Hepatobiliary And Pancreatic Surgery (100q).1

Reviewed by Editorial Team
The ProProfs editorial team is comprised of experienced subject matter experts. They've collectively created over 10,000 quizzes and lessons, serving over 100 million users. Our team includes in-house content moderators and subject matter experts, as well as a global network of rigorously trained contributors. All adhere to our comprehensive editorial guidelines, ensuring the delivery of high-quality content.
Learn about Our Editorial Process
| By Sysplore3
S
Sysplore3
Community Contributor
Quizzes Created: 3 | Total Attempts: 12,477
| Attempts: 1,067
Quiz Flashcard
SettingsSettings
Please wait...
  • 1/100 Questions

    Standard supportive measures for patients with mild pancreatitis include the following:

    • Intravenous fluid and electrolyte therapy.
    • Withholding of analgesics to allow serial abdominal examinations.
    • Subcutaneous octreotide therapy
    • Nasogastric decompression
    • Prophylactic antibiotics
Please wait...
About This Quiz

This quiz, titled 'Hepatobiliary and pancreatic surgery,' assesses knowledge on liver segmental anatomy, therapy for hepatic abscesses, benign liver lesions, bile duct cancers, hemobilia, and hepatic artery ligation. It is crucial for medical professionals specializing in hepatobiliary and pancreatic surgery.

Surgery Quizzes & Trivia

Quiz Preview

  • 2. 

    A 55-year-old woman presents with vague right upper quadrant pain and a palpable liver. Laboratory tests are normal and a noncontrast CT scan (patient has a history of contrast allergy) reveals an 8 cm right hepatic mass. Which of the following statement(s) is/are correct concerning the patient’s diagnosis and management.  

    • A gadilinium-enhanced MRI would be indicated to define the extent of the lesion and confirm the diagnosis of hemangioma

    • A fine needle aspiration should be performed regardless of radiographic workup

    • Hepatic embolization is the treatment of choice

    • The lesion should be resected because of concern for malignant degeneration

    Correct Answer
    A. A gadilinium-enhanced MRI would be indicated to define the extent of the lesion and confirm the diagnosis of hemangioma
    Explanation
    Cavernous hemangiomas of the liver are the most common benign hepatic tumor and are detected in some 2% to 7% of autopsies. Overall, hemangiomas are exceeded only by hepatic metastases as the most common hepatic tumor. Cavernous hemangiomas consist histologically of cystically dilated, endothelium-lined vascular spaces. They occur in all ages but are observed more commonly in females. Hemangiomas are not premalignant. Less than half of affected patients have symptoms. Those that have symptoms usually have large masses. Symptoms usually occur including vague right upper quadrant discomfort, pain, fullness, and early satiety. Physical examination may be notable for hepatomegaly, mass or bruit. There are no laboratory abnormalities in patients with hemangiomas. The most useful radiologic test for diagnosing hemangiomas are MRI, CT and tagged red blood cell scanning. These tests have largely replaced angiography. CT with vascular contrast often demonstrates a diagnostically characteristic enhancement pattern. Gadilinium-enhanced MRI has recently been shown to be sensitive and specific in the diagnosis of hemangioma and has better resolution than tagged red blood cell scans. FNA biopsy of suspected hemangiomas can be performed, however this procedure should be avoided if the diagnosis is secure using noninvasive procedures. Given the natural history of hemangiomas and its low risk of rupture, observation is indicated for asymptomatic patients, especially for lesions smaller than 4 cm. Surgical excision is the only consistently effective treatment for symptomatic masses and should be performed if the lesion is localized and accessible with an acceptable operative risk. Embolization is indicated only for unresectable lesions and is only modestly effective

    Rate this question:

  • 3. 

    Which of the following statements most accurately describes the current therapy for pyogenic hepatic abscess?

    • Antibiotics alone are adequate for the treatment of most cases.

    • All patients require open surgical drainage for optimal management

    • Optimal treatment involves treatment of not only the abscess but the underlying source as well.

    • Percutaneous drainage is more successful for multiple lesions than for solitary ones

    Correct Answer
    A. 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:

  • 4. 

    The islets of Langerhans contain four major endocrine cell types that secrete which of the following hormones?

    • Insulin, somatostatin, glucagon, secretin

    • Insulin, somatostatin, cholecystokinin, pancreatic polypeptide

    • Insulin, somatostatin, glucagon, pancreatic polypeptide

    • Insulin, secretin, glucagon, cholecystokinin

    Correct Answer
    A. Insulin, somatostatin, glucagon, pancreatic polypeptide
    Explanation
    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:

  • 5. 

    Which of the following veins is preserved in performing the extensive esophagogastric devascularization procedure described by Sugiura?

    • Left gastric (coronary) vein

    • Short gastric vein.

    • Splenic vein.

    • Left gastroepiploic vein.

    Correct Answer
    A. Left gastric (coronary) vein
    Explanation
    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:

  • 6. 

    Which of the following veins is preserved in performing the extensive esophagogastric devascularization procedure described by Sugiura?

    • Left gastric (coronary) vein

    • Short gastric vein.

    • Splenic vein.

    • Left gastroepiploic vein.

    Correct Answer
    A. Left gastric (coronary) vein
    Explanation
    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:

  • 7. 

    Which of the following complications of portal hypertension often require surgical intervention (for more than 25% of patients)?

    • Hypersplenism

    • Variceal hemorrhage.

    • Ascites

    • Encephalopathy

    Correct Answer
    A. 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:

  • 8. 

    Which of the following complications of portal hypertension often require surgical intervention (for more than 25% of patients)?

    • Hypersplenism

    • Variceal hemorrhage.

    • Ascites

    • Encephalopathy

    Correct Answer
    A. 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:

  • 9. 

    Standard supportive measures for patients with mild pancreatitis include the following:

    • Intravenous fluid and electrolyte therapy.

    • Withholding of analgesics to allow serial abdominal examinations.

    • Subcutaneous octreotide therapy

    • Nasogastric decompression

    • 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:

  • 10. 

    A 35-year-old female presents with typical biliary colic symptoms, however her sonogram shows no gallstones. Which of the following statement(s) is/are true concerning her diagnoses

    • Chronic acalculous cholecystitis or gallbladder dyskinesia is seldom associated with classic biliary colic symptoms

    • The most specific test for diagnosing gallbladder dyskinesia is CCK-enhanced cholescintigraphy with assessment of gallbladder ejection fraction

    • An ejection fraction greater than 75% is considered abnormal and indicative of gallbladder dyskinesia

    • Cholecystectomy is not indicated for chronic acalculous cholecystitis

    Correct Answer
    A. The most specific test for diagnosing gallbladder dyskinesia is CCK-enhanced cholescintigraphy with assessment of gallbladder ejection fraction
    Explanation
    Motility abnormalities of the gallbladder and cystic duct present with symptoms suggesting gallstones. The most common presentation for patients with gallbladder motility disorders such as chronic acalculous cholecystitis or gallbladder dyskinesia is recurrent biliary-type pain. Currently, the most specific test for diagnosing gallbladder dyskinesia is CCK-enhanced cholescintigraphy with assessment of gallbladder ejection fraction. CCK is infused intravenously 15 to 30 minutes after ejecting an analogue of 99MTC imminodiacetic acid and calculating the ejection fraction of the isotope by the contracting gallbladder. An ejection fraction of less than 35% is considered abnormal and cholecystectomy may be indicated. Most patients will have relief of symptoms following cholecystectomy.

    Rate this question:

  • 11. 

    Which of the following is the most common acid-base disturbance in patients with cirrhosis and portal hypertension?

    • Metabolic acidosis.

    • Respiratory alkalosis.

    • Metabolic alkalosis

    • Respiratory acidosis.

    Correct Answer
    A. Metabolic alkalosis
    Explanation
    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:

  • 12. 

    The most appropriate test to confirm a clinical diagnosis of early chronic pancreatitis is which of the following?

    • Serum amylase determination

    • Calculation of urinary amylase clearance

    • Measurement of para-aminobenzoic acid absorption

    • Endoscopic retrograde cholangiopancreatography

    Correct Answer
    A. Endoscopic retrograde cholangiopancreatography
    Explanation
    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:

  • 13. 

    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?

    • The most important diagnostic study for insulinoma is an oral glucose tolerance test.

    • It may be helpful to perform ERCP in an effort to localize the tumor

    • Most patients with insulinoma present with extensive disease, rendering them only rarely resectable or curable

    • 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
    A. 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:

  • 14. 

    Which of the following is the most common clinical manifestation of chronic pancreatitis?

    • Epigastric pain with radiation to the hypogastrium

    • Diabetes mellitus

    • Steatorrhea

    • Epigastric pain with radiation to the upper lumbar vertebrae

    Correct Answer
    A. Epigastric pain with radiation to the upper lumbar vertebrae
    Explanation
    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:

  • 15. 

    Which of the following statements most accurately describes the current therapy for pyogenic hepatic abscess?

    • Antibiotics alone are adequate for the treatment of most cases.

    • All patients require open surgical drainage for optimal management

    • Optimal treatment involves treatment of not only the abscess but the underlying source as well.

    • Percutaneous drainage is more successful for multiple lesions than for solitary ones

    Correct Answer
    A. 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:

  • 16. 

    Which of the following complications of portal hypertension often require surgical intervention (for more than 25% of patients)?

    • Hypersplenism

    • Variceal hemorrhage.

    • Ascites

    • Encephalopathy

    Correct Answer
    A. 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:

  • 17. 

    The islets of Langerhans contain four major endocrine cell types that secrete which of the following hormones?

    • Insulin, somatostatin, glucagon, secretin

    • Insulin, somatostatin, cholecystokinin, pancreatic polypeptide

    • Insulin, somatostatin, glucagon, pancreatic polypeptide

    • Insulin, secretin, glucagon, cholecystokinin

    Correct Answer
    A. Insulin, somatostatin, glucagon, pancreatic polypeptide
    Explanation
    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:

  • 18. 

    Which of the following is the most common acid-base disturbance in patients with cirrhosis and portal hypertension?

    • Metabolic acidosis.

    • Respiratory alkalosis.

    • Metabolic alkalosis

    • Respiratory acidosis.

    Correct Answer
    A. Metabolic alkalosis
    Explanation
    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:

  • 19. 

    Which of the following statements about the segmental anatomy of the liver are not true?

    • Segments are subdivisions in both the French and American systems.

    • Segments are determined primarily by the hepatic venous drainage

    • The French anatomic system is more applicable than the American system to clinical hepatic resection

    • Segments are important to the understanding of the topographic anatomy of the liver

    Correct Answer
    A. Segments are important to the understanding of the topographic anatomy of the liver
    Explanation
    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:

  • 20. 

    The islets of Langerhans contain four major endocrine cell types that secrete which of the following hormones?

    • Insulin, somatostatin, glucagon, secretin

    • Insulin, somatostatin, cholecystokinin, pancreatic polypeptide

    • Insulin, somatostatin, glucagon, pancreatic polypeptide

    • Insulin, secretin, glucagon, cholecystokinin

    Correct Answer
    A. Insulin, somatostatin, glucagon, pancreatic polypeptide
    Explanation
    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:

  • 21. 

    Which of the following is the most effective definitive therapy for both prevention of recurrent variceal hemorrhage and control of ascites?

    • Endoscopic sclerotherapy.

    • Distal splenorenal shunt

    • Esophagogastric devascularization (Sugiura procedure).

    • Side-to-side portacaval shunt

    • End-to-side portacaval shunt

    Correct Answer
    A. Side-to-side portacaval shunt
    Explanation
    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:

  • 22. 

    Ligation of all of the following arteries usually causes significant hepatic enzyme abnormalities except:

    • Ligation of the right hepatic artery

    • Ligation of the left hepatic artery

    • Ligation of the hepatic artery distal to the gastroduodenal branch

    • Ligation of the hepatic artery proximal to the gastroduodenal artery

    Correct Answer
    A. Ligation of the hepatic artery proximal to the gastroduodenal artery
    Explanation
    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:

  • 23. 

    Ligation of all of the following arteries usually causes significant hepatic enzyme abnormalities except:

    • Ligation of the right hepatic artery

    • Ligation of the left hepatic artery

    • Ligation of the hepatic artery distal to the gastroduodenal branch

    • Ligation of the hepatic artery proximal to the gastroduodenal artery

    Correct Answer
    A. Ligation of the hepatic artery proximal to the gastroduodenal artery
    Explanation
    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:

  • 24. 

    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?

    • The most important diagnostic study for insulinoma is an oral glucose tolerance test.

    • It may be helpful to perform ERCP in an effort to localize the tumor

    • Most patients with insulinoma present with extensive disease, rendering them only rarely resectable or curable

    • 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
    A. 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:

  • 25. 

    Which of the following treatments most effectively preserves hepatic portal perfusion?

    • Distal splenorenal shunt.

    • Conventional splenorenal shunt

    • Endoscopic sclerotherapy.

    • Side-to-side portacaval shunt

    Correct Answer
    A. 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 shunt

    Rate this question:

  • 26. 

    Which of the following statement(s) relating to chronic pancreatitis is/are correct?

    • In the United States, the most common cause of chronic pancreatitis is alcohol abuse

    • Approximately 50% of chronic alcoholics develop chronic pancreatitis

    • Clinically significant chronic pancreatitis develops on average after five years of alcohol abuse in men

    • 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 abuse
    Explanation
    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:

  • 27. 

    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?

    • Pancreatectomy to include the pseudocyst

    • Cystgastrostomy

    • Repeat aspiration followed by injection of sodium morrhuate into the pseudocyst cavity

    • Pancreatic debridement followed by external drainage

    Correct Answer
    A. Cystgastrostomy
    Explanation
    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 pancreas

    Rate this question:

  • 28. 

    Which of the following lesions are believed to be associated with the development of carcinoma of the gallbladder?

    • Cholecystoenteric fistula.

    • A calcified gallbladder.

    • Adenoma of the gallbladder

    • Xanthogranulomatous cholecystitis

    • All of the above.

    Correct Answer
    A. 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:

  • 29. 

    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?

    • Abdominal ultrasonography

    • Computed tomography of the abdomen

    • Magnetic resonance imaging of the abdomen

    • Endoscopic retrograde cholangiography

    Correct Answer
    A. Abdominal ultrasonography
    Explanation
    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:

  • 30. 

    The most appropriate test to confirm a clinical diagnosis of early chronic pancreatitis is which of the following?

    • Serum amylase determination

    • Calculation of urinary amylase clearance

    • Measurement of para-aminobenzoic acid absorption

    • Endoscopic retrograde cholangiopancreatography

    Correct Answer
    A. Endoscopic retrograde cholangiopancreatography
    Explanation
    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:

  • 31. 

    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?

    • Gastric inhibitory peptide

    • Somatostatin

    • Pancreatic polypeptide

    • Secretin

    Correct Answer
    A. Gastric inhibitory peptide
    Explanation
    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:

  • 32. 

    Which of the following are indications for cholecystectomy?

    • The presence of gallstones in a patient with intermittent episodes of right-side upper quadrant pain

    • The presence of gallstones in an asymptomatic patient

    • The presence of symptomatic gallstones in a patient with angina pectoris.

    • 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 pain
    Explanation
    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:

  • 33. 

    The most common cause of death in the postoperative period following pancreaticoduodenectomy is which of the following?

    • Myocardial infarction

    • Intraperitoneal hemorrhage

    • Pulmonary embolism

    • Pneumonia

    Correct Answer
    A. Intraperitoneal hemorrhage
    Explanation
    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:

  • 34. 

    Which of the following statement(s) is/are true concerning biopsy techniques for hepatic masses?

    • A fine needle aspiration (FNA for cytology is contraindicated for patients with hypervascular masses)

    • Percutaneous biopsy should be performed only if results may obviate the need for exploratory laparotomy

    • Needle track seeding of tumor is not a risk associated with percutaneous biopsy

    • Laparoscopy and biopsy play little role in the management of liver lesions

    Correct Answer
    A. Percutaneous biopsy should be performed only if results may obviate the need for exploratory laparotomy
    Explanation
    Biopsy of a liver mass can be done percutaneously (with or without CT or ultrasound guidance), laparoscopically, or at laparotomy. The biopsy may be done for cytology only (FNA) or for histology (larger-core biopsy). Guided FNA has an overall sensitivity of 77% to 94% and may allow a distinction between primary and secondary malignancy. The risks associated with needle biopsy include bleeding, infection, needle track seeding of tumor, and sampling error. Hypervascular masses, coagulopathy, and ascites are contraindications to percutaneous core biopsy, however, FNA biopsy is generally considered safe under these circumstances. In evaluation of any liver mass, percutaneous biopsy should be performed only if it can reasonably be expected to obviate the need for exploratory laparotomy. Biopsy of suspected primary metastatic malignancy with clinical indications of unresectability may spare the patient an unnecessary laparotomy. Laparoscopy with biopsy may also be used to evaluate liver masses and to possibly avoid laparotomy in patients considered to be borderline resectable.

    Rate this question:

  • 35. 

    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?

    • 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?

    • The entire pancreatic ductal system drains via the ampulla of Vater

    • The entire pancreatic ductal system drains via an accessory ampulla proximal to the ampulla of Vater

    • The body and tail of the pancreas are absent. The uncinate process drains via the ampulla of Vater

    Correct Answer
    A. The entire pancreatic ductal system drains via an accessory ampulla proximal to the ampulla of Vater
    Explanation
    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:

  • 36. 

    Which of the following statement(s) is/are true concerning biopsy techniques for hepatic masses?

    • A fine needle aspiration (FNA for cytology is contraindicated for patients with hypervascular masses)

    • Percutaneous biopsy should be performed only if results may obviate the need for exploratory laparotomy

    • Needle track seeding of tumor is not a risk associated with percutaneous biopsy

    • Laparoscopy and biopsy play little role in the management of liver lesions

    Correct Answer
    A. Percutaneous biopsy should be performed only if results may obviate the need for exploratory laparotomy
    Explanation
    Biopsy of a liver mass can be done percutaneously (with or without CT or ultrasound guidance), laparoscopically, or at laparotomy. The biopsy may be done for cytology only (FNA) or for histology (larger-core biopsy). Guided FNA has an overall sensitivity of 77% to 94% and may allow a distinction between primary and secondary malignancy. The risks associated with needle biopsy include bleeding, infection, needle track seeding of tumor, and sampling error. Hypervascular masses, coagulopathy, and ascites are contraindications to percutaneous core biopsy, however, FNA biopsy is generally considered safe under these circumstances. In evaluation of any liver mass, percutaneous biopsy should be performed only if it can reasonably be expected to obviate the need for exploratory laparotomy. Biopsy of suspected primary metastatic malignancy with clinical indications of unresectability may spare the patient an unnecessary laparotomy. Laparoscopy with biopsy may also be used to evaluate liver masses and to possibly avoid laparotomy in patients considered to be borderline resectable.

    Rate this question:

  • 37. 

    Ligation of all of the following arteries usually causes significant hepatic enzyme abnormalities except:

    • Ligation of the right hepatic artery

    • Ligation of the left hepatic artery

    • Ligation of the hepatic artery distal to the gastroduodenal branch

    • Ligation of the hepatic artery proximal to the gastroduodenal artery

    Correct Answer
    A. Ligation of the hepatic artery proximal to the gastroduodenal artery
    Explanation
    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:

  • 38. 

    A 35-year-old female presents with typical biliary colic symptoms, however her sonogram shows no gallstones. Which of the following statement(s) is/are true concerning her diagnoses

    • Chronic acalculous cholecystitis or gallbladder dyskinesia is seldom associated with classic biliary colic symptoms

    • The most specific test for diagnosing gallbladder dyskinesia is CCK-enhanced cholescintigraphy with assessment of gallbladder ejection fraction

    • An ejection fraction greater than 75% is considered abnormal and indicative of gallbladder dyskinesia

    • Cholecystectomy is not indicated for chronic acalculous cholecystitis

    Correct Answer
    A. The most specific test for diagnosing gallbladder dyskinesia is CCK-enhanced cholescintigraphy with assessment of gallbladder ejection fraction
    Explanation
    Motility abnormalities of the gallbladder and cystic duct present with symptoms suggesting gallstones. The most common presentation for patients with gallbladder motility disorders such as chronic acalculous cholecystitis or gallbladder dyskinesia is recurrent biliary-type pain. Currently, the most specific test for diagnosing gallbladder dyskinesia is CCK-enhanced cholescintigraphy with assessment of gallbladder ejection fraction. CCK is infused intravenously 15 to 30 minutes after ejecting an analogue of 99MTC imminodiacetic acid and calculating the ejection fraction of the isotope by the contracting gallbladder. An ejection fraction of less than 35% is considered abnormal and cholecystectomy may be indicated. Most patients will have relief of symptoms following cholecystectomy.

    Rate this question:

  • 39. 

    The islets of Langerhans contain four major endocrine cell types that secrete which of the following hormones?

    • Insulin, somatostatin, glucagon, secretin

    • Insulin, somatostatin, cholecystokinin, pancreatic polypeptide

    • Insulin, somatostatin, glucagon, pancreatic polypeptide

    • Insulin, secretin, glucagon, cholecystokinin

    Correct Answer
    A. Insulin, somatostatin, glucagon, pancreatic polypeptide
    Explanation
    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:

  • 40. 

    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?

    • The most important diagnostic study for insulinoma is an oral glucose tolerance test.

    • It may be helpful to perform ERCP in an effort to localize the tumor

    • Most patients with insulinoma present with extensive disease, rendering them only rarely resectable or curable

    • 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
    A. 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:

  • 41. 

    Standard supportive measures for patients with mild pancreatitis include the following:

    • Intravenous fluid and electrolyte therapy.

    • Withholding of analgesics to allow serial abdominal examinations.

    • Subcutaneous octreotide therapy

    • Nasogastric decompression

    • 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:

  • 42. 

    Which of the following statement(s) is/are true concerning the pathophysiology of variceal hemorrhage?

    • All patients with portal hypertension will develop esophageal varices

    • All patients with esophageal varices eventually bleed

    • Variceal size can predict the incidence of variceal hemorrhage

    • Control of acid secretion by H2 blockade can decrease the incidence of rebleeding after esophageal hemorrhage

    • None of the above

    Correct Answer
    A. None of the above
    Explanation
    About two-thirds of patients with portal hypertension develop varices; of these only two-thirds subsequently experience variceal hemorrhage. A number of factors are important in the pathogenesis of variceal hemorrhage. These include portal pressure, intravariceal pressure, variceal size and structure, and other factors. Variceal size alone is not predictive of variceal hemorrhage. Evidence conflicts about whether erosive esophagitis is a cause of variceal rupture. Control of acid reflux by H2 blockade has not been shown to decrease the incidence of rebleeding after esophageal hemorrhage.

    Rate this question:

  • 43. 

    Which of the following complications of portal hypertension often require surgical intervention (for more than 25% of patients)?

    • Hypersplenism

    • Variceal hemorrhage.

    • Ascites

    • Encephalopathy

    Correct Answer
    A. 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:

  • 44. 

    The following statement(s) is/are true concerning the management of ascites associated with chronic liver disease

    • Spontaneous bacterial peritonitis is an insignificant complication

    • Large volume paracentesis is unsafe due to excessive volume loss from the intervascular space

    • Peritoneovenous shunting is a trivial surgical procedure with minimal perioperative morbidity and mortality

    • Transjugular intrahepatic portosystemic shunts (TIPS) can effectively treat ascites in patients refractory to conventional medical therapy

    Correct Answer
    A. Transjugular intrahepatic portosystemic shunts (TIPS) can effectively treat ascites in patients refractory to conventional medical therapy
    Explanation
    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:

  • 45. 

    Which of the following statements about biliary tract problems are correct?

    • Choledochal cyst should be treated by Roux-en-Y cystojejunostomy

    • Sclerosing cholangitis is characterized by long, narrow strictures in the extrahepatic biliary duct system

    • Operative (needle) cholangiography is indicated in patients who at operation appear to have no gallbladder

    • 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
    A. Operative (needle) cholangiography is indicated in patients who at operation appear to have no gallbladder
    Explanation
    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:

  • 46. 

    Which of the following statement(s) about gallstone ileus is/are not true?

    • The condition is seen most frequently in women older than 70.

    • Concomitant with the bowel obstruction, air is seen in the biliary tree

    • The usual fistula underlying the problem is between the gallbladder and the ileum.

    • 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.

    • Ultrasound studies may be of help in identifying a gallstone as the obstructing agent

    Correct Answer
    A. 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:

  • 47. 

    Which of the following statements about the segmental anatomy of the liver are not true?

    • Segments are subdivisions in both the French and American systems.

    • Segments are determined primarily by the hepatic venous drainage

    • The French anatomic system is more applicable than the American system to clinical hepatic resection

    • Segments are important to the understanding of the topographic anatomy of the liver

    Correct Answer
    A. Segments are important to the understanding of the topographic anatomy of the liver
    Explanation
    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:

  • 48. 

    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?

    • Abdominal ultrasonography

    • Computed tomography of the abdomen

    • Magnetic resonance imaging of the abdomen

    • Endoscopic retrograde cholangiography

    Correct Answer
    A. Abdominal ultrasonography
    Explanation
    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:

  • 49. 

    Which of the following statement(s) is/are true about benign lesions of the liver?

    • Adenomas are true neoplasms with a predisposition for complications and should usually be resected

    • Focal nodular hyperplasia (FNH) is a neoplasm related to birth control pills (BCPs) and usually requires resection

    • Hemangiomas are the most common benign lesions of the liver that come to the surgeon's attention

    • Nodular regenerative hyperplasia does not usually accompany cirrhosis.

    Correct Answer
    A. Adenomas are true neoplasms with a predisposition for complications and should usually be resected
    Explanation
    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:

Quiz Review Timeline (Updated): Mar 20, 2023 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 20, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Feb 28, 2012
    Quiz Created by
    Sysplore3
Back to Top Back to top
Advertisement
×

Wait!
Here's an interesting quiz for you.

We have other quizzes matching your interest.