NUR 2063 / NUR2063: Essentials of Pathophysiology Final Exam Review Study Guide (Updated), Exams of Nursing

Download NUR 2063 / NUR2063: Essentials of Pathophysiology Final Exam Review Study Guide (Updated) and more Exams Nursing in PDF only on Docsity! NUR 2063 / NUR2063: Essentials of Pathophysiology Final Exam Review Study Guide (Updated 2024-2025). Questions and Correct Verified Answers. Graded A Liver pancreas and biliary system 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. Answer: D DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1419 2. Which of the following anatomic features of the biliary system are important considerations in operative cholangiography? A. The left hepatic duct comes off farther anterior than the right one. B. At the confluence there may be more than just a right and a left hepatic duct. C. Dissection of the triangle of Calot is more important than cholangiography in preventing bile duct injury. D. all of the above Answer: D DISCUSSION: All of these features are important. The angle of takeoff of the left hepatic duct may make operative visualization difficult with the patient in the supine position. Because there may be more than two major hepatic ducts, visualization of two large ducts does not ensure that the system is normal. Ducts from any of the right-side segments can join below the confluence. Dissecting one superior edge of the gallbladder before it joins the cystic duct is particularly important in preventing injury. pg. 1 Ref – sabiston 20th ed. Pg-1419 3. The hepatic artery: A. Supplies the same amount of blood to the liver as the portal vein. B. Provides more blood to the bile ducts than the portal vein. C. Is autoregulated just as the portal vein is. D. Supplies no blood to hepatic metastases. Answer: B pg. 2 with an antiamebic agent such as metronidazole constitute presumptive diagnosis of amebic abscess. Aspiration of abscess contents rarely yields amebic organisms. In contrast to pyogenic abscess, amebic abscess rarely requires surgical or percutaneous drainage, except in the case of an extremely large abscess or bacterial superinfection. Amebic abscess affects males in a 9:1 to 10:1 ratio and generally affects a younger population than pyogenic abscess. Additionally, in the United States the populations most affected are immigrants from endemic areas such as Mexico or Latin America and American tourists to those regions. Ref – sabiston 20th ed. Pg-1450 9. 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. Answer: A DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1456 10. Which of the following statement(s) about malignant neoplasms of the liver is/are true? A. Hepatocellular carcinoma is probably the number 1 cause of death from cancers worldwide. B. The most common resectable hepatic malignant neoplasm in the United States is colorectal metastasis. C. Hepatoma has at least one variant that has a much more benign course than hepatomas in general. D. all of the above Answer: D DISCUSSION: Although exact comparisons are impossible, hepatoma seems to be the most common cause of cancer death worldwide, despite its relative infrequency in the United States. Colorectal metastasis is a more common indication for surgical treatment in the United States. The fibrolamellar variant and possibly the very well-differentiated tumor probably have a better prognosis than hepatomas in general. Previous studies from Africa in which there was a high pg. 5 incidence of rupture account for the poor prognosis that was generally attributed to hepatoma. Recent studies from Europe and the United States have shown that survival after presentation is usually measured in years. Ref – sabiston 20th ed. Pg-1458 11. 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 usuallysuccessful if the lesion seems confined to the liver. E. None of the above is true. Answer: E DISCUSSION: 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. 12. Echinococcosis liver disease caused by Echinococcus granulosus: A. Is not a neoplasm. B. Is endemic to parts of Europe, but not the United States. C. Is usually curable by resection. D. all of the above Answer: D DISCUSSION: The parasitic infection is fairly common in certain parts of Europe but very rare in the United States. Resection without peritoneal soilage is the treatment of choice. The E. multilocularis form, which is endemic to parts of the United States, is more likely to be fatal because it is rarely resectable. This form is more likely to resemble a malignancy than E. granulosus, although the natural course of the disease usually spans many years. Ref – sabiston 20th ed. Pg-1453 13. 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. Answer: C pg. 6 DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1473 14. 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. Answer: D DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1425 15. 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. Answer: C DISCUSSION: 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. pg. 7 A. Hypersplenism. B. Variceal hemorrhage. C. Ascites. D. Encephalopathy. Answer: B DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1439 21. Which of the following effects are advantages of combined vasopressin and nitroglycerin intravenous infusion, as compared with vasopressin infusion alone, in controlling acute variceal bleeding? A. Lower frequency of encephalopathy. B. Lower incidence of vasopressinside effects. C. less effective control of bleeding. D. Less “rebound effect” when discontinuing the infusion. Answer: B DISCUSSION: Vasopressin acts through vasoconstriction of splanchnic arterioles. Both portal venous inflow and portal venous pressure are reduced, resulting in control of acute variceal bleeding in approximately 50% of patients. However, the adverse side effects of systemic hypertension, bradycardia, decreased cardiac output, and coronary vasoconstriction are quite common during vasopressin infusion. Simultaneous administration of nitroglycerin or nitroprusside eliminates these side effects—and in one controlled trial enhanced therapeutic effectiveness. Although the mechanism of action of this combined infusion is not clear, vasodilation of portal-systemic collaterals, resulting in a further reduction in portal pressure, may be responsible. Ref – sabiston 20th ed. Pg-1438 pg. 10 22. Which of the following statements about the peritoneovenous shunt (PVS) is/are correct? A. For cirrhotic patients with intractable ascites, the LeVeen shunt is an effective “bridge” to liver transplantation. B. Replacement of ascites with saline or lactated Ringer's solution reduces the coagulopathy following PVS. C. For patients with cirrhotic ascites, the survival using repeated paracentesis with 5% albumin infusion is inferior to that with the PVS. D. Oliguria (less than 25 ml. per hour) in the immediate postoperative period following PVS should be treated with a 5% albumin infusion. Answer: B DISCUSSION: The PVS is a palliative procedure that does not prolong life. In comparing the early risks of the procedure with those of repeated paracentesis, the shunt cannot be justified as a temporizing procedure to facilitate ascites control in the patient awaiting liver transplantation. Oliguria is common in the first 24 hours after shunt insertion. A correctly placed PVS (patency confirmed using an intraoperative “shuntogram”) expands the intravascular volume with a continuous reinfusion of ascites. Inspection should identify elevation of the jugular venous pressure, and a diuretic (usually furosemide) is needed. The mechanisms of action of the two shunts are very different. TIPSS reduces portal pressure and controls ascites by reducing the rate of ascites formation. PVS reinfuses the ascites fluid, thereby reducing the prerenal stimulus to sodium retention and making the patient more responsive to diuretic therapy. Ref – sabiston 20th ed. Pg-1418-77 23. 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. Answer: C DISCUSSION: 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 pg. 11 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. Ref – sabiston 20th ed. Pg-1418-77 24. Which of the following explanations account(s) for the fact that hepatitis C is the most common cause of posttransfusion hepatitis? A. There are more carriers of hepatitis C virus (HCV) in the normal population who serve as blood donors. B. Blood infected with hepatitis B virus (HBV) cannot be eliminated through routine testing C. Current serologic tests for HCV antigen do not exclude carriers. D. Questions designed to eliminate risk groups for HCV from the normal donor population may not be as specific as would be desirable. Answer: D DISCUSSION: The ability to specifically identify persons infected with HCV has only recently become available. Therefore, data about epidemiology are less than complete. It is very likely not true that more blood donors carry HCV because of the large preponderance of HBV in the United States. It is true, however, that successful elimination of most of the HBV carriers occurs through routine testing. Although serologic tests are available for HCV, they are tests, not of antigen, but of antibody. Therefore, this test alone may not screen out persons who are infected but have not yet developed or may never develop antibody. Risk groups for the relatively newly defined HCV may well not be comprehensively established, and therefore this explanation may be a contributor. There are no differences in virulence between these classes of hepatitis virus. Ref – sabiston 20th ed. Pg-1418-77 25. which of the following statement about HBV infections is true: A. Are usually asymptomatic. B. May not be clinically recognized but may lead to chronic hepatitis. C. Does not protect against subsequent HBV infection regardless of the measured antibody titer to hepatitis B surface antigen (HBsAg). D. Are completely prevented by postexposure administration of HBIg hepatitis B immunoglobulin (HBIg). Answer: B DISCUSSION: Although some types of hepatitis are more often asymptomatic than symptomatic, that is not the case for hepatitis B. Further, even if the HBV infection is asymptomatic, serious long-term side effects may occur. A prior infection with hepatitis B confers lifelong immunity even if the antibody titer wanes below the protective level of 10 mIU. HBIg is useful in reducing the incidence of postexposure HBV infection from around 30% with no intervention, to 15% pg. 12 the insidious development of jaundice. Ref – sabiston 20th ed. Pg- 1482-1518 29. Which of the following statements about biliary tract problems are correct? A. Choledochal cystshould 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. Answer: C DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1482-1518 30. Which of the following statements about the diagnosis of acute calculous cholecystitis are true? A. Pain is so frequent that its absence almost precludes the diagnosis. B. Jaundice is present in a majority of patients. C. Ultrasonography is the definitive diagnostic test. D. Cholescintigraphy is not the definitive diagnostic test. Answer: A pg. 15 DISCUSSION: The presence of pain is the sine qua non of acute calculous cholecystitis. Chronic cholecystitis associated with cholelithiasis may develop in the absence of pain, and in critically ill patients pain may not be a prominent feature of acute acalculous cholecystitis. Only about 10% of patients with acute cholecystitis are jaundiced. Although an occasional patient may have concomitant bile duct obstruction, the jaundice associated with acute cholecystitis is probably due to absorption of bile pigments from the diseased gallbladder. The presence of jaundice in a patient with right-side upper quadrant pain should also suggest the possibility of acute cholangitis secondary to bile duct obstruction. Ultrasonography is very accurate in the detection of gallstones, but stones may be present in the absence of acute cholecystitis. Thickening of the gallbladder wall and a collection of fluid around the gallbladder are ultrasonographic findings in some patients with acute cholecystitis, but they are not always present and are not specific. Ultrasonography may be useful when the diagnosis is obscure because other conditions in the liver, pancreas, and kidney can be detected; however, it is not the definitive test for acute cholecystitis. Cholescintigraphy is specific for the diagnosis of acute calculous cholecystitis (accuracy over 95% in experienced hands). The rapidity, simplicity, and accuracy make cholescintigraphy the definitive diagnostic test in acute calculous cholecystitis; however, it must be interpreted cautiously in the context of another critical illness or recent surgery or trauma, because false-positives are not unusual in these situations. Ref – sabiston 20th ed. Pg-1482-1518 31. Which statements about acute acalculous cholecystitis are correct? A. The disease is often accompanied by or associated with other conditions. B. The diagnosis is often difficult. C. The mortality rate is higher than that for acute calculous cholecystitis. D. all of the above Answer: D DISCUSSION: About half of the cases of acute acalculous cholecystitis are associated with other conditions, including sepsis, sarcoidosis, polyarteritis nodosa, and systemic lupus erythematosus. A majority of cases occur after trauma, burns, or major surgical procedures performed for other conditions. The precise pathogenesis has not been determined. The diagnosis of acute acalculous cholecystitis is often difficult because symptoms may be masked by another illness, injury, or the postoperative state. Unlike acute calculous cholecystitis, in which pain is always present, pain occurs in only about 70% of cases. In addition, cholescintigraphy is sometimes inaccurate. These factors make the diagnosis difficult, and a high index of suspicion is necessary, especially in patients who have had operations or trauma. Unexplained abdominal pain, sepsis, and ileus should prompt a thorough investigation. The mortality rate for acute acalculous cholecystitis is higher than that of the calculous type. The incidence of gangrene and perforation of the gallbladder is higher. The accompanying illnesses and conditions and the frequent delays in diagnosis undoubtedly contribute to the higher death rate. Percutaneous cholecystostomy has been used as a diagnostic and therapeutic maneuver in pg. 16 patients who are thought to have acute acalculous cholecystitis. Aspiration and culture of bile assist in confirming the diagnosis, and continuous drainage successfully treats the acute condition. Surprisingly, persistent gangrene and subsequent complications have been infrequent. Immediate cholecystectomy should be done if significant improvement does not take place within 12 hours of percutaneous cholecystostomy. Long-term management of the tube and the need for elective cholecystectomy must be individualized. The experience with percutaneous cholecystostomy is too small to determine whether this technique reduces the mortality rate. Ref – sabiston 20th ed. Pg-1482-1518 32. True statements about the surgical management of patients with acute calculous cholecystitis include: A. Operation should be performed in all patients as soon as the diagnosis is made. B. Antibiotic therapy should not be initiated as soon as the diagnosis is made. C. Dissection of the gallbladder is facilitated by decompression of the organ with the use of a trocar. D. An operative cholangiogram should be done in every patient. Answer: C DISCUSSION: Cholecystectomy should be done in an otherwise healthy patient as soon as the diagnosis is made and the patient is properly prepared for surgery. However, patients who have one or more significant risk factors such as a recent myocardial infarction, unstable angina, clinically significant coronary artery disease, or cirrhosis should not have immediate cholecystectomy unless they do not improve within 24 to 36 hours in response to antibiotic administration and supportive care. Antibiotic administration should commence as soon as the diagnosis is made and should be continued for 24 hours postoperatively—or for 7 days if significant peritonitis is present. This use of antibiotics has significantly reduced septic complications after cholecystectomy for acute cholecystitis. In most cases the gallbladder is tensely distended, making visualization and dissection of the cystic duct area difficult and perhaps dangerous. Decompression of the gallbladder by insertion of a needle facilitates retraction and dissection of the gallbladder. Although some advise that operative cholangiography be done only on a selective basis, its routine use helps to delineate anatomy and facilitates detection of an occasionally unsuspected bile duct stone. Accordingly, it is used routinely in elective cases. In acute cholecystitis, however, the biliary duct system may be very friable, and operative cholangiography should be done only when it is safe to do so. Ref – sabiston 20th ed. Pg-1482-1518 33. 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. pg. 17 cholangitis. Pigment stone and sludge formation may result from the bacterial deconjugation of bilirubin diglucuronide to bilirubin monoglucuronide, which precipitates as calcium bilirubinate. This material can occlude indwelling tubes and predispose to more frequent episodes of cholangitis. Long-term administration of an oral antibiotic may reduce the frequency and severity of attacks of cholangitis; however, this method of management should not be routine. Correction of the underlying problem is essential. Chronic obstruction and recurrent infection eventually lead to secondary biliary cirrhosis and its complications of portal hypertension, ascites, and bleeding esophageal varices. Once this stage of the disease is reached, correction of the underlying biliary tract problem does not reverse the changes in the liver. Once again, every effort should be made to eliminate the cause of the cholangitis early in the course of disease. The only effective treatment for end-stage liver disease is hepatic transplantation. Ref – sabiston 20th ed. Pg-1482-1518 37. 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. Answer: A DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1482-1518 38. The clinical picture of gallstone ileus includes which of the following? pg. 20 A. Air in the biliary tree. B. Small bowel obstruction. C. A stone at the site of obstruction. D. All of the above Answer: D DISCUSSION: An antecedent biliary-enteric fistula is necessary to allow stone migration into the intestinal tract, and this results in air entering the biliary tree (pneumobilia). It also allows contamination of the bile ducts with intestinal bacteria, which in fact occurs in only a minority of such cases. The stone obstructs the narrower distal bowel, producing small bowel obstruction. Such a stone, if opaque, can be seen on plain radiography and, if not, can be appreciated by sonography. Stools are not acholic, since the cholecystoenteric fistula allows bile access to the intestinal lumen. Ref – sabiston 20th ed. Pg-1482-1518 39. 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. Answer: C DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1482-1518 40. Which of the following lesions are believed to be associated with the development of pg. 21 carcinoma of the gallbladder? A. Cholecystoenteric fistula. B. A calcified gallbladder. C. Adenoma of the gallbladder. D. All of the above. Answer: D DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1482-1518 41. 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. None of the above. Answer: D DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1482-1518 42. Which of the following statement(s) about pancreatic embryonic malformations is/are correct? A. Pancreas divisum can be a cause of gastrointestinal bleeding. pg. 22 useful in the early evaluation of a patient with acute pancreatitis? A. Elevated blood glucose. B. Leukocytosis. C. Amylase value greater than 1000 U per dl. D. Serum lactic dehydrogenase (LDH) greater than 350 IU per dl. Answer: C DISCUSSION: Several prognostic systems have been demonstrated to predict the severity of pancreatitis accurately. Two Ranson prognostic criteria have been developed: one each, for pancreatitis that is not due to gallstones and pancreatitis that is. The systems have minor differences. In both of the Ranson systems elevated blood glucose, leukocytosis, and elevations of serum LDH have proved to have prognostic importance. The degree of amylase elevation is not one of the parameters, nor is the degree of ALT elevation. Ref – sabiston 20th ed. Pg-1520-1553 47. 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. Answer: A DISCUSSION: 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). Ref – sabiston 20th ed. Pg-1520-1553 48. 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. 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. Answer: D pg. 25 DISCUSSION: 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. Ref – sabiston 20th ed. Pg-1520-1553 49. Which of the following statements about pancreatic ascites is/are correct? A. Patients typically present with painful ascites, reflecting the release of toxic pancreatic enzymes into the peritoneal cavity. B. The standard evaluation of a patient with new-onset ascites includes abdominal paracentesis. In cases of pancreatic ascites, the peritoneal fluid contains high concentrations of both amylase and protein. C. Pancreatic ascites does not occurafter an episode of acute pancreatitis. D. Patients with pancreatic ascites may fail to improve with nonoperative therapy and require surgical procedures. At abdominal exploration an acceptable approach to the pancreatic duct disruption involves suture ligation with omental patching. Answer: B DISCUSSION: Pancreatic ascites typically occurs because of a pancreatic duct disruption, most commonly involving alcohol abuse and resultant acute pancreatitis. In pancreatic ascites, pancreatic exocrine secretions exit a pancreatic duct disruption and drain anteriorly into the peritoneal cavity. Patients typically present with painless massive ascites, as the pancreatic enzymes that extravasate into the peritoneal cavity are typically nonactivated. The diagnosis of pancreatic ascites is best made by paracentesis, in which the analysis of the ascites fluid reveals it to be high in amylase (more than 1000 U. per dl.) and high in albumin (more than 3 gm. per dl.). Nonoperative treatment is initially indicated in most patients with pancreatic ascites. Should nonoperative therapy fail, surgical therapy is directed to closure of the pancreatic duct disruption. Preoperative pancreatography is useful in directing surgical therapy. Distal pancreatic duct disruption may be treated with distal pancreatectomy or with Roux-en-Y pancreaticojejunostomy. Pancreatic leaks in the more proximal aspects of the gland are treated with Roux-en-Y pancreaticojejunostomy. Suture ligation of the pancreatic duct with omental patching is not considered appropriate therapy for pancreatic duct disruptions. pg. 26 Ref – sabiston 20th ed. Pg-1520-1553 50. 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). Answer: A DISCUSSION: 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, a re 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. Ref – sabiston 20th ed. Pg-1520-1553 51. 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. Answer: D DISCUSSION: 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 pg. 27 55. 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 Vater 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 Answer: c 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. Ref – sabiston 20th ed. Pg-1520-1553 56. Which of the following statements is/are correct with regard to the blood supply of the pancreas? a. The inferior pancreaticoduodenal artery, a branch of the celiac artery, divides into anterior and posterior branches to supply the pancreatic head b. The body and tail of the pancreas are supplied by branches of the splenic artery c. The superior pancreaticoduodenal artery is a branch of the hepatic artery d. The body and tail of the pancreas are supplied by branches derived from the left renal artery Answer: b The pancreas receives its blood supply from a variety of major arterial sources. In the head of the pancreas, there are arcades in the anterior and posterior surfaces, which generally collateralize. These arcades arise from branches of the gastroduodenal and the superior mesenteric arteries. Just distal to the first portion of the duodenum, the gastroduodenal artery pg. 30 becomes the superior pancreaticoduodenal artery, which divides into anterior and posterior branches. The inferior pancreaticoduodenal artery is the first branch of the superior mesenteric artery and divides into anterior and posterior branches. The body and tail of the pancreas are supplied by the splenic artery. The splenic artery arises from the celiac trunk and courses along the superior surface of the pancreas to the spleen. Approximately ten branches of the splenic artery supply the body and tail of the pancreas. Ref – sabiston 20th ed. Pg-1520-1553 57. 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 Answer: a 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. Ref – sabiston 20th ed. Pg-1520-1553 58. 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 Answer: c Within the pancreas are small nests of cells that are responsible for the secretion of hormones pg. 31 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. Ref – sabiston 20th ed. Pg-1520-1553 59. 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 Answer: b 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. Ref – sabiston 20th ed. Pg-1520-1553 60. 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% pg. 32 Ref – sabiston 20th ed. Pg-1520-1553 64. Which of the following is/are prognostic signs reported by Ranson to predict outcomes associated with acute pancreatitis? a. Age greater than 60 years b. Hematocrit decrease of 105 within 48 hours of hospital admission c. Serum amylase value greater than 4 times upper limit of normal d. Serum glucose greater than 300 mg/dL on admission Answer: b Ranson prognostic signs include: ON ADMISSION Age above 55 years White blood cell count above 16,000/µL Glucose level above 200 mg/dL Lactase dehydrogenate level above 350 IU/L SGOT value above 250 IU/L AFTER 48 HOURS Hematocrit decrease of 10% Blood urea nitrogen level increase of 5 mg/dL Ca2+ level below 8 mg/dL PaO2 level below 60 mmHg Base deficit value above 4 mEq/L Fluid sequestration greater than 6 L Ref – sabiston 20th ed. Pg-1520-1553 65. 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 pg. 35 Answer: a pg. 36 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. Ref – sabiston 20th ed. Pg-1520-1553 66. 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 Answer: b 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. Ref – sabiston 20th ed. Pg-1520-1553 67. With regard to acute pancreatitis: which of the following statements is/are correct? a. The majority of patients presenting with acute pancreatitis of biliary type are female pg. 37 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 pancreaticojejunostomy. Ref – sabiston 20th ed. Pg-1520-1553 71. 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 Answer: b 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. Ref – sabiston 20th ed. Pg-1520-1553 72. 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 Answer: c 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. pg. 40 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 dilated. Ref – sabiston 20th ed. Pg-1520-1553 73. 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 Answer: d 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. Ref – sabiston 20th ed. Pg-1520-1553 74. Which of the following statements regarding prognosis in chronic pancreatitis is/are correct? a. Patients with chronic pancreatitis have increased long-term survival compared with the general population b. Patients with chronic pancreatitis exhibit no excess mortality relative to the general population c. Excess mortality in patients with chronic pancreatitis is related to cancers of the aerodigestive system, complications of diabetes, and complications of cirrhosis d. Excess mortality in patients with chronic pancreatitis is due to development of adenocarcinoma of the pancreas and to the complications of recurrent pancreatitis Answer: c Patients with chronic pancreatitis have decreased long-term survival compared to the general population. An excess of mortality of 30% over 20 years has been estimated. Less than 20% of deaths are directly attributable to pancreatitis or its complications. Excess mortality is related to pg. 41 extrapancreatic complications of alcoholism and smoking, including cancers of the aerodigestive system, complications of diabetes, and complications of cirrhosis. Ref – sabiston 20th ed. Pg-1520-1553 75. 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 Answer: d 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. Ref – sabiston 20th ed. Pg-1520-1553 76. 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 Answer: a 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%. Ref – sabiston 20th ed. Pg-1520-1553 pg. 42 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. Ref – sabiston 20th ed. Pg-1520-1553 81. For the above patient, ultrasonography reveals dilated extrahepatic and intrahepatic bile ducts and the absence of gallstones within the gallbladder. A 2 cm mass within the pancreatic head is visualized. Computed tomography of the abdomen is performed. Which of following CT findings indicate probable unresectability? a. Common bile duct diameter of 2 cm b. Ascites c. Infiltration of the deudonum d. Dilatation of the main pancreatic duct to 1.5 cm Answer: b CT scans provide the best available radiologic information to determine whether or not a pancreatic neoplasm is resectable, but they cannot be considered absolutely definitive in this regard. Only about half of pancreatic tumors that appear to be confined to the pancreas on CT scan are found to be resectable in the operating room. CT scanning is more accurate in the diagnosis of unresectability. CT findings that indicate that the tumor is unlikely to be surgically curable include vascular invasion, enlarged lymph nodes outside the boundaries of resection, ascites, distant metastases (usually liver), and distant organ invasion (usually colon). When a CT scan shows distant metastases or extensive local invasion, the positive predictive value of the technique is high; some 90% of such patients have unresectable disease at laparotomy. Ref – sabiston 20th ed. Pg-1520-1553 82. Which of the following have been shown to be risk factors for development of adenocarcinoma of the pancreas? a. Cigarette smoking b. Coffee drinking c. Adult-onset diabetes mellitus d. Chronic coumadin usage Answer: a pg. 45 Most cases of pancreatic cancer have no obvious predisposing host factors. The most consistently observed risk factor for pancreatic cancer is cigarette smoking. Most studies estimate that smoking results in a two-to three-fold increase in risk of developing pancreatic cancer. Alcohol consumption has been implicated in some case-control studies of pancreatic cancer, but the overall evidence is inconsistent and alcohol is not likely to be a major factor in the development of the disease. Although considerable public interest was focused in the past few years on coffee consumption as a risk factor for pancreatic cancer, evidence linking coffee consumption to pancreatic cancer is not compelling. Abnormal glucose tolerance is present in about 80% of patients with pancreatic cancer, if carefully sought. Although diabetes and pancreatic cancer occur together far more frequently than would be expected by chance, persons with long-standing diabetes are not at increased risk of developing pancreatic cancer. Chronic pancreatitis is a significant risk factor for the development of pancreatic cancer. It appears that all forms of chronic pancreatitis are associated with an increased risk of pancreatic cancer, suggesting that it is the pancreatitis and not the injuring agent which is responsible for the augmented cancer risk. Studies indicate that patients who have previously undergone gastric resection may be from three to seven times more likely to develop pancreatic cancer than a control population. There have been several reports of familial clustering of pancreatic cancer. Recent epidemiological studies suggest that about 7% of pancreatic cancer patients have a positive family history of the disease. For most cases, however, no hereditary basis for pancreatic cancer has been identified. Ref – sabiston 20th ed. Pg-1520-1553 83. 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 Answer: d 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 pg. 46 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. Ref – sabiston 20th ed. Pg-1520-1553 84. 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 Answer: d 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. Ref – sabiston 20th ed. Pg-1520-1553 85. A 45-year-old woman develops upper gastrointestinal hemorrhage. Evaluation by upper endoscopy reveals three ulcers in the second portion of the duodenum. Bleeding is controlled using an endoscopic heat probe. Further investigation reveals a serum gastrin value of 240 pg/mL. Which of the following would support the presumptive diagnosis of gastrinoma? a. An increase of 320 pg/mL in serum gastrin upon intravenous infusion of secretin b. Gastric acid analysis demonstrating fasting acid secretion of 3 mEq/h c. Absent gastric rugae on upper gastrointestinal contrast study d. An increase of 150 pg/mL in serum gastrin upon intravenous infusion of cholecystokinin Answer: a pg. 47 without defined capsules or situated deep in the pancreatic parenchyma may require partial pancreatic resection. In the absence of an identifiable pancreatic or duodenal tumor, a longitudinal duodenotomy may be performed at the level of the second portion of the duodenum to allow for eversion of the duodenum in a search for duodenal microgastrinomas. Primary gastrinomas identified within the duodenal wall are resected locally, with primary closure of the duodenal defect. Ref – sabiston 20th ed. Pg-1520-1553 89. 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 Answer: a 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. Ref – sabiston 20th ed. Pg-1520-1553 90. 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 Answer: a Gastrinoma patients whose localization and staging studies are indicative of unresectable hepatic metastases should undergo percutaneous or laparoscopically-directed liver biopsy for pg. 50 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. Ref – sabiston 20th ed. Pg-1520-1553 91. The following statement(s) is/are true concerning the widely accepted French or Couinaud’s nomenclature for liver anatomy. a. The liver is divided into eight discrete segments based on portal pedicle branches and hepatic venous drainage b. This anatomy is particularly useful in allowing less than lobar segmental anatomical resections that minimize blood loss and loss of hepatic reserve c. Segments II and III are synonymous with the left lateral segment based on English nomenclature d. all of the above Answer: d In the now widely accepted French (Couinaud’s) nomenclature, the liver can be divided into eight discrete segments based on portal pedicle branches and hepatic venous drainage. Enumeration of the segments begins left to right, beginning with segment I, the caudate lobe. The left lateral sector consists of a superior segment II and an inferior segment III and is synonymous with the left lateral segment in older terminology. The major advantage to this detailed segmental anatomy, which is based on discrete portal pedicle branches, is to accurately locate individual lesions in the hepatic substance by preoperative imaging and intraoperative ultrasound and to allow the possibility of less than lobar segmental anatomical resections that minimize blood loss and functional loss of hepatic reserve. Ref – sabiston 20th ed. Pg-1418-1477 92. 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 Answer: c pg. 51 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. Ref – sabiston 20th ed. Pg-1418-1477 93. 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. The short hepatic veins are difficult to detect with intraoperative ultrasound Answer: b 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. pg. 52 portal inflow occlusion by clamping or compression of the portal triad (Pringle maneuver). There has been considerable debate over early versus late isolation and ligation of a given hepatic vein during lobectomy since the extraparenchymal component of the hepatic vein may be quite short or absent. Since hemorrhage in this location may be difficult to control, a safe strategy is to always avoid early isolation of a given hepatic vein or to attempt isolation only when a considerable length of vein is found on mobilization of the respective triangular ligament. Ref – sabiston 20th ed. Pg-1418-1477 97. Which of the following statement(s) is/are true concerning the arterial venous anatomy of the liver? a. Most commonly, the right, left, and middle hepatic veins join the inferior vena cava as a separate trunk b. Most frequently, the entire length of each hepatic vein is within the parenchyma of the liver c. A replaced left hepatic artery may be placed in jeopardy during performance of a pancreaticoduodenectomy d. There is little collateral arterial circulation between the right and left hepatic lobes Answer: b There are three major hepatic veins which carry blood from the central veins of the hepatic substance to the inferior vena cava (IVC). In two-thirds of patients, there is a single large right hepatic vein which joins the right anterior wall of the IVC and a middle and a left hepatic vein which converge one-to-two cm from the IVC and enter the left anterior wall of the IVC as a single vessel. In one-third of patients, each major hepatic vein joins at the same horizontal level of the IVC as a separate trunk. In some patients, there is a short but definable extraparenchymal segment of one or more of the hepatic veins at the confluence with the IVC. More frequently, the entire length of the hepatic veins is intraparenchymal, which may preclude early, safe hepatic venous isolation during hepatic resection. There is considerable variability in the origin and course of the right and left hepatic arteries. The most common finding (55% of patients) is a transverse common hepatic artery from the celiac trunk which gives off the gastroduodenal, right gastric, and supraduodenal arteries and courses obliquely in the left anterior aspect of the hepatoduodenal ligament as a proper hepatic artery. After giving off the cystic artery to the gallbladder, there is then a fairly low trifurcation into a single right, middle, and left hepatic arteries. Knowledge of the most common variations is extremely importance since inadvertent division may occur during gastric, pancreatic, and hepatobiliary procedures. There may be a replaced or accessory left hepatic artery which arises from the left gastric artery and courses transversely in the lesser omentum. With nearly equal frequency, there is a replaced or accessory right hepatic artery from the superior mesenteric artery near its origin which courses posterior or through the head of the pancreas obliquely along the right posterior border of the hepatoduodenal ligament. Although original anatomic descriptions deny the existence of collateral vessels to the opposite hepatic lobe, image perfusion studies after ligation of main or replaced hepatic arteries have clearly demonstrated pg. 55 the presence of collateral flow to the deprived lobe. Ref – sabiston 20th ed. Pg-1418-1477 98. 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 Answer: a 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. Ref – sabiston 20th ed. Pg-1418-1477 99. Transport of substances from the blood into the hepatocyte occurs through the sinusoidal membrane. The following statement(s) is/are true concerning this plasma membrane. a. The high lipid content of this phospholipid bilayer allows lipid-soluble molecules to enter the cell by simple diffusion b. Carrier proteins within the phospholipid bilayer bind to a solute in blood and by conformational change allow it to be transported into the cell pg. 56 c. The transmission of a signal to the interior of the cell by receptor-ligand binding which generates intracellular second messengers is known as signal transduction d. all of the above Answer: d The hepatocyte plasma membrane consists of a phospholipid bilayer in which hydrophobic fatty acid tails are oriented to the interior membrane and hydrophilic phospholipid head groups are oriented to the exterior (sinusoidal or cytoplasmic) membrane. Within this phospholipid bilayer are proteins which serve either structural functions or metabolic functions. The hepatocyte sinusoidal plasma membrane is heavily studded with microvilli to increase the absorptive area in contact with sinusoidal blood. The cell membrane, by virtue of its high lipid content, allows lipid-soluble molecules to enter the cell by simple diffusion. Polar molecules must enter cells via membrane transport proteins. Channel proteins allow molecules to diffuse simply into cells without binding, whereas carrier proteins first bind the solute and, by conformational change, allow it to be transported into the cell. The glucose carrier in hepatocytes is an example of carrier-facilitated diffusion. The sinusoidal membrane is studded with receptors, which are large glycoprotein molecules that span the plasma membrane lipid bilayer. A ligand-binding site of this receptor molecule projects into the space of Disse. When appropriate ligand-receptor binding occurs, the entire ligand may be internalized for intracellular degradation or biliary transport, or the ligand may transmit a signal to the interior of the hepatocyte by a number of intracellular second messenger systems, a process known as signal transduction. Such second messengers include cAMP, inositol triphosphate, and diacylglycerol. Each of these structurally simple chemicals can amplify cell membrane events and bring about major changes in cellular physiology. Ref – sabiston 20th ed. Pg-1418-1477 100. The liver is an important site of protein metabolism. Which of the following statement(s) is/are true concerning protein metabolism by the liver? a. Amino acids are taken up by hepatocytes by active transport mechanisms and are generally stored long-term for later synthetic activity b. Under certain conditions the amine group is removed from the amino acids in the liver and the carbon chain used for carbohydrate, lipid, or nonessential amino acid synthesis c. The most important route of detoxification of ammonia formed as the result of deamination of amino acids is via excretion of ammonia into the urine d. Albumin is a sensitive indicator of hepatic synthetic function Answer: b Essentially all of the end products of dietary protein digestion are amino acids, which are absorbed by the enterocytes into the portal circulation in ionized states. Amino acids are taken up by hepatocytes by one of several active transport mechanisms. Amino acids are not stored in the liver but are rapidly used in the production of plasma proteins, purines, heme proteins, and pg. 57 Ref – sabiston 20th ed. Pg-1418-1477 104. The following statement(s) is/are true containing lipid metabolism in the liver. a. Hepatic mitochondrial hydrolysis of fatty acids is a tremendous source of ATP b. Significant hepatic storage of triglyceride or fatty infiltration can cause hepatic fibrosis or necrosis c. Approximately 10% of cholesterol synthesis occurs in the liver d. Most cells in the body are capable of phospholipid synthesis, therefore the liver plays a minimal role in this process Answer: a The liver has a number of important functions in the metabolism of lipids: 1) the synthesis of apolipoproteins, 2) the degradation of fatty acids into energy substrates, 3) the synthesis of triglycerides from carbohydrates and proteins, and 4) the synthesis of cholesterol and phospholipids from fatty acids. The mitochondrial hydrolysis of fatty acids is a source of large quantities of ATP. The conversion of stearic acid to CO2 and H2O, for instance, generates 136 ATP molecules and demonstrates the highly efficient storage of energy in fat. In times of unrestrained lipolysis, such as starvation, uncontrolled diabetes or other conditions of triglyceride mobilization from adipose tissue, the ability of the liver to perform beta-oxidation may be inadequate. Under these circumstances, significant hepatic storage of triglycerides or fatty infiltration of the liver may occur. Triglyceride storage by itself does not appear to be a cause of hepatic fibrosis or necrosis, but fatty infiltration may be a marker for derangement of normal processes by alcohol or drug toxicity, diabetes, chronic parenteral nutrition, or morbid obesity. Cholesterol is an important regulator of membrane fluidity and is a substrate for bile acid and steroid hormone synthesis. Cholesterol may be available by dietary intake or by de novo synthesis. In mammals, about 90% of new cholesterol is synthesized by the liver from its precursor, acetyl CoA. Dietary cholesterol intake suppresses endogenous synthesis by inhibiting the rate-limiting enzyme in cholesterol by a synthetic pathway, HMG-CoA reductase. There are three major classes of phospholipids synthesized by the liver: the lecithins, the cephalins, and the sphingomyelins. Although most cells in the body are capable of some phospholipid synthesis, the liver produces 90%. Ref – sabiston 20th ed. Pg-1418-1477 105. Hepatic biotransformation is defined as the intracellular metabolism of endogenous and exogenous organic compounds. Which of the following is/are enzyme families responsible for hepatic bile transformation? a. Cytochromes P-450 b. UDB-glucuronyl transferases c. Glutathione-transferases pg. 60 d. all of the above Answer: d The liver contains enzyme systems that can expose functional groups such as hydroxyl ions and alter the size and solubility of a wide variety of organic and inorganic compounds by conjugation with small polar molecules. The general strategy of the liver is to convert hydrophobic, potentially toxic compounds into hydrophilic conjugates that can then be excreted into bile or urine. There are four general enzyme families responsible for hepatic bile transformation. The cytochromes P-450 catalyze reactions such as oxidation, hydroxylation, sulfoxide formation, oxidative deamination, dealcoholization and dehalogination. Such reactions allow further phase II conjugation with polar groups such as glucuronate, glutathione and sulfate. Glucuronidation is the conjugation of UDB-glucuronic acid to a wide variety of xenobiotics by either esther or ether linkages. The glutathione transferases and sulfotransferases play a role in conjugation of P-450 derivatives. However, the glucuronyl transferase system is the predominant mechanism. Ref – sabiston 20th ed. Pg-1418-1477 106. The following statement(s) is/are true concerning the differential diagnosis between an amoebic and a pyogenic liver abscess. a. The clinical presentation is often clearly distinguishable b. A history of travel or origin from a high risk area might suggest an amebic liver abscess c. Routine liver chemistries frequently can distinguish pyogenic from amoebic liver abscess d. Distinguishing pyogenic from hepatic abscesses preoperatively is not important since surgical drainage is imperative for both Answer: b Distinguishing amoebic from pyogenic liver abscess can be a diagnostic challenge. It is of major importance, however, because effective medical therapy with metronidazole can obviate the need for either percutaneous or surgical drainage in most cases of amoebic abscess. The clinical presentation for both conditions with acute onset of fever, abdominal pain, and altered liver function tests are almost identical. Important features such as travel to or origin from a high risk area is particularly important for amebic liver abscess. Routine liver chemistries and radiographic studies can rarely distinguish between amoebic and pyogenic liver abscesses. Specific serologic tests for the presence of antibody to E. histolytica are specific and sensitive for amoebic hepatic abscess being positive in 95% of the cases, and therefore, are key in distinguishing the two infections. Ref – sabiston 20th ed. Pg-1418-1477 107. A patient is found to develop evidence of hepatitis approximately eight weeks after receiving blood transfusions during a surgical procedure. Which of the following statement(s) is/are true? pg. 61 a. The virus responsible is most likely hepatitis C b. A chronic carrier state will never develop in most patients c. There is no role for interferon in the treatment of chronic hepatitis C viral infection d. Chronic infection with hepatitis C is not associated with an increased risk of developing hepatocellular carcinoma Answer: a Hepatitis C virus is a virus that is responsible for more than 90% of post-transfusion hepatitis and most sporadic non-A, non-B hepatitis throughout the world. The most common identifiable sources of acquisition of hepatitis C virus are prior transfusion of blood or blood-derived products or a history of intravenous illicit drug use. The usual incubation period of post- transfusion hepatitis C viral infection is 5 to 10 weeks. An initial elevation of liver enzymes may be associated with little or no clinical disturbance. In some patients, acute hepatitis C viral infection does not progress to chronic infection, however, chronic hepatitis C viral infection develops in up to 70% of patients with post-transfusion hepatitis C infection with many progressing to cirrhosis. Hepatitis C does not appear to alter life expectancy at least in the first 15 years of infection. However, once cirrhosis and end stage liver disease develop, the clinical syndrome is indistinguishable from other forms of chronic liver disease with a predisposition to the development of hepatoma. Interferon alpha is the only FDA approved therapy for chronic hepatitis C viral infection. There is some evidence that early administration of interferon in acute hepatitis C viral infection may reduce the risk of progression to the chronic state. As yet, there is no evidence that interferon alters the natural history of chronic hepatitis C viral infection or changes the incidence. Ref – sabiston 20th ed. Pg-1418-1477 108. A surgeon is suspected of having contacted hepatitis B virus via needle stick. Which of the following statement(s) is/are true concerning his diagnosis and outcome? a. The patient has about a 10% chance of developing a chronic carrier state b. All susceptible household or sexual contacts of the surgeon should receive hepatitis B viral vaccine c. The surgeon should receive hepatitis B immunoglobulin as soon as possible after the accidental needle stick d. all of the above Answer: d Hepatitis B viral infection is insidious. The incubation period of the virus is about eight weeks. The first serum indicator of infection by hepatitis B virus is detection of the serum hepatitis B surface antigen (HBsAg) which may proceed the onset of jaundice. In most cases, hepatitis B infection is self-limited and does not progress to chronic hepatitis. However, some 10% of patients with acute hepatitis B viral infection, whether it is clinical or subclinical, will develop a chronic carrier state. The carrier state is defined by the presence of HBsAg in serum for longer pg. 62 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%. Ref – sabiston 20th ed. Pg-1418-1477 112. Which of the following statement(s) is/are true concerning the natural history and clinical features of alcoholic cirrhosis? a. In patients with compensated cirrhosis, the probability of survival at 10 years approaches 50% b. The development of clinical evidence of hepatic decompensation reduces five year survival to less than 20% c. Continued consumption of alcohol worsens prognosis d. all of the above Answer: d Recent studies have analyzed the natural history of cirrhosis as a function of the degree of hepatic decompensation at the time of diagnosis. A high proportion of patients with compensated cirrhosis remain well for many years after diagnosis. In these studies the probability of remaining compensated 10 years after diagnosis was 42%, and survival probability of compensated patients was 47%. The prognosis worsened considerably once patients developed clinical evidence of hepatic decompensation (ascites, jaundice, encephalopathy, or gastrointestinal hemorrhage). Among these patients, the probability of five-year survival was only 16%. The risk of death from variceal hemorrhage depends much more of the severity of the underlying liver disease than on the type of therapy. It would also appear from natural history studies that continued alcohol consumption does affect survival. In one study, the overall five-year survival is 63% for abstainers versus 40.5% for those who continued to drink. Continued alcohol consumption may have less of an effect on survival than the intensity of alcohol consumption. Furthermore, the degree of hepatic compensation at the time of inclusion into the study may have also been an important factor. 113. Which of the following statement(s) is/are true concerning the morphologic and histologic findings of cirrhosis? a. Micronodular cirrhosis is a pattern typical of chronic alcoholic liver disease b. Mallory bodies and megamitochondria are typical findings of alcoholic cirrhosis c. Large regenerating nodules separated by coarse irregular scars in piecemeal parenchyma necrosis is common in liver disease secondary to chronic active hepatitis d. all of the above Answer: d Morphologic classification of cirrhosis includes micronodular, macronodular, and mixed forms. pg. 65 Micronodular cirrhosis is characterized by uniform nodules and scars. The nodules are usually less than 3 mm in diameter and are typically associated with Laennec or nutritional cirrhosis in alcoholics. Post-necrotic cirrhosis is characterized by large regenerating nodules separated by coarse irregular broad as well as thin scars. This pattern is frequently seen in patients with viral hepatitis. Biliary cirrhosis is characterized by a coarsely granular macronodular liver. This condition results from long-standing cholestasis secondary to obstruction of intrahepatic or extrahepatic bile ducts. The most distinctive feature of large duct obstruction is the presence of bile leaks caused by rupture of bile duct with extravasation of bile into portal triads. Portal cirrhosis, which is typically observed in alcoholics, can generally be distinguished histologically by the presence of several specific hepatocellular alterations such as Mallory bodies and megamitochondria. Ref – sabiston 20th ed. Pg-1418-1477 114. 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 Answer: d 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% pg. 66 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. Ref – sabiston 20th ed. Pg-1418-1477 115. Which of these statement(s) is/are true concerning the etiologic factors in the development of cirrhosis? a. Viral hepatitis of any type (A, B, or non-A, non-B) can all progress to cirrhosis b. Acetaminophen can cause acute liver failure and necrosis but will not lead to cirrhosis c. Alcohol does not exerts toxic effects on the liver via reactive intermediates such as acetaldehyde d. Long-standing congestive heart failure can lead to cirrhosis secondary to centrilobular congestion, hemorrhage, and necrosis Answer: d Liver cells are sensitive to a variety of physical, microbiologic, and chemical agents, all of which may produce cellular injury. The eventual development of cirrhosis is determined by the nature and severity of the cellular injury and the liver’s ability to regenerate. Most infectious hepatitides are viral in origin. There is no documentation that hepatitis A progresses to cirrhosis, however hepatitis B and non-A, non-B hepatitis do demonstrate a propensity to become chronic with the development of cirrhosis. Chemical hepatotoxicity include direct and indirect actions. Acetaminophen under normal circumstances is detoxified chiefly by conjugation with glucuronic acid or sulfate. Saturation of glucuronic pathway with large doses of acetaminophen results in progressive depletion of intracellular glutathione stores, accumulation of toxic intermediate, and eventual cell necrosis which may progress to either acute liver failure or chronic cirrhosis. Alcohol can affect liver cell function in a number of ways. Like many hepatotoxins, the toxic effects of alcohol are caused indirectly by reactive intermediates. Acetaldehyde is the principal reactive compound generated by alcohol metabolism. The hepatotoxicity of acetaldehyde is related to its binding two major constituents of cellular membranes altering membrane integrity and enzymatic function frequently to the detriment of the cell. Early morphologic changes of long-standing cardiac decompensation and right-sided heart failure are central lobular congestion, hemorrhage, and necrosis combined with phlebosclerosis of central veins and scars connecting centrizonal areas (cardiac cirrhosis). Ref – sabiston 20th ed. Pg-1418-1477 116. Important spontaneous portosystemic collaterals which develop in the face of portal hypertension include: a. The hemorrhoidal veins b. Left renal vein pg. 67 c. Endoscopic sclerotherapy is more effective than conservative medical therapy in the treatment of bleeding esophageal varices d. all of the above Answer: d A number of invasive and noninvasive therapies exist for the treatment of bleeding esophageal varices. Vasopressin is frequently used in the treatment of acute variceal hemorrhage and acts by decreasing portal venous pressure or flow through splanchnic vasoconstriction. Vasopressin alone has been reported to temporarily control variceal hemorrhage in 50% to 75% of patients, however, it can be associated with cardiac and peripheral extremity cutaneous ischemia. Somatostatin also acts as a vasoconstrictor to reduce splanchnic flow, with trials demonstrating similar efficacy in controlling acute hemorrhage when compared to vasopressin but without the cardiac side effects. Balloon tamponade is generally used for the temporary control of acute variceal hemorrhage unresponsive to vasopressin or sclerotherapy. Initial control of acute variceal hemorrhage occurs in about 80% of patients, but bleeding recurs promptly on deflation of the balloons in over 50%. Endoscopic sclerotherapy has become the primary treatment for bleeding esophageal varices. A number of clinical trials demonstrate that emergent sclerotherapy is able to halt variceal bleeding that fails to respond to more conservative measures, with no increase in frequency or severity of complications. The long- term survival of patients treated with sclerotherapy continues to be debated. Metaanalysis has been performed on the data from seven randomized clinical trials evaluating the effect of repeated sclerotherapy on long-term survival. This analysis demonstrates that sclerotherapy reduces the number of deaths by 25% therefore supporting the use of sclerotherapy as an effective means of prolonging survival in patients who have experienced variceal hemorrhage. Ref – sabiston 20th ed. Pg-1418-1477 121. Which of the following statement(s) is/are true concerning the surgical management of bleeding esophageal varices. a. A side-to-side portacaval shunt may be associated with the development of hepatofugal blood flow b. Selective shunts preserve prograde (hepatopedal) blood flow while decompressing esophageal varices or reducing portal pressure c. The presence of intractable ascites is a contraindication to the Warren shunt d. all of the above Answer: d Although portosystemic shunts are the most effective therapy for preventing recurrent variceal hemorrhage, they are associated with the increased incidence of encephalopathy. A number of types of shunts have been described, primarily to avoid the consequences of complete diversion of portal blood flow or to simplify the operation. End-to-side portocaval shunts are hemodynamically unique in that all portal flow is diverted and the hepatic limb of the portal pg. 70 vein is ligated, thus preventing hepatofugal blood flow from the liver. With lateral side-to-side shunts, the hepatic limb of the portal vein remains patent. A greater compensatory increase in hepatic arterial flow occurs when the portal vein serves as an outflow track and the liver extracts oxygen and metabolites from the blood exiting through the patent limb of the portal vein (hepatofugal). The goal of selective shunts is to preserve prograde (hepatopedal) portal flow to the liver while selectively decompressing gastroesophageal varices (Warren shunt) or reducing portal pressures sufficiently to prevent variceal hemorrhage (small-diameter shunts). Most surgeons with a special interest in this field attempt to construct a selective shunt when the operation is elective, unless contraindications are present. The distal splenorenal shunt of Warren and the small-diameter interposition portocaval shunt of Sarfeh are the most common selective shunts used. The Warren shunt is an ascitogenic operation and therefore the presence of ascites that is difficult to control medically is a contraindication of this operation. An interposition mesocaval shunt is frequently preferred in emergent situations because the shunt is relatively safe to construct and promptly halts variceal hemorrhage. If future hepatic transplantation is contemplated, this shunt offers the advantages in that it does not involve dissection of the area of the hepatoduodenal ligament. Ref – sabiston 20th ed. Pg-1418-1477 122. Which of the following statement(s) is/are true concerning the results of portosystemic shunting? a. When comparing shunts with nonshunting procedures, only minor differences in long-term survival are reported, but the mode of death usually changes b. Distal splenorenal shunts are associated with the development of less hepatic encephalopathy c. Survival statistics following distal splenorenal shunt in good risk patients (Child’s Class A) are in excess of 80% d. all of the above Answer: d Multiple randomized comparisons of distal splenorenal shunt with other types of portosystemic shunts have been reported. Operative mortality and long-term prognosis are similar, but patients undergoing distal splenorenal shunts develop less encephalopathy. Less encephalopathy is also seen with the selective Sarfeh shunt and after nonshunting proced ures, such as sclerotherapy or devascularization. When comparing shunts with nonshunting procedures, only minor differences in long-term survival are reported, but the mode of death usually changes. With nonshunting procedures, a greater proportion of patients die of recurrent hemorrhage; after construction of a shunt, a greater proportion die of hepatic failure. Class A patients undergoing distal splenorenal shunts can be predicted to have an actuarial survival including operative mortality in excess of 80%. This is a substantial improvement over previous experience with portocaval shunts and is likely better than the results that can be obtained with hepatic transplantation. pg. 71 Ref – sabiston 20th ed. Pg-1418-1477 123. Which of the following statement(s) is/are true concerning radiologic examinations used for the assessment of hepatic neoplasms? a. Magnetic resonance imaging is considered the test of choice for distinguishing hemangiomas from other mass lesions b. Dynamic CT scanning is the dominant imaging modality for routine screening and diagnosis c. CT angio-portography (CTAP) is the gold standard for early detection of metastatic hepatic lesions d. all of the above Answer: d In the Western world, the test most commonly used for screening, detection, and diagnosis of hepatic neoplasms are dynamic bolus-enhanced CT scan, MRI, and ultrasound. Dynamic CT scanning remains the dominant imaging modality for routine screening and diagnosis because it is sensitive, widely available, provides helpful anatomic information and allows the evaluation of other intraabdominal structures in the detection of extrahepatic disease. The most sensitive test for the detection of liver masses is CTAP, however, like angiography is generally reserved for preoperative evaluation of resectability and not for screening. Hepatic MRI imaging is another useful tool in the detection and diagnosis of the liver lesions, with sensitivities equal to that of CT. MRI with T1 and T2-weighted images and gadilinium enhancement can aid in the differential diagnosis of a mass. For example, MRI is now considered the test of choice for distinguishing hemangiomas from other mass lesions. Radionucleotide imaging is less sensitive and specific than CT, MRI, or ultrasound, and has a high percentage of false-positive and false-negative results. Therefore, nuclear medicine scans play a limited role in modern screening and detection, but they can help differentiate discrete masses. Ref – sabiston 20th ed. Pg-1418-1477 124. A 45-year-old woman undergoes an ultrasound because of vague right upper quadrant pain and epigastric fullness. A 7 cm cystic lesion is detected. Which of the following statement(s) is/are true concerning the patient’s diagnosis and management? a. Simple aspiration is indicated for treatment and diagnosis b. Bile stained fluid suggests underlying biliary pathology c. The cyst is likely lined by cuboidal epithelium d. Laparoscopic unroofing of the cyst does not provide satisfactory treatment Answer: c A symptomatic solitary hepatic cyst may cause vague right upper quadrant discomfort or pain, a sensation of epigastric fullness or heaviness, and early satiety, however, most cases are asymptomatic. Complications are rare but include hemorrhage into the cyst, secondary bacterial infection, or obstructive jaundice from compression of extrahepatic ducts. In the absence of pg. 72 Hepatocellular carcinoma has three well-known epidemiologic associations: hepatitis B infection, cirrhosis, and various hepatotoxins, most notably aflatoxin B1 (a microtoxin from the fungus Aspergillus flavus). Hepatocellular carcinoma is strongly associated with hepatitis B viral infection but there is no link between the neoplasm and the hepatitis A viral infection. There does appear to be some link between hepatocellular carcinoma and hepatitis C virus. Cirrhosis, predominantly macronodular, is a frequent result of hepatitis B viral infection and is a risk factor for hepatocellular carcinoma. Nevertheless, the micronodular form, which is more common in early alcoholic cirrhosis, will progress to hepatocellular carcinoma in about 2% to 3% of cases. Thus, hepatocellular carcinoma can develop in patients with hepatitis B viral infection and cirrhosis, hepatitis B viral infection alone, and with cirrhosis from any cause alone. Ref – sabiston 20th ed. Pg-1418-1477 128. A 38-year-old woman with a 17 year history of oral contraceptive use presents with right upper quadrant pain. A CT scan demonstrates a 4 cm lesion in the right lobe of the liver. Which of the following statement(s) is/are true concerning the patient’s diagnosis and management? a. The lesion is likely premalignant b. A 99mTc sulfur colloid scan will distinguish this benign lesion from a malignant hepatoma c. The lesion, although benign, may be associated with life-threatening hemorrhage d. The lesion would be expected to be hypovascular on angiographic study Answer: c Hepatic adenomas are clearly linked with the use of oral contraceptives. The likelihood of developing a hepatic adenoma appears to be related to the duration and dosage of estrogen, and is greater at ages above 30 years. The majority (75%) of these lesions occur in the right lobe of the liver. Although adenomas may be a symptomatic, most patients have symptoms, usually of abdominal pain (as many as 50%), and 10% to 33% of patients present with acute signs and symptoms secondary to bleeding or rupture with intraperitoneal hemorrhage. No radiologic test is specific for adenomas. CT is the most useful preliminary test and often reveals areas of hemorrhage and necrosis. Angiography may add to CT findings by demonstrating the hypervascular tumor with a peripheral blood supply. 99mTc sulfur colloid scans show a cold spot thereby distinguishing adenoma from focal nodular hyperplasia but not from other solid masses. For asymptomatic patients or patients with minimal symptoms, surgery is the treatment of choice given the tumors have the tendency to bleed and a small chance of coexisting malignancy. 129. Which of the following statement(s) is/are true concerning focal nodular hyperplasia (FNH)? a. The lesion predominantly affects young women b. The lesion is associated with the use of oral contraceptives and other estrogens pg. 75 c. Radionucleotide scanning is not useful in the specific diagnosis of FNH d. Excisional biopsy is indicated in almost all cases because of the risk of bleeding Answer: a Focal nodular hyperplasia (FNH) should not be confused with a hepatic adenoma. Although FNH predominantly affects young women, it is also found in men and children. Unlike adenomas, there is no clear relationship between oral contraceptives and the development of FNH. FNH is most commonly asymptomatic and does not have a propensity to bleed or undergo malignant change. Histologically, FNH contains normal-appearing hepatocytes, bile ducts, and Kupffer cells in distinction to adenomas. Radionucleotide imaging can be useful in diagnosing FNH because FNH is the only lesion that contains Kupffer cells and therefore appears isodense rather than a filling defect. Treatment of asymptomatic patients is conservative when the diagnosis is clear. If there is doubt regarding the diagnosis, then excisional biopsy is indicated for small, easily removable lesions. Ref – sabiston 20th ed. Pg-1418-1477 130. Which of the following statement(s) is/are true concerning the prognosis of patients with hepatic metastases and colorectal carcinoma? a. Five year survivals following hepatic resection for an isolated metastasis is in excess of 25% b. Survival beyond five years after resection suggests a high probability of cure c. Survival rates are improved with a margin of resection greater than 1 cm d. all of the above Answer: d Studies consistently report five-year survival rates averaging 25% for hepatic resection for colorectal metastases. Those who survive beyond five years seem to do well with only an additional 5% dying of recurrence within the next five years. Median survival of patients with untreated metastases is on the order of three to 10 months, with only 20% surviving past one year. Overall survival is significantly improved with surgical margins greater than 1 cm with decreased survival in patients with positive margins or margins less than 1 cm in size. The number of metastasis is a less consistent but statistically significant factor. Patients with four or more metastases have a poorer prognosis. As for the size of the metastasis, it is not a significant factor except that a larger total liver volume of metastasis requires a larger hepatic resection. Larger size may preclude adequate margins and indicate longer development of time with an increased likelihood of micrometastases. Ref – sabiston 20th ed. Pg-1418-1477 131. Which of the following statement(s) is/are true concerning the treatment and prognosis of hepatocellular carcinoma? a. The fibrolamellar variant of hepatocellular carcinoma has a distinctly better prognosis than pg. 76 other forms of the disease b. Patients with untreated hepatocellular carcinoma survive more than a year c. Multiagent chemotherapy is extremely effective in hepatocellular carcinoma and should be considered for the treatment for most patients d. Hepatic artery ligation or embolization has been demonstrated to be highly effective for hepatocellular carcinoma Answer: b Hepatocellular carcinoma has a tendency for local and vascular invasion. Untreated, patients have a dismal prognosis with a median survival of only three to four months after diagnosis with only rare survival beyond one year. The fibrolamellar variant of hepatocellular carcinoma has a distinctly better prognosis with a five year survival after resection of 50% to 60% versus 25% for other varieties. Surgical resection offers the only chance for cure for primary hepatic malignancy, and survival is better if tumors are small and asymptomatic. The role of orthotopic liver transplantation for hepatocellular carcinoma continues to evolve. For patients with severe hepatic dysfunction or larger or centrally located tumors or bilobar tumors, this may be the preferred approach. Extrahepatic disease including lymph node involvement is a contraindication to resection or transplantation. No single-or multiple-agent chemotherapy is particularly effective in treating hepatocellular carcinoma. The rationale for treating vascular liver tumors with arterial obstruction is the fact that the nutritional blood supply of these tumors comes primarily from the hepatic artery. Hepatic artery ligation or embolization alone or in combination with regional chemotherapy has been shown to be ineffective for liver cancer. In addition, hepatic artery ligation has a high complication rate and cannot often be used in patients with compromised liver function from cirrhosis. Ref – sabiston 20th ed. Pg-1418-1477 132. The following statement(s) is/are true concerning the relationship of the biliary tree and the hepatic artery and portal vein. a. The common hepatic and common bile duct lie immediately anterior to the portal vein b. The cystic artery, which usually arises from the right hepatic artery, crosses behind the hepatic duct in most cases c. A replaced right hepatic artery arising from the superior mesenteric artery system will run to the right of the common bile duct d. all of the above Answer: d The common hepatic duct passes downward in the superior and lateral portions of the hepatoduodenal ligament and lies in front of the portal vein and to the right of the hepatic artery. The cystic artery which in most cases arises from the right hepatic artery usually crosses behind the hepatic duct (84%) of cases but is sometimes anterior to that structure (16%) of cases. A number of anatomic variations of the arterial supply of the liver can be seen. In patients in which the right hepatic artery arises from the superior mesenteric artery system, the pg. 77 b. In the postprandial state about 70% of hepatic bile flows into the gallbladder before reaching the duodenum c. During the interdigestive period, only a small fraction of gallbladder bile enters the duodenum d. all of the above Answer: d As bile is secreted from the liver, it flows through the hepatic ducts into the common hepatic duct and continues through the common bile duct into the duodenum. With an intact and contracted sphincter of Oddi, bile flows directly into the gallbladder where it is concentrated and stored. In the postprandial state, about 70% of hepatic bile flows into the gallbladder before reaching the duodenum and entering the enterohepatic cycle. During the interdigestive phase, 90% of bile from the liver enters the gallbladder, while only a small fraction of gallbladder bile enters the duodenum. Gallbladder emptying during fasting is associated with phase II of the interdigestive migrating motor complex (MMC). Motilin may account for this stimulatory effect since plasma elevations of motilin seem to correlate with the onset of phase II waves. Following a meal, the gallbladder empties by a steady tonic contraction thought to be due to release of endogenous cholecystokinin (CCK) from the mucosa of the small intestine. Ref – sabiston 20th ed. Pg-1482-1518 137. The following statement(s) is/are true concerning the anatomy of the gallbladder. a. The gallbladder lies between the right, left, and quadrate hepatic lobes or hepatic segments IV and V b. The cystic duct contains the spiral valve of Heister which serves an important valvular function for the gallbladder c. The cystic artery arises from the left hepatic artery in 95% of cases d. The cystic artery crosses anterior to the hepatic duct in the majority of cases Answer: a The gallbladder is a pear-shaped organ bound to a fossa on the right inferior surface of the liver located between the right, left, and quadrate hepatic lobes or hepatic segments IV and V. The gallbladder can be divided into four areas: the fundus, body, infundibulum, and neck. The body of the gallbladder extends from the fundus into the tapered portion, or neck, which curves backward and upward toward the transverse fissure of the liver and terminates in the cystic duct. The cystic duct lumen contains a thin mucosal septum, the spiral valve of Heister; the valve may make catheterization to the cystic duct difficult but does not have true valvular function. The arteries of the gallbladder are derived from the cystic branch of the hepatic artery which in 95% of cases originates from the right hepatic artery. From its origin, the cystic artery usually crosses behind the hepatic duct (84% of cases) but is sometimes anterior to that structure. The cystic artery proceeds to the neck of the gallbladder, where it divides into anterior and posterior divisions that supply the corresponding areas of the gallbladder. The cystic veins empty into the right branch of the portal vein indirectly into the liver. pg. 80 Ref – sabiston 20th ed. Pg-1482-1518 138. The gallbladder plays an important role in altering bile composition by absorption and secretion. Which of the following statement(s) is/are true concerning this mucosal function? a. The absorption of water by the gallbladder can result in concentration of the solute components of bile from 2-to 10-fold b. Gallbladder mucosal absorption can occur by both active and passive mechanisms c. Secretory products of the gallbladder include bicarbonate and glycoproteins d. all of the above Answer: d The gallbladder rapidly absorbs water and solutes from bile and concentrates the solute components 2-to 10-fold. The gallbladder has an active mucosa and is able to absorb water and solutes against significant concentration gradients. Water absorption is linked to the transport of ions. The two major mechanisms of absorption are active and passive. In passive absorption, sodium and chloride enter the gallbladder epithelial cells because of electrochemical gradients. This results in an osmotic gradient, and water flows into the cell. Intracellular sodium is extruded across the basolateral membrane into the lateral intercellular spaces by active transport. The active transport of sodium against an electrochemical gradient is associated by an Na+-K+-ATPase pump. Cyclic AMP may inhibit NaCl-coupled transport and may also influence tight junction permeability. Other peptides, such as secretin, glucagon, and gastric inhibitory peptide, have been shown to inhibit absorption. Secretion by the gallbladder occurs either by inhibiting net ion and fluid absorption or with stimulation of bicarbonate secretory mechanisms. Gallbladder epithelium may also secrete mucin and nonmucin glycoproteins which may play a role in gallstone formation. Ref – sabiston 20th ed. Pg-1482-1518 139. Abnormalities of the sphincter of Oddi have been recently recognized to cause symptoms which are referable to the biliary tree or pancreas. The following statement(s) is/are true concerning sphincter of Oddi motor function. a. The sphincter’s basal resting pressure is 10 to 15 mm Hg above duodenal pressure b. Vagal stimulation results in relaxation of the sphincter c. Manometry of the sphincter of Oddi may be performed at the time of ERCP to characterize basal pressure, amplitude, frequency of contraction, and direction of propagation of contractile waves d. all of the above Answer: d The sphincter of Oddi is about 4 to 6 mm in length. The sphincter’s basal resting pressure is about 13 mm Hg above duodenal pressure. The sphincter exhibits phasic contractions at a pg. 81 frequency of 4 per minute and a duration of 8 seconds. The regulation of bile flow is primarily controlled by the sphincter and not by the surrounding smooth muscle of the duodenum. Relaxation of the sphincter occurs with CCK stimulation leading to diminished amplitude of phasic contractions and reduced basal pressure, allowing increased passive flow of bile into the duodenum. Parasympathetic stimulation also causes intermittent relaxation of the sphincter, and sympathetic splanchnic stimulation causes increased pressure. Abnormalities of the sphincter of Oddi may cause symptoms which are referable to the biliary tree or pancreas. Manometry of the sphincter of Oddi may be performed at the time of ERCP to characterize its basal pressure, the amplitude and frequency of contractions, and the direction of propagation of contractile waves. Stenosis of the sphincter of Oddi is characterized by abnormally elevated basal pressure (> 40 mm Hg) whereas dyskinesia is characterized by abnormalities of other manometric parameters. Ref – sabiston 20th ed. Pg-1482-1518 140. A 32-year-old woman with symptomatic gallstones wishes to discuss nonsurgical options for her gallstones. Which of the following statement(s) are true? a. The best commercially available oral dissolution agent, ursodeoxycholic acid, is associated with a complete dissolution rate of less than 50% b. If the gallstones dissolve, there is minimal risk of gallstone recurrence c. Contact dissolution is applicable regardless of stone type d. Extracorporial shock wave lithotripsy (ESWL) in combination with oral dissolution agents is an appropriate technique for most patients and can result in complete stone fragment clearance in over 90% of patients by one year Answer: a Prior to the introduction of laparoscopic cholecystectomy, there was tremendous enthusiasm for a number of nonsurgical techniques for managing gallstones. Dissolution of existing gallstones with pharmacologic agents has been addressed by several national cooperative studies. Ursodeoxycholic acid is the best, safest, and most effective commerically available drug currently available. However, it still has a rate of complete dissolution of only 40%. It is also estimated that only 10% of patients will be suitable candidates for this therapy. Furthermore, gallstone recurrence is a major problem. Actuarial life table analysis indicates that the risk of gallstone recurrence in patients who have undergone dissolution of gallstones with oral bile acid therapy is 50% by five years. The addition of extracorporial shock wave lithotripsy increases the efficiency of gallstone clearance and in selected patients complete fragment clearance can be obtained in over 90% of patients by one year. However, optimal results can be obtained only by setting relatively strict criteria for inclusion. In applying such criteria, less than 20% of patients in the United States would be considered eligible for ESWL. Similar problems with gallstone recurrence have been observed with this technique. Finally, contact dissolution primarily with the ether solvent methyl tert-butyl ether (MTBE) is extremely effective in dissolving cholesterol gallstones. This technique, however, will work only in stones which are composed of cholesterol and the patient pg. 82 biliary air in the setting of a small bowel obstruction seen on abdominal radiography. Patients with gallstone ileus are best managed as if they had a mechanical small bowel obstruction with aggressive fluid resuscitation, broad spectrum antibiotics, and early laparotomy. The primary goals at laparotomy are correction of the obstruction and removal of the offending gallstone. Since many of the patients are elderly and ill, cholecystectomy and takedown of the biliary enteric fistula may not be appropriate. Enterolithotomy alone, without cholecystectomy, has an associated mortality of 5% in contrast to 15% mortality rate in patients who undergo both procedures at the same time. Ref – sabiston 20th ed. Pg-1482-1518 144. The pathogenesis of cholesterol gallstones is multifactorial. A number of key processes, however, appear to interact closely in the formation of cholesterol gallstones. These include: a. Cholesterol supersaturation b. Gallbladder stasis c. Accelerated nucleation d. all of the above Answer: d The development of gallstones is a complex multifactorial process. Although a number of factors may contribute to gallstone formation, a number of steps are considered critical in the formation of gallstones. These include cholesterol supersaturation whereby the amount of cholesterol present is in excess of the ability of the micelles and vesicles to transport cholesterol in a soluble state. In addition, the process by which cholesterol crystals form and agglomerate is referred to as nucleation. It is likely that the process of nucleation is altered by a number of biliary proteins or other compounds which may promote or inhibit the nucleation process. Gallbladder stasis provides the proper environment for gallbladder crystal precipitation and stone formation. The stagnant pool of bile within the gallbladder may facilitate both cholesterol supersaturation, the nucleation process, as well as altering the gallbladder’s absorptive or secretory functions. Although bilirubin has been suggested to play a small role in cholesterol gallstone formation, perhaps in either nucleation or solubilization of cholesterol, excessive production of bilirubin as seen in hemolytic disorders is associated primarily with the formation of pigment gallstones. Ref – sabiston 20th ed. Pg-1482-1518 145. Which of the following statement(s). is/are true concerning the diagnosis of biliary tract disease? a. Nonvisualization of the gallbladder on oral cholecystogram is diagnostic of biliary calculous disease b. Ultrasonography has a diagnostic accuracy and sensitivity for cholelithiasis in excess of 95% c. Ultrasonography is the preferred test to distinguish chronic from acute cholecystitis pg. 85 d. Hepatobiliary scintigraphy is not indicated to confirm the clinical diagnosis of acute cholecystitis Answer: b A number of radiographic studies can be used to diagnose cholelithiasis. Visualization of gallstones on plain abdominal radiographs is possible in about 20% of patients whose stones are grossly calcified. Traditionally, oral cholecystogram has been the gold standard for the diagnostic evaluation of patients with suspected gallstones. Although the accuracy for oral cholecystography has been reported to be as high as 95%, several conditions preclude satisfactory examination, including acute illness; poor patient compliance; inability to absorb the tablets as the result of emesis, malabsorption, or diarrhea; and jaundice or hepatic dysfunction. Abdominal ultrasonography has therefore become the preferred test for evaluation of patients with suspected gallstones. Most large series suggest that diagnostic accuracy and sensitivity for cholelithiasis exceeds 95%. In addition to detecting gallstones, information is provided concerning the size and shape of the gallbladder, gallbladder wall thickness, presence of pericholcystic fluid, or a sonographic Murphy’s sign. The latter has been suggested to have an 85% accuracy rate in patients with acute cholecystitis. Nonetheless, while abdominal sonography is most helpful in identifying the presence or absence of gallstones, it is of limited use in distinguishing chronic from acute cholecystitis. Hepatobiliary scintigraphy provides information on the patency of the bile ducts, including the cystic duct. Recognition that cystic duct obstruction is the sine qua non of acute cholecystitis, failure of the gallbladder to visualize during hepatobiliary scintigraphy is highly suggestive of acute cholecystitis. Although a number of false positive exams can occur, nonvisualization of the gallbladder during hepatobiliary scanning in the appropriate clinical setting is highly diagnostic of acute cholecystitis. Ref – sabiston 20th ed. Pg-1482-1518 146. Which of the following statement(s) is/are true concerning the solubilization of cholesterol in bile? a. Cholesterol is highlysoluble in both serum and bile b. Mixed micelles are the primary transport mechanism for biliary cholesterol c. Most cholesterol found in bile is the result of excretion from serum d. Biliary vesicles are composed primarily of biliary phospholipid Answer: d Bile is secreted by the liver and is composed primarily of water, electrolytes, and organic solutes. Bile salts, cholesterol, and phospholipids are the main solutes found within bile and account for about 80% of the dry weight of bile. Most of the cholesterol found in bile is synthesized de novo in the liver. Cholesterol is an organic molecule that is virtually insoluble in an aqueous medium such as bile. Therefore, mechanisms for maintaining cholesterol in solution have been evolved. For decades, the mixed micelle which is composed of the amphiphatic bile salts and phospholipid was considered the primary carrier of bile. More recently, it has been demonstrated that up to 70% of the total amount of cholesterol normally found in gallbladder pg. 86 bile is transported and solubilized in the vesicular form. Bile vesicles are composed primarily of phospholipid of which in the human, lecithin accounts of 90% of the phospholipid content. Ref – sabiston 20th ed. Pg-1482-1518 147. Appropriate options for management of common bile duct stones identified at laparoscopic cholecystectomy include: a. Conversion to open cholecystectomy and common duct exploration b. Transcystic duct dilatation and exploration c. Complete the laparoscopic cholecystectomy with postoperative ERCP and stone removal d. all of the above Answer: d Common bile duct stones found unexpectedly during laparoscopic procedures presents the surgeon with a different set of choices from that of stones found during an open procedure where one would invariably proceed to common duct exploration. The practice of converting to an open procedure for the purposes of common duct exploration is acceptable and should be considered based on the surgeon’s experience and expertise and other options available. Transcystic duct dilatation and exploration with stone removal is being performed in increasing numbers and appears to be safe and effective. Although experience with laparoscopic choledochotomy and common duct exploration has been reported with limited experience, this technique is probably not appropriate for the average surgeon. Many surgeons, depending on their clinical situation, may opt to complete the laparoscopic removal of the gallbladder and proceed to postoperative management of the stone using endoscopic technique. Ref – sabiston 20th ed. Pg-1482-1518 148. Risk factors associated with development of gallstones include: a. Increasing age b. Obesity c. Rapid weight loss d. all of the above Answer: d Incidence of gallstones varies widely throughout the world} In the United States, about 10% of the population has cholelithiasis. Although the physiologic explanation for increasing incidence of gallstone disease in the elderly is unclear, epidemiologic studies have demonstrated a relationship between increasing age and the prevalence of cholelithiasis in both males and females. Gallstone disease is a much more common in women than men, however with the higher incidence of cholelithiasis in women persisting until the seventh or eighth decade of life, at which time the incidence approaches 20% in both men and women. Clinical evidence suggests a two to three-fold increase in the incidence of cholelithiasis among morbidly obese pg. 87 significantly worse c. If a full thickness tumor had been recognized at the time of cholecystectomy, an "extended cholecystectomy" may have been appropriate d. all of the above Answer: d Gallbladder cancers with the best prognosis are those that are found incidentally at the time of cholecystectomy for symptomatic gallstone disease. This point emphasizes the importance of opening all gallbladders at the time of cholecystectomy so that any suspicious lesions can be immediately examined histologically. When gallbladder cancer is limited to muc osa and submucosa, cholecystectomy is adequate treatment and has a good prognosis, with up to 100% five year survival. When the cancer involves the deeper layers of the gallbladder wall, the prognosis is more grim. A 64% five year survival was reported in patients who had carcinoma confined to the mucosa and submucosa, whereas none of the patients with cancer involving all layers of the gallbladder wall survived more than 2.5 years. Even though these tumors are relatively localized at the time of cholecystectomy, cholecystectomy alone was not adequate treatment for long-term survival. In hopes of improving these survival rates and considering the lymphatic and venous drainage of the gallbladder, it has been recommended that gallbladder cancers be treated by cholecystectomy with wide resection of the liver around the gallbladder bed (liver segments IV and V) and regional lymphadenectomy. This procedure has been termed an "extended cholecystectomy." Although this treatment has prolonged median survival, an overall improvement in five year survival has not been observed. When a gallbladder cancer has been recognized incidentally at the time of pathology examination after routine cholecystectomy, reexploration will likely show evidence of residual disease in the lymph nodes or adjacent liver and therefore resection of this residual disease may improve survival. More radical excision including hepatic resection and bile duct resection and sometimes even pancreaticoduodenectomy has been reported. However, the associated increased morbidity and mortality of these operations has not resulted in an improvement in survival. Ref – sabiston 20th ed. Pg-1482-1518 153. Gallbladder cancer accounts for 3% to 4% of all gastrointestinal tumors. Which of the following statement(s) is/are true concerning the incidence of gallbladder cancer? a. Gallbladder cancer is much more frequent in men b. Southwest Native Americans, Alaskans, Mexicans, and Hispanics have a greater incidence of gallbladder cancer than the general population c. The minority of patients with gallbladder cancer have gallstones d. The association of gallstones with gallbladder cancer is greater in patients with multiple small stones Answer: b Gallbladder cancer accounts for 3% to 4% of all gastrointestinal tract tumors and about 2% of all biliary procedures are done for gallbladder cancers. Gallbladder cancer is much more frequent pg. 90 in women, with a female/male ratio of 3:1. The disease is most commonly seen in elderly women with a mean age of 65 at diagnosis. Southwest Native Americans, Alaskans, Mexicans, and Hispanics living in the United States have an estimated five to six times greater incidence of gallbladder cancer than the general population. On the other hand, gallbladder cancer is much less common in blacks. The association of gallstones with gallbladder cancer is well known. Seventy to ninety percent of all patients with gallbladder cancers have gallstones, and about 0.4% of all patients with gallstones have gallbladder cancer. The association of gallstones with cancer may be related to gallstone size; larger stones have a greater cancer risk. There is a 10- fold increase in the incidence of gallbladder cancer in patients who have gallstones that are larger than 3 cm in diameter. Ref – sabiston 20th ed. Pg-1482-1518 154. The following statement(s) is/are true concerning the prognosis for gallbladder cancer. a. Average survival is in the range of one year b. Five year survival rates approach 50% c. The combination of postoperative adjuvant radiation and chemotherapy have been associated with overall improved survival d. For most patients, the goal of treatment is palliation Answer: d The prognosis for gallbladder cancer remains poor, with an average survival in the range of six months. Less than 5% of patients survive five years because 90% of gallbladder cancer patients present with stage V disease. For stage V disease, the goal of treatment is palliation. If these patients present with obstructive jaundice, a major goal of treatment is relief of jaundice and its attendant symptoms such as pruritus and cholangitis. Although radiation and chemotherapeutic regimens have been tried, none have been associated with a good response. 155. Which of the following statement(s) is/are true concerning gallbladder polyps? a. Sonographic findings of a gallbladder polyp include a filling defect which does not move with change in position b. Benign gallbladder polyps does not cause symptoms similar to those caused by gallstones c. Ultrasonography can readily distinguish benign from malignant gallbladder lesions d. An asymptomatic gallbladder polyp 1 cm in size can usually be followed with serial ultrasounds and does not require cholecystectomy Answer: a Benign gallbladder polyps cause symptoms similar to those caused by cholelithiasis. Biliary symptoms including right upper quadrant pain and discomfort, fatty food intolerance, nausea, vomiting, and an increase in flatulence are common complaints in patients with symptomatic benign gallbladder polyps. Gallbladder tumors, when diagnosed preoperatively, may be pg. 91 visualized by ultrasound, oral cholescintography, or less commonly, computed tomography. A filling defect that does not move with changes in position is probably a benign or malignant gallbladder polyp. Symptomatic patients who have lesions in the gallbladder should have a cholecystectomy. Since neither ultrasound nor cholecystography can distinguish benign from malignant lesions, all gallbladders that contain polypoid lesions should be removed. Ref – sabiston 20th ed. Pg-1482-1518 156. The following statement(s) is/are true concerning the surgical therapy of cholangiocarcinomas. a. A resectable distal bile duct carcinoma is best treated by a Whipple procedure b. Klatskin tumors may require hepatic resection in attempt for potential cure c. Regardless of the surgical resection for proximal biliary tumors, stenting of the biliary anastomosis is important d. all of the above Answer: d The surgical treatment of a cholangiocarcinoma is dependent upon its location. For lesions of the middle third of the bile duct, resection of the bile duct tumor with reanastomosis is the procedure of choice when possible. For distal lesions, the Whipple procedure (pancreaticoduodenectomy) is often necessary. Overall, both middle and lower third lesions have a better prognosis than tumors in the hilum. The prognosis for patients with hilar bile duct cancer (Klatskin tumors) is extremely poor with mortality rates of 80% to 90% in five years. Most patients are unresectable at the time of diagnosis. Unless contraindicated for other reasons, however, surgical exploration should be performed in all patients whose tumors are potentially resectable. Hepatic lobectomy is indicated for potential cure if the bile duct lesion extends into the hepatic parenchyma. Regardless of the surgical therapy, stenting of the biliary anastomosis is important since postoperative strictures or recurrent tumors are common and long-standing stents allow for cholangiographic followup and for dilatation should strictures arise. These stents have also been used for placement of iridium seeds used for local irradiation. More aggressive surgical therapy including complete hepatic resection followed by hepatic transplantation have been performed. However, the results have been associated with a very high rate of recurrence in the post-transplantation period and therefore at the present time this treatment is not recommended. Ref – sabiston 20th ed. Pg-1482-1518 157. The following statement(s) is/are true concerning carcinoma of the bile ducts. a. Carcinoma of the bile ducts is more common than gallbladder carcinoma b. Similar to gallbladder cancer, bile duct cancer is more common in females c. Unlike gallbladder cancer, there is no association of bile duct cancer and gallstones d. Ulcerative colitis is associated with an increased incidence of bile duct cancer pg. 92 disturbance in cholesterol metabolism. Other pseudotumors of the gallbladder are inflammatory polyps which are composed of vascular connective tissue stalk with a single layer columnar epithelial cells and have a chronic inflammatory infiltrate. These lesions are not considered to be premalignant and are felt to be the result of chronic inflammation. Adenomas with hyperplasia of the epithelial layer of the gallbladder, like adenomas in other gastrointestinal organs can be sessile or papillary. Carcinoma in situ has been reported in these lesions, and they are thought to be premalignant. The cause of adenomas of the gallbladder is unknown; but most are not associated with the presence of gallstones. An adenomyoma of the gallbladder is a rare intramural mass or nodule. This lesion is characterized by a proliferation of the mucosal epithelium and hypertrophy of the mucosal layers of the gallbladder. Histologically in addition to muscular hypertrophy, invagination of the epithelial mucosa between muscle layers is evidenced. These lesions are also not considered premalignant. Ref – sabiston 20th ed. Pg-1482-1518 161. Which of the following statement(s) concerning bile duct strictures due to chronic pancreatitis is/are true? a. Strictures are classically long and tapered involving the entire intrapancreatic bile duct b. Patients may be asymptomatic and diagnosed only by persistent elevation of serum alkaline phosphatase c. An excellent option for surgical management is choledochoduodenostomy d. all of the above Answer: d The clinical presentation of patients with common bile duct strictures secondary to chronic pancreatitis is variable. A large number of patients are asymptomatic with a diagnosis of bile duct strictures suggested only by abnormal liver function tests. The serum alkaline phosphatase appears to be the most sensitive laboratory finding and is elevated in over 80% of patients. Although in most cases, transient jaundice may occur, progressive jaundice is rare. Cholangiography will demonstrate a classic long smooth gradual tapering of the common bile duct throughout its entire intrapancreatic segment. Biliary reconstruction is the appropriate management for most patients. Choledochoduodenostomy is preferred by many surgeons because it does not divert bile from the duodenum, is technically easier to perform, and leaves the jejunum intact for any associated procedures that may be required for decompression of the obstructed gastrointestinal tract or pancreatic duct. Ref – sabiston 20th ed. Pg-1482-1518 162. If a bile duct injury is suspected at laparoscopic cholecystectomy, appropriate management includes which of the following? a. Conversion to open cholecystectomy and intraoperative cholangiography b. Ducts > 3 mm demonstrated by cholangiography to drain a single liver segment can be ligated pg. 95 c. If the injured segment is greater than 1 cm. in length an end-to-end ductal anastomosis is the procedure of choice d. Postoperative external drainage should be avoided Answer: a In many cases, proper initial management of a bile duct injury recognized at the time of cholecystectomy can avoid the development of a bile duct stricture. Unfortunately recognition of a bile duct injury is uncommon during either open or laparoscopic cholecystectomy. It must be emphasized that should bile leakage be noted or if "a typical" anatomy is encountered during laparoscopic cholecystectomy, early conversion to an open technique and prompt cholangiography is imperative. If a segment of accessory duct less than 3 mm has been injured, and cholangiography demonstrates segmental or sub-segmental drainage of the injured ductal system, simple ligation of the injured duct is indicated. If the injured duct is 4 mm or larger, however, it is likely to drain multiple hepatic segments or the entire right or left lobe and thus requires operative repair. If the injured segment of the bile duct is short (< 1 cm) and the two ends can be opposed without tension, an end-to-end anastomosis can be performed with placement of a T-tube through a separate choledochotomy either above or below the anastomosis. For proximal injuries, or if the injured segment of bile duct is greater than 1 cm in length, an end-to-end bile duct anastomosis should be avoided because of the excessive tension that usually exists in these situations. The use of Roux-en-Y jejunal limb is preferable for creation of the anastomosis. Regardless of the type of anastomosis, all repairs at the time of initial operation should involve some form of external drainage either with a T-tube or intraoperatively-placed transanastomotic stent. Ref – sabiston 20th ed. Pg-1482-1518 163. Which of the following statement(s) is/are true concerning the incidence of bile duct injury following cholecystectomy? a. Data from the pre-laparoscopic cholecystectomy era would suggest the incidence of bile duct injury during open cholecystectomy to be 0.1–0.2% b. The current incidence of bile duct injury during laparoscopic cholecystectomy is greater than 1% c. The experience of the surgeon performing laparoscopic cholecystectomy cannot be correlated with the incidence of bile duct injury d. Intraoperative cholangiography during laparoscopic cholecystectomy will prevent bile duct injury in virtually all cases Answer: a A number of large surveys encompassing thousands of patients undergoing open cholecystectomy would suggest the incidence of bile duct injury to be 0.1–0.2%. Although a number of early individual series of laparoscopic cholecystectomy reported bile duct injuries in 1% of patients, as larger series have been reported and surveys including thousands of patients pg. 96 have appeared, the true incidence would appear to be 0.3–0.6%. A number of factors are associated with bile duct injury during laparoscopic cholecystectomy including the experience of the surgeon. This reflects the steep learning curve with this procedure. Although strongly debated, there is no evidence that intraoperative cholangiography prevents bile duct injury during laparoscopic cholecystectomy. The use of intraoperative cholangiography may however detect the injury early in the course of the procedure and thus minimize the extent of injury. Ref – sabiston 20th ed. Pg-1482-1518 164. Primary sclerosing cholangitis has a number of treatment options—both medical and surgical. Which of the following statement(s) is/are true? a. A number of immunosuppressive oral agents can provide specific effective treatment for primary sclerosing cholangitis b. Biliary reconstruction with long-term transanastomotic stents can be useful in selected patients with focal strictures at the hepatic duct bifurcation c. Biliary reconstruction should be reserved only for patients with established biliary cirrhosis d. Hepatic transplantation for primary sclerosing cholangitis can be associated with survival rates inferior to other indications for transplantation Answer: b There is no known specific, effective medical therapy for primary sclerosing cholangitis. Although encouraging results from a prospective, randomized, placebo-controlled trial suggests that ursodeoxycholic acid significantly improves serum liver function tests and clinical symptoms. Because of the lack of effective medical therapy, an aggressive surgical approach is indicated for most symptomatic patients with primary sclerosing cholangitis. One surgical approach, in patients with a predominant stricture at the hepatic duct bifurcation, is resection of the bifurcation and long-term transhepatic stenting with silastic stents. Results in patients without established cirrhosis are excellent. However, in those patients with secondary biliary cirrhosis present before surgery, perioperative morbidity and mortality have been high and long-term results poor. Patients with established secondary biliary cirrhosis should be referred for hepatic transplantation. Recent reviews of the experience with hepatic transplantation for primary sclerosing cholangitis would suggest survival to be similar to those reported for hepatic transplantation for patients with any diagnosis. Ref – sabiston 20th ed. Pg-1482-1518 165. The following statement(s) regarding the elective repair of a bile duct stricture is/are true: a. A transanastomotic stent is necessary for a successful result b. Long-term stenting for approximately one year is necessary for an anastomosis performed at the distal common hepatic duct c. A Roux-en-Y hepaticojejunostomy provides the worst route for restoring biliary- enteric continuity pg. 97