includes sodium and fluid restriction, the use of diuretics, and the use of therapeutic paracentesis. Several studies have shown that repeated paracentesis in stable cirrhotic patients may be safe and effective as medical therapy and shortens the length of hospitalization. Single, large volume paracentesis has been reported to be effective and safe. Up to 10 liters of ascites can be removed in one hour if salt-poor albumen is administered simultaneously. In a small percentage of patients, surgical implantation of a peritoneovenous shunt may be advisable. The principal indication for use of peritoneovenous shunt is to stabilize ascites that is refractory to conventional medical therapy and therapeutic paracentesis. Despite the simplistic nature of the device, postoperative mortality and morbidity rates of 20% to 60%, respectively have been reported. Precipitation of disseminated intravascular coagulopathy, variceal hemorrhage, or hepatic failure may complicate this procedure. Transintrahepatic portosystemic shunts (TIPS) have been demonstrated to control ascites in one study in over 90% of patients with ascites refractory to medical management. However, patients with poor hepatic reserve in this study all died if orthotopic liver transplantation was not performed. This data suggests that TIPS is effective for refractive ascites in patients with good to moderate hepatic reserve but poor risk cirrhotics require orthotopic liver transplantation to correct this problem.Rate this question:
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Mar 20, 2023Quiz Edited by
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Feb 28, 2012Quiz Created by
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