NUR2063 Essentials of Pathophysiology Final Exam Review Study Guide (Latest 2022), Exams of Pathophysiology

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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-

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.

Ref – sabiston 20th^ ed. Pg-

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

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DISCUSSION: The portal vein provides two thirds to three quarters of the total hepatic blood flow. The portal vein is incapable of direct autoregulation. The hepatic artery after transplantation classically infarcts portions of the biliary system, whereas hepatic metastases often arrive there via the portal vein. Most of their blood supply comes from the hepatic artery.

Ref – sabiston 20th^ ed. Pg-

4. Bile formation is: A. An active secretory process. B. Determined at two sites principally. C. Regulated physiologically by hormones. D. all of the above Answer: D

DISCUSSION: Bile formation is an active process at both the canalicular and ductular sites. The paracellular pathway probably plays a minor physiologic role. Secretin and glucagon are likely physiologic regulators of biliary secretion. Bile salts are extremely important and are probably the most important agent in the changes that occur when enterohepatic circulation is interrupted.

Ref – sabiston 20th^ ed. Pg-

5. Generally, the two most important hepatic functions to consider after hepatic resection are: A. Hepatic synthetic function. B. Protein metabolism. C. The liver's role in lipid metabolism. D. The liver's role in vitamin metabolism. Answer: A

DISCUSSION: While other functions undoubtedly may be important postoperatively, the most common abnormalities occurring after a major hepatic resection are related to loss of protein synthesis and consequences of glucose metabolism. Therefore, it is usually advisable to administer supplemental amounts of protein and sugar postoperatively.

Ref – sabiston 20th^ ed. Pg-

6. Which of the following statements about pyogenic abscess of the liver are true? A. The right lobe is more commonly involved than the left lobe. B. Appendicitis with perforation and abscess is the most common underlying cause of hepatic abscess. C. Mortality is largely not determined by the underlying disease. D. Mortality from hepatic abscess is currently greater than 40%. Answer: A

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DISCUSSION: Involvement of the right lobe with abscess formation approximates 70% of pyogenic abscesses. This is thought to be due to the streaming effect of superior mesenteric venous inflow to the right lobe. In addition, the greater volume of the right lobe predisposes more tissue to seeding by bacterial organisms. While appendicitis comprised 25% to 40% of cases in early series, early recognition and operative therapy for appendicitis have reduced its importance significantly. In current series, malignant or benign biliary obstruction is the underlying cause of 35% to 50% of cases. Recent studies have shown that the underlying disease or an immunocompromised host is more important prognostically than solitary versus multiple abscesses.

Ref – sabiston 20th^ ed. Pg-

7. Which of the following statements most accurately describes the current therapy for pyogenic hepatic abscess? A. Antibiotics alone are adequate for the treatment of most cases. B. All patients require open surgical drainage for optimal management. C. Optimal treatment involves treatment of not only the abscess but the underlying source as well. D. Percutaneous drainage is more successful for multiple lesions than for solitary ones. Answer: C

DISCUSSION: The development of ultrasonography and computed tomography (CT) in the past two decades has enabled earlier diagnosis and advances in treatment of hepatic abscess. Formerly, open surgical drainage was considered necessary in essentially all cases of pyogenic abscess. Numerous recent series, however, have reported high success rates and low mortality from the percutaneous catheter drainage of abscesses under CT or ultrasonographic guidance. Optimal management of pyogenic abscess, however, involves not only treatment of the abscess, whether by percutaneous or surgical methods, but correction of the underlying source as well. All modes of therapy are more successful in treating solitary lesions than multiple ones.

Ref – sabiston 20th^ ed. Pg-

8. Which of the following statements characterize amebic abscess? A. Mortality is higher than that for similarly located pyogenic abscesses. B. The diagnosis of amebic abscess may be based on serologic tests and resolution of symptoms. C. In contrast to amebic abscess, the treatment of pyogenic abscess is primarily medical. D. Patients with amebic abscess tend to be older than those with pyogenic abscess. B

DISCUSSION: Mortality for uncomplicated amebic abscess should be less than 5%, in contrast to the 15% to 20% rate for pyogenic abscess. After the demonstration by radiologic examination of an abscess, appropriate serologic tests and resolution of symptoms after a course of treatment

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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-

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-

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

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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-

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 usually successful 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-

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

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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-

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-

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.

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Ref – sabiston 20th^ ed. Pg-

16. A portal venous pressure of 30 mm. Hg (elevated) and a hepatic venous wedge pressure of 5 mm. Hg (normal) may be associated with which of the following causes of portal hypertension? A. Portal vein thrombosis. B. Alcoholic cirrhosis. C. amebic abscess. D. Alcoholic hepatitis. Answer: A

DISCUSSION: Pressure measured by wedging a catheter into a hepatic vein (hepatic venous wedge pressure) closely correlates with directly measured portal venous pressure in patients with portal hypertension when the site of elevated resistance is at the sinusoidal or postsinusoidal level. Such is the case in alcoholic cirrhosis and alcoholic hepatitis. When the site of increased resistance is at the presinusoidal level, either within (schistosomiasis) or outside (portal vein thrombosis) the liver, the hepatic venous wedge pressure is normal despite markedly elevated portal vein pressure. Although schistosomiasis is one of the more frequent causes of portal hypertension worldwide, in North America presinusoidal portal hypertension is considerably less common than alcoholic liver disease. A normal hepatic venous wedge pressure in a patient who has bled from varices should lead one to suspect a presinusoidal cause. A specific diagnosis can often be made by visceral angiography or liver biopsy.

Ref – sabiston 20th^ ed. Pg-

17. Which of the following is the most effective definitive therapy for both prevention of recurrent variceal hemorrhage and control of ascites? A. Endoscopic sclerotherapy. B. Distal splenorenal shunt. C. Esophagogastric devascularization (Sugiura procedure). D. Side-to-side portacaval shunt. E. End-to-side portacaval shunt. Answer: D

DISCUSSION: Shunt operations are the most effective means of preventing recurrent variceal hemorrhage. Rebleeding rates after endoscopic sclerotherapy range from 40% to 60%. Although extensive esophagogastric devascularization has effectively prevented recurrent bleeding in Japanese series, these operations have been followed by rebleeding rates in excess of 25% in most Western series. Although one controlled trial has shown more frequent recurrent hemorrhage following the distal splenorenal shunt than after the portacaval shunt, most series have reported rebleeding rates of less than 10% for both of these operations. Both the liver and the splanchnic viscera are important sites of ascites formation. Since the distal splenorenal shunt maintains sinusoidal and mesenteric venous hypertension and requires interruption of important retroperitoneal lymphatics, it tends to aggravate rather than relieve ascites. Hepatic sinusoidal pressure may be unchanged or even increased after an end-to-side portacaval shunt.

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Only side-to-side portal-systemic shunts, such as the side-to-side portacaval shunt, reliably decompress both the liver and splanchnic viscera, thus preventing ascites formation.

Ref – sabiston 20th^ ed. Pg-

18. Which of the following treatments most effectively preserves hepatic portal perfusion? A. Distal splenorenal shunt. B. Conventional splenorenal shunt. C. Endoscopic sclerotherapy. D. Side-to-side portacaval shunt. Answer: C

DISCUSSION: The conventional splenorenal shunt and side-to-side portacaval shunts completely divert portal flow away from the liver (nonselective shunts). The distal splenorenal shunt is a selective shunt that preserves hepatic portal perfusion in the majority of patients; however, the magnitude of portal flow is decreased because the gastrosplenic component is diverted into the renal vein. Additionally, many patients (especially alcoholic cirrhotics) develop collaterals between the mesenteric venous circulation and the shunt, resulting in gradual attrition of the remaining portal flow. Although there have been anecdotal reports of portal vein thrombosis after endoscopic sclerotherapy, two controlled trials have demonstrated better preservation of hepatic portal perfusion in sclerotherapy patients than in persons who receive the distal splenorenal shunt.

Ref – sabiston 20th^ ed. Pg-

19. Which of the following veins is preserved in performing the extensive esophagogastric devascularization procedure described by Sugiura? A. Left gastric (coronary) vein. B. Short gastric vein. C. Splenic vein. D. Left gastroepiploic vein. Answer: A

DISCUSSION: The Sugiura procedure consists of devascularization of the esophagus to the inferior pulmonary vein and the proximal two thirds of the stomach, splenectomy, and distal esophageal transection. The devascularization component should be done as close to the esophagus and stomach as possible. The coronary vein and paraesophageal collaterals are preserved to maintain an effective portal-systemic collateral pathway and thereby discourage reformation of varices.

Ref – sabiston 20th^ ed. Pg-

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

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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-

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 vasopressin side 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-

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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-

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

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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-

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-

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%

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with standard immune globulin, to about 5% to 7% with HBIg. HBV infection is required for infection with HDV and is therefore an essential step toward, rather than preventive of, HBV infection.

Ref – sabiston 20th^ ed. Pg-1418-

26. Which of the following statements about choledocholithiasis are correct? A. Common duct stones can originate in the gallbladder and migrate to the common duct, and stones can form de novo in the duct system. B. Calcium bilirubinate stones are associated with the presence of bacteria in the duct system. C. Common duct stones discovered at laparoscopic cholecystectomy should be treated by postoperative endoscopic extraction. D. all of the above Answer: D

DISCUSSION: Most common duct stones originate in the gallbladder and migrate to the common duct, where they may become larger. These stones tend to consist predominantly of cholesterol (about 80% of gallbladder stones are predominantly cholesterol). Stones found in the bile ducts after cholecystectomy may have been overlooked, but de novo stone formation does occur. Arbitrarily, stones found 2 years after cholecystectomy are assumed to have formed within the duct system. Calcium bilirubinate stones are thought to result from precipitation of insoluble bilirubin monoglucuronide formed by deconjugation of bilirubin diglucuronide, a reaction promoted by the enzyme beta-glucuronidase, which is produced by bacteria in the biliary tract. Calcium bilirubinate stones are found almost exclusively in patients who have some form of biliary tract lesion that causes partial obstruction, and these patients tend to have bactibilia. Stones smaller than approximately 5 mm. often can be extracted through a dilated cystic duct or pushed into the duodenum. Larger stones are best left for postoperative endoscopic sphincterotomy and extraction. Patients with more than five stones or stones larger than 1.5 cm. should be treated by open choledocholithotomy or, when indicated, a biliary- enteric anastomosis. Not all patients with symptomatic common duct stones have elevated serum bilirubin, but when jaundice is present the bilirubin is only rarely greater than 15 mg. per dl.

Ref – sabiston 20th^ ed. Pg-1482-

27. A benign biliary duct stricture: A. Need not be treated unless it causes clinical jaundice. B. Should always be treated by percutaneous balloon drainage. C. Is prone to recur after treatment with biliary-enteric anastomosis. D. When due to chronic pancreatitis should be treated by end to end anastomosis Answer: C

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DISCUSSION: Even a minor obstructing lesion in the extrahepatic duct system can produce cirrhosis over time, and the development of portal hypertension, ascites, and esophageal varices. Therefore, all biliary strictures should be treated unless this is not possible or there is no chance for success. The presence or absence of jaundice is of no significance. Often, the only biochemical abnormality is mild elevation of alkaline phosphatase. The long -term results of percutaneous balloon dilatation are not yet known, but short-term results are good. Although some argue that balloon dilatation should be the initial treatment, its role is ill-defined, and it should not be viewed as standard therapy at this time. Biliary-enteric anastomoses are predisposed to stricture, for reasons that are ill-understood. A mucosa-to-mucosa anastomosis, large size of the anastomosis, a normal duct at the point of anastomosis, and stenting appear to be elements that work against stricture. About 70% of anastomoses are not complicated by strictures. Common duct strictures caused by chronic pancreatitis are located in the distal portion of the duct and are easily treated by side-to-side choledochoduodenostomy. A wide anastomosis is usually possible, and because of this stenting often is not necessary. Although a Roux-en-Y biliary-enteric reconstruction is acceptable treatment, no advantage over choledochoduodenostomy has been demonstrated.

Ref – sabiston 20th^ ed. Pg-1482-

28. Which statements about extrahepatic bile duct cancer are correct? A. Cholangiography is not essential in evaluating patients for resectability. B. The prognosis is excellent when appropriate surgical and adjuvant therapy are given. C. The location of the tumor determines the type of surgical procedure. D. The disease usually becomes manifest by moderate to severe right-side upper quadrant pain. Answer: C

DISCUSSION: Cholangiography is essential for both diagnosis and evaluation of resectability. Brushings of the lesion for diagnosis and temporary stenting, done percutaneously or endoscopically, are often done at the time of cholangiography. Angiography and CT are helpful, but in the absence of hepatic artery or portal vein occlusion these tests are not accurate predictors of resectability. The primary obstacles to complete resection are invasion of the portal vein or the hepatic artery and proximal extension of the tumor into the liver. The long- range prognosis for patients who undergo treatment for extrahepatic bile duct cancer is poor, even when the lesion is surgically resectable and adjuvant therapy is given. Only about 10% of patients are alive without disease at 10 years. Nevertheless, bile duct cancer tends not to metastasize to distant sites, so resection and radiation therapy are useful in prolonging symptom-free life. Tumors in the proximal third of the extrahepatic bile duct system are treated by a Roux-en-Y biliary-enteric anastomosis. To ensure excision of the entire tumor this anastomosis usually must be made to the individual hepatic ducts, which must be stented individually. Tumors of the middle third usually require anastomosis to the proximal hepatic duct. In contrast, lesions of the distal third require Whipple's procedure with appropriate reconstruction. Thus, the treatment of extrahepatic bile duct cancer depends on the location of the tumor. Pain is not a prominent feature of bile duct cancer. Most cases become manifest by

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the insidious development of jaundice.

Ref – sabiston 20th^ ed. Pg-1482-

29. Which of the following statements about biliary tract problems are correct? A. Choledochal cyst should be treated by Roux-en-Y cystojejunostomy. B. Sclerosing cholangitis is characterized by long, narrow strictures in the extrahepatic biliary duct system. C. Operative (needle) cholangiography is indicated in patients who at operation appear to have no gallbladder. D. The long cystic duct, which appears to be fused with the common duct and enters it distally, should be dissected free and ligated at its entrance into the common duct. 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-

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

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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-

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 surgi cal 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

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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-

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-

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.

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B. The presence of gallstones in an asymptomatic patient. C. The presence of symptomatic gallstones in a patient with angina pectoris. D. The presence of asymptomatic gallstones in a patient who has insulin-dependent diabetes. Answer: A

DISCUSSION: Cholecystectomy (and concomitant operative cholangiography) are indicated for symptomatic patients to relieve pain and to prevent the development of acute cholecystitis and its complications. Morbidity and expense are not as great for elective cholecystectomy as they are for cholecystectomy for acute cholelithiasis. The risk of the development of symptoms in patients who have asymptomatic stones is approximately 2% per year, a rate associated with mortality and morbidity that do not exceed those of elective cholecystectomy. Therefore, cholecystectomy is not indicated for asymptomatic patients. Patients who have angina pectoris should not have cholecystectomy until their coronary artery disease has been treated adequately, even if this requires a coronary artery bypass procedure. Heart disease is the most frequent cause of death after cholecystectomy. Prophylactic cholecystectomy, formerly recommended for insulin-dependent diabetics, is not indicated because several studies have shown that the mortality rate from acute cholecystitis is no higher for diabetics than for nondiabetics.

Ref – sabiston 20th^ ed. Pg-1482-

34. Which of the following statements about laparoscopic cholecystectomy are correct? A. The procedure is associated with less postoperative pain and earlier return to normal activity. B. The incidence of bile duct injury is lower than for open cholecystectomy. C. Laparoscopic cholecystectomy should be used in asymptomatic patients because it is safer than open cholecystectomy. D. Pregnancy is a contraindication. Answer: A

DISCUSSION: Studies have clearly documented that postoperative pain following laparoscopic cholecystectomy is less than that experienced after open cholecystectomy and that patients can resume normal activity sooner. This appears to be related to the reduced trauma to the abdominal wall by virtue of the very small incisions used in laparoscopic procedures. The best evidence is that the bile duct injury rate (0.4%) is approximately double that for open cholecystectomy. The incidence of this serious complication will probably decrease with improved techniques, better training, and more advanced instrumentation. Only symptomatic patients should have cholecystectomy. Prophylactic removal of the gallbladder is not cost effective. All elective operations are contraindicated in the first trimester, so as to prevent fetal anomalies and spontaneous abortion. The laparoscopic technique is not contraindicated thereafter except in patients in whom peritoneal access cannot safely be established. This is rarely a problem. Premature labor is a risk in the third trimester. Thus, unless cholecystectomy can be avoided altogether during pregnancy, the second trimester is the most propitious time.

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Ref – sabiston 20th^ ed. Pg-1482-

35. Which of the following statements about cholangitis are correct?

A. Associated biliary tract disease is always present. B. Chills and fever are due to the presence of bacteria in the bile duct system. C. The most common cause of cholangitis is choledocholithiasis. D. All of the above Answer: D

DISCUSSION: Although Charcot's triad (pain, chills and fever, jaundice) is diagnostic of cholangitis, the complete triad occurs only in 50% to 70% of patients. Fever is the most common symptom; therefore, cholangitis should be considered in all patients who have unexplained fever. Episodes of pain, chills, and fever are often so brief as not to concern the patient. Cholangitis does not occur in the absence of partial or complete bile duct obstruction. All patients diagnosed as having cholangitis should have appropriate diagnostic studies to determine the cause. This usually involves cholangiography. The presence of bacteria in bile does not produce symptoms in the absence of partial or complete obstruction of the bile duct system. When obstruction is present, pressure within the system increases, giving rise to reflux of bacteria or their toxic products into the hepatic venous circulation. This cholangiovenous reflux produces chills, fever, and the hemodynamic changes of sepsis. Death may ensue if treatment is not instituted promptly. Choledocholithiasis, the most commonly associated problem, may produce partial or complete obstruction. When bacteria are not present in the bile duct system, choledocholithiasis may go undetected unless the degree of obstruction is sufficient to cause jaundice. Other causes of cholangitis are benign and malignant strictures, biliary-enteric anastomoses, invasive procedures, foreign bodies, and parasitic infestation of the bile ducts.

Ref – sabiston 20th^ ed. Pg-1482-

36. Recurrent episodes of cholangitis: A. Suggest the presence of undetected or overlooked bile duct pathology. B. Occur frequently in patients who have indwelling biliary tubes or stents. C. May be ameliorated by long-term administration of antibiotics. D. All of the above Answer: D

DISCUSSION: Cholangitis does not occur in the presence of a normal bile duct system, and all patients with cholangitis have an abnormality. Thus, recurrent episodes of cholangitis signal the need for diagnostic studies. Cholangiography usually will be necessary. The presence of any foreign body in the biliary tract is frequently associated with bactibilia and recurrent episodes of cholangitis. Even a silk suture exposed to the lumen of a bile duct has been known to cause

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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-

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 th reat 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-

38. The clinical picture of gallstone ileus includes which of the following?

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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-

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-

40. Which of the following lesions are believed to be associated with the development of

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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.

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B. Heterotopic pancreatic tissue predisposes to pancreatic adenocarcinoma. C. Annular pancreas does not cause gastrointestinal obstruction in children or in adults. D. Relative obstruction to the flow of pancreatic juice through the minor papilla appears to be the cause of pancreatitis in some patients with pancreas divisum. Answer: D

DISCUSSION: The clinically recognized embryonic malformations of the pancreas include heterotopic pancreas, pancreas divisum, and annular pancreas. Heterotopic pancreatic tissue most often takes the form of a firm nodule of variable size in the stomach, duodenum, small bowel, or Meckel's diverticulum. The typical complications of heterotopic pancreas include intestinal obstruction, ulceration, or hemorrhage. Pancreas divisum is an anatomic variant that results from failure of fusion of the two primordial pancreatic duct systems. In pancreas divisum the major portion of the pancreas is drained via the duct of Santorini through the minor duodenal papilla. Relative stenosis of the minor duodenal papilla can cause pancreatitis. Pancreas divisum is not associated with gastrointestinal bleeding. Annular pancreas results when histologically normal pancreatic tissue completely or partially encircles the second portion of the duodenum. Varying degrees of duodenal obstructive symptoms may be observed in both children and adults with this condition.

Ref – sabiston 20th^ ed. Pg-1520-1553

43. The pancreas occupies a retroperitoneal position in the upper abdomen. Which statement(s) is/are correct? A. The superior mesenteric vein and the splenic vein join to form the portal vein posterior to the neck of the pancreas. B. The tail of the pancreas extends to the left of the aorta, toward the splenic hilum. C. The head of the pancreas is jointly supplied by arterial blood from the celiac axis and the superior mesenteric artery. D. All of the above Answer: D

DISCUSSION: The pancreas occupies a retroperitoneal position in the upper abdomen, extending obliquely from the duodenal C loop to a more cephalad position where the pancreatic tail abuts the hilum of the spleen. The portion of the pancreas anterior to the confluence of the superior mesenteric vein, splenic vein, and portal vein is designated the neck of the gland. The uncinate process extends posterior to the superior mesenteric vein and approaches the superior mesenteric artery. The head of the pancreas is intimately associated with the second portion of the duodenum, and these two structures are jointly supplied by two arterial arcades known as the anterior and posterior pancreaticoduodenal arteries, which originate as branches of the celiac axis and superior mesenteric artery.

Ref – sabiston 20th^ ed. Pg-1520-1553

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44. Both endocrine and exocrine tissue comprise the pancreas. Which statement(s) is/are true? A. The islets of Langerhans total 1 million per gland and drain their secretions via intercalated duct cells through the ampulla of Vater. B. Islet alpha cells produce glucagon. C. Islet sigma cells produce somatostatin. D. The acini and ductal systems constitute the endocrine portion of the pancreas. Answer: B

DISCUSSION: The endocrine portion of the pancreas is served by the islets of Langerhans, which number 1 million islets per gland. The islets of Langerhans drain their endocrine secretions into the bloodstream. Insulin-producing beta cells comprise the majority of the islet population. Alpha cells produce glucagon and constitute approximately 20% to 25% of the total islet cell number. Delta cells of the islets produce somatostatin. The acini and ductal systems constitute the exocrine portion of the pancreas. The acinar cells contain zymogen granules in their narrow, centrally located apical portion. The pancreatic duct system includes intercalated duct cells along the ductal pathway, terminating in the main excretory duct of the pancreas.

Ref – sabiston 20th^ ed. Pg-1520-1553

45. Pancreatic exocrine secretory products include a bicarbonate-rich electrolyte solution as well as digestive enzymes. Which of the following statement(s) is/are true? A. Cholecystokinin (CCK) is the most potent endogenous stimulant of pancreatic enzyme secretion. B. The chloride and bicarbonate concentrations of pancreatic juice vary and depend on the secretory flow rate. C. Secretin is the most potent endogenous stimulant of pancreatic water and electrolyte secretion. D. All of the above Answer: D

DISCUSSION: CCK is the most potent endogenous stimulant of pancreatic enzyme secretion. The pancreatic acinar cells respond to CCK with release of their zymogen granules into the ductal system. Peptidases are released in inactive form, later to be activated by contact with duodenal enterokinase and activated trypsin. Secretin is the most potent endogenous stimulant of pancreatic water and electrolyte secretion. The concentrations of the anions bicarbonate and chloride vary and are largely dependent on the secretory flow rate stimulated by secretin.

Ref – sabiston 20th^ ed. Pg-1520-1553

46. Which of the following parameters is/are not included in the Ranson's prognostic signs

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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

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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.