MCQ bank · 36 questions · free
Hepatobiliary & pancreas MCQs with answers
36 single-best-answer questions on gallstones, cholecystitis, pancreatitis, jaundice and liver lesions. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A fit 45-year-old woman (ASA II) has had right upper quadrant pain and fever for 36 hours. Ultrasound shows gallstones, a thickened gallbladder wall and pericholecystic fluid. There is no organ dysfunction. What is the best management?
- Percutaneous cholecystostomy
- Early laparoscopic cholecystectomy during the same admission
- Antibiotics and interval cholecystectomy after 6 weeks
- ERCP and sphincterotomy
- Antibiotics alone, with no surgery
Show the answer and explanation
Answer: B. Early laparoscopic cholecystectomy during the same admission. For mild or moderate acute cholecystitis in a fit patient, early laparoscopic cholecystectomy (ideally within 7 days of admission and 10 days of symptom onset) shortens hospital stay and avoids recurrent attacks, without more complications.
Why not the others? Cholecystostomy is for patients too unwell for surgery. ERCP is for common bile duct stones or cholangitis.
References
A 50-year-old man is recovering from mild gallstone pancreatitis. His pain has settled and he is eating. When should he have a cholecystectomy?
- Only if he has a second attack
- After ERCP and sphincterotomy, which removes the need for surgery
- Never; gallstone pancreatitis does not recur
- During the same admission
- After 6–8 weeks, once inflammation settles
Show the answer and explanation
Answer: D. During the same admission. In mild gallstone pancreatitis, same-admission cholecystectomy reduces recurrent gallstone-related complications compared with waiting (the PONCHO trial). Delay is appropriate only in severe pancreatitis with collections.
Why not the others? Recurrence while waiting is common. Sphincterotomy reduces recurrent pancreatitis but not cholecystitis or colic.
References
A 45-year-old man is admitted with acute pancreatitis. He is not in shock. Which initial fluid strategy is supported by the best evidence?
- Restrict fluids to 1 L/day to prevent pancreatic oedema
- Moderate, goal-directed fluid with lactated Ringer’s, reassessed often
- 0.9% saline at 250 mL/h for 72 hours
- Aggressive resuscitation: a 20 mL/kg bolus then 3 mL/kg/h for every patient
- Albumin as the main resuscitation fluid
Show the answer and explanation
Answer: B. Moderate, goal-directed fluid with lactated Ringer’s, reassessed often. The WATERFALL trial found that aggressive fluid resuscitation increased fluid overload without improving outcomes. Moderate, goal-directed resuscitation with a balanced crystalloid such as lactated Ringer’s is now preferred.
Why not the others? Fluid restriction risks hypovolaemia and kidney injury. Albumin offers no advantage.
References
During a laparoscopic cholecystectomy in a general hospital, you recognise that the common bile duct has been clipped and divided. No hepatobiliary surgeon is available. What is the safest course?
- Leave the clips and arrange ERCP in 6 weeks
- Immediate end-to-end repair of the duct over a T-tube
- Place drains, do not attempt repair, and transfer urgently to a hepatobiliary centre
- Close without drains and observe
- Convert to open and perform a hepaticojejunostomy yourself
Show the answer and explanation
Answer: C. Place drains, do not attempt repair, and transfer urgently to a hepatobiliary centre. Major bile duct injury has the best outcome when repaired by an experienced hepatobiliary surgeon. If that expertise is not available, the safest step is to drain the area, avoid further damage, and transfer. Primary end-to-end repair of a transected duct has a high stricture rate.
Why not the others? An unplanned repair by an inexperienced surgeon is a strong predictor of a poor long-term result.
References
A 76-year-old woman has fever, jaundice and right upper quadrant pain. Her blood pressure is 82/50 despite 2 litres of fluid, and she is confused. Ultrasound shows a dilated common bile duct. What does she need?
- Antibiotics for 7 days, then elective ERCP
- MRCP before deciding
- Resuscitation, broad-spectrum antibiotics, and urgent biliary drainage (ERCP) as soon as she is stabilised
- Oral antibiotics and discharge
- Emergency open cholecystectomy
Show the answer and explanation
Answer: C. Resuscitation, broad-spectrum antibiotics, and urgent biliary drainage (ERCP) as soon as she is stabilised. This is severe (grade III) acute cholangitis with organ dysfunction. Alongside resuscitation and antibiotics, the obstructed, infected bile must be drained urgently, usually by ERCP; percutaneous drainage is an alternative if ERCP fails.
Why not the others? Delaying drainage in severe cholangitis increases mortality. Cholecystectomy does not drain the bile duct and is done later.
References
A 50-year-old woman with biliary colic has mildly abnormal liver tests (ALP and GGT raised, bilirubin 30 µmol/L). Ultrasound shows gallstones and a common bile duct of 7 mm, with no duct stone seen. She is not septic. What is the best next step before cholecystectomy?
- ERCP for every patient with abnormal liver tests
- Cholecystectomy without further tests
- MRCP or endoscopic ultrasound to look for a bile duct stone
- CT of the abdomen
- Repeat liver tests in 6 months
Show the answer and explanation
Answer: C. MRCP or endoscopic ultrasound to look for a bile duct stone. She has an intermediate probability of a bile duct stone. MRCP or EUS is the right test: it avoids the risks of a diagnostic ERCP (pancreatitis, bleeding, perforation) in the many patients who turn out to have no stone. Intraoperative cholangiography is an acceptable alternative.
Why not the others? ERCP is reserved for high probability: a stone seen on imaging, cholangitis, or high bilirubin with a dilated duct. CT misses many duct stones.
References
Five weeks after severe necrotising pancreatitis, a patient has fever and rising inflammatory markers. CT shows a walled-off collection of necrosis containing gas. What is the recommended first intervention?
- Antibiotics plus drainage, percutaneous or endoscopic transluminal, as the first step of a step-up approach
- Cholecystectomy
- Immediate open necrosectomy
- Total pancreatectomy
- Antibiotics alone for 6 months
Show the answer and explanation
Answer: A. Antibiotics plus drainage, percutaneous or endoscopic transluminal, as the first step of a step-up approach. Infected necrosis is managed with a step-up approach: drainage first (endoscopic or percutaneous), then minimally invasive necrosectomy only if the patient does not improve. Delaying intervention until the necrosis is walled off (about 4 weeks) is safer. This strategy reduced major complications and death compared with primary open necrosectomy (PANTER).
Why not the others? Early open necrosectomy has high morbidity and mortality.
References
A 39-year-old woman has a 4-cm liver lesion found on ultrasound. MRI shows the typical features of a haemangioma: bright on T2 with peripheral nodular enhancement that fills in. She has no symptoms. What is the management?
- Stop the oral contraceptive pill and rescan every 6 months
- Percutaneous biopsy
- Liver resection
- Transarterial embolisation
- Reassurance; no treatment or follow-up imaging is needed
Show the answer and explanation
Answer: E. Reassurance; no treatment or follow-up imaging is needed. Haemangioma is the commonest benign liver tumour. When imaging is typical, no follow-up is required, regardless of size, pregnancy or contraceptive use. Treatment is reserved for rare symptomatic or complicated lesions.
Why not the others? Biopsy risks bleeding and adds nothing when the imaging is diagnostic. Monitoring with the pill matters for hepatocellular adenoma, not haemangioma.
References
Ultrasound in a 48-year-old woman with dyspepsia shows a single 12-mm polyp in the gallbladder. She has no gallstones. What do you advise?
- Ursodeoxycholic acid
- Cholecystectomy, because polyps of 10 mm or more carry a risk of malignancy
- ERCP
- No follow-up
- Ultrasound in 5 years
Show the answer and explanation
Answer: B. Cholecystectomy, because polyps of 10 mm or more carry a risk of malignancy. The risk of cancer in a gallbladder polyp rises with size. Polyps of 10 mm or more should be removed by cholecystectomy if the patient is fit. Smaller polyps are followed with ultrasound, with surgery if they grow by 2 mm or more or reach 10 mm.
Why not the others? ERCP does not assess or treat gallbladder polyps.
References
A patient with predicted severe acute pancreatitis is in the high-dependency unit on day 2. There is no evidence of infection. Which statement is correct?
- Keep the patient nil by mouth until the amylase is normal
- Perform urgent ERCP in every case
- Give prophylactic carbapenems to every patient with severe pancreatitis
- Prophylactic antibiotics are not recommended, and early oral or enteral feeding is preferred to parenteral nutrition
- Start total parenteral nutrition on day 1
Show the answer and explanation
Answer: D. Prophylactic antibiotics are not recommended, and early oral or enteral feeding is preferred to parenteral nutrition. Prophylactic antibiotics do not reduce infected necrosis or mortality. Early feeding by mouth, or by nasogastric or nasojejunal tube if needed, protects the gut barrier and reduces infection compared with parenteral nutrition. ERCP is indicated only for coexisting cholangitis or persistent biliary obstruction.
Why not the others? Antibiotics are reserved for proven or strongly suspected infection.
References
A 62-year-old diabetic man has fever, rigors and right upper quadrant pain. CT shows a single 7-cm multiloculated liver abscess. What is the treatment?
- Right hepatectomy
- Laparoscopic cholecystectomy
- Intravenous antibiotics with percutaneous image-guided drainage, then a search for the source
- Oral antibiotics only
- Observation
Show the answer and explanation
Answer: C. Intravenous antibiotics with percutaneous image-guided drainage, then a search for the source. Most pyogenic liver abscesses respond to antibiotics plus percutaneous drainage (catheter or aspiration), particularly when larger than about 5 cm. Look for the source, such as biliary disease or colorectal cancer; Klebsiella is common in diabetic patients. Surgery is for failure of drainage or rupture.
Why not the others? Small abscesses (under about 3 cm) may respond to antibiotics alone.
References
A 38-year-old shepherd has a 9-cm hydatid cyst in the right lobe of the liver with daughter cysts. He is booked for surgery. Which statement is correct?
- Steroids are the main treatment
- No drug treatment is needed with surgery
- Puncture the cyst without protecting the field
- Perform percutaneous biopsy first to confirm
- Give albendazole before and after surgery, and protect the operative field with scolicidal-soaked packs to prevent spillage
Show the answer and explanation
Answer: E. Give albendazole before and after surgery, and protect the operative field with scolicidal-soaked packs to prevent spillage. Spillage of cyst contents can cause anaphylaxis and secondary hydatidosis. Perioperative albendazole and careful protection of the field (with hypertonic saline packs) reduce recurrence. Imaging is usually diagnostic, supported by serology; diagnostic puncture outside a planned therapeutic procedure is avoided.
Why not the others? Small, simple (CE1) cysts may be treated with albendazole alone or PAIR (puncture, aspiration, injection, re-aspiration).
References
A 67-year-old man has painless jaundice (bilirubin 180 µmol/L) from a 2.5-cm mass in the head of the pancreas that is resectable on CT. He has no cholangitis and will not receive neoadjuvant therapy. What is the best plan?
- Proceed to pancreatoduodenectomy without routine preoperative biliary drainage
- Repeat CT in 3 months
- Chemotherapy only
- Palliative bypass
- Routine ERCP stenting and surgery 6 weeks later
Show the answer and explanation
Answer: A. Proceed to pancreatoduodenectomy without routine preoperative biliary drainage. Routine preoperative biliary drainage increases complications (mainly stent-related infection) without improving outcome when surgery can be performed promptly. Drainage is indicated for cholangitis, severe symptoms, very high bilirubin, delayed surgery or neoadjuvant therapy.
Why not the others? Delaying a resectable cancer for drainage gives the tumour time to progress.
References
A 45-year-old woman is about to have ERCP for a bile duct stone. Which measure reduces the risk of post-ERCP pancreatitis in all patients without a contraindication?
- Proton pump inhibitor
- Octreotide infusion
- Rectal NSAID (100 mg diclofenac or indomethacin) around the time of the procedure
- Prophylactic antibiotics
- Routine somatostatin
Show the answer and explanation
Answer: C. Rectal NSAID (100 mg diclofenac or indomethacin) around the time of the procedure. Rectal NSAIDs reduce post-ERCP pancreatitis and are recommended for all patients unless contraindicated. In high-risk cases, a prophylactic pancreatic stent and generous Ringer’s lactate are added.
Why not the others? Antibiotics prevent cholangitis in selected cases, not pancreatitis.
References
A ventilated patient in intensive care after major trauma develops fever and right upper quadrant tenderness. Ultrasound shows a distended, thick-walled gallbladder without stones. He is too unstable for surgery. What is the treatment?
- Percutaneous cholecystostomy with antibiotics
- Emergency open cholecystectomy
- Oral ursodeoxycholic acid
- ERCP and sphincterotomy
- Observation only
Show the answer and explanation
Answer: A. Percutaneous cholecystostomy with antibiotics. Acute acalculous cholecystitis occurs in critically ill patients and progresses rapidly to gangrene and perforation. In patients too unstable for surgery, percutaneous cholecystostomy drains the gallbladder, combined with antibiotics. Cholecystectomy is done if the patient deteriorates or later if needed.
Why not the others? Observation allows gangrene and perforation to develop.
References
MRI in a 34-year-old woman who has taken the oral contraceptive pill for 15 years shows a 6-cm hepatocellular adenoma. She has no symptoms. What do you advise?
- Stop the pill, encourage weight loss if needed, and re-image after 6 months; resect if it remains 5 cm or more
- Continue the pill and review in 5 years
- Immediate liver transplantation
- Radiotherapy
- No action, as all adenomas are harmless
Show the answer and explanation
Answer: A. Stop the pill, encourage weight loss if needed, and re-image after 6 months; resect if it remains 5 cm or more. Hepatocellular adenomas in women often shrink after stopping oestrogen. Those that remain 5 cm or larger after 6 months carry a higher risk of bleeding and malignant change, so they are resected. In men, any adenoma is resected because the risk of cancer is higher.
Why not the others? Haemorrhage is treated with embolisation first.
References
A 62-year-old man had a sigmoid colectomy for cancer 2 years ago. CT and MRI now show two metastases in the right lobe of the liver, with no disease elsewhere. He is fit. What do you advise?
- Palliative care only, as metastatic disease is incurable
- Radiotherapy only
- Liver transplantation as first choice
- Discussion in a multidisciplinary meeting; liver resection, usually with perioperative chemotherapy, offers a chance of long-term survival
- Observation
Show the answer and explanation
Answer: D. Discussion in a multidisciplinary meeting; liver resection, usually with perioperative chemotherapy, offers a chance of long-term survival. Resection of colorectal liver metastases gives 5-year survival of around 40–50% in selected patients. Resectability depends on leaving enough healthy liver with clear margins. Ablation can be combined with resection, and chemotherapy can convert some unresectable cases.
Why not the others? Metastatic colorectal cancer confined to the liver is potentially curable.
References
MRI shows a cystic lesion in the head of the pancreas communicating with a main pancreatic duct dilated to 11 mm, with a 6-mm enhancing nodule. The patient is fit. What do you advise?
- Surgical resection, because these are high-risk features of an intraductal papillary mucinous neoplasm (IPMN)
- Discharge
- Surveillance with MRI in 2 years
- Pancreatic enzyme supplements only
- Endoscopic drainage of the cyst
Show the answer and explanation
Answer: A. Surgical resection, because these are high-risk features of an intraductal papillary mucinous neoplasm (IPMN). A main duct of 10 mm or more, an enhancing mural nodule of 5 mm or more, jaundice, positive cytology or a solid component are absolute indications for resection in IPMN, because they predict high-grade dysplasia or cancer. Branch-duct IPMNs without worrying features are kept under surveillance.
Why not the others? Mucinous cysts must not be internally drained.
References
A 22-year-old woman has recurrent episodes of right upper quadrant pain and mild jaundice. MRCP shows a fusiform dilatation of the common bile duct (type I choledochal cyst). What is the treatment?
- Cholecystectomy only
- Observation
- Internal drainage by cyst-duodenostomy
- Complete cyst excision with Roux-en-Y hepaticojejunostomy
- ERCP and sphincterotomy only
Show the answer and explanation
Answer: D. Complete cyst excision with Roux-en-Y hepaticojejunostomy. Choledochal cysts carry a significant lifetime risk of cholangiocarcinoma, along with cholangitis, stones and pancreatitis. The cyst is excised completely and bile flow is restored with a Roux-en-Y hepaticojejunostomy.
Why not the others? Internal drainage leaves the cyst lining behind, with a high risk of later cancer.
References
Histology after a routine laparoscopic cholecystectomy unexpectedly shows a gallbladder adenocarcinoma invading the perimuscular connective tissue (T2). The cystic duct margin is clear. What is the next step?
- Chemotherapy only
- Repeat cholecystectomy
- Radiotherapy only
- Staging CT, then re-resection: liver bed resection (segments IVb/V) with regional lymphadenectomy
- No further treatment
Show the answer and explanation
Answer: D. Staging CT, then re-resection: liver bed resection (segments IVb/V) with regional lymphadenectomy. Incidental gallbladder cancer at stage T1b or above has a significant risk of residual disease in the liver bed and lymph nodes. Re-resection improves survival in these patients after staging excludes distant spread. T1a cancers with clear margins need no further surgery.
Why not the others? Port-site excision is not routinely recommended.
References
During a laparoscopic cholecystectomy, what defines the “critical view of safety” before clipping?
- Identifying the cystic duct by palpation
- Seeing the common bile duct along its full length
- Seeing a single structure entering the gallbladder
- Performing an intraoperative cholangiogram
- Clearing the hepatocystic triangle of fat and fibrous tissue, separating the lower third of the gallbladder from the liver, and seeing only two structures entering the gallbladder
Show the answer and explanation
Answer: E. Clearing the hepatocystic triangle of fat and fibrous tissue, separating the lower third of the gallbladder from the liver, and seeing only two structures entering the gallbladder. The critical view of safety reduces bile duct injury caused by misidentification. All three criteria should be met, documented (for example with photographs), and confirmed before any structure is clipped or divided.
Why not the others? The infundibular technique alone is less reliable, especially with inflammation.
References
During a laparoscopic cholecystectomy for severe acute cholecystitis, the hepatocystic triangle is obscured by dense inflammation and the critical view of safety cannot be achieved. What is a safe option?
- A “bail-out” strategy, such as subtotal cholecystectomy, or stopping and placing a drain/cholecystostomy
- Close and discharge without further plans
- Continue dissecting deeper into the porta hepatis
- Clip the largest structure you can see
- Use diathermy freely near the common duct
Show the answer and explanation
Answer: A. A “bail-out” strategy, such as subtotal cholecystectomy, or stopping and placing a drain/cholecystostomy. When safe identification is impossible, bail-out strategies avoid bile duct injury. Subtotal cholecystectomy removes most of the gallbladder and stones while leaving the posterior wall or neck. Conversion to open surgery does not by itself guarantee safety.
Why not the others? Persisting in a hostile triangle is the setting of most major bile duct injuries.
References
Three days after a laparoscopic cholecystectomy, a patient has abdominal pain and fever. Ultrasound shows a collection in the gallbladder bed, and a percutaneous drain produces bile. MRCP shows a leak from the cystic duct stump and an intact common bile duct. What is the treatment?
- Observation without drainage
- ERCP with biliary stenting (and/or sphincterotomy), with continued percutaneous drainage
- Immediate hepaticojejunostomy
- Antibiotics alone
- Liver resection
Show the answer and explanation
Answer: B. ERCP with biliary stenting (and/or sphincterotomy), with continued percutaneous drainage. Cystic duct stump leaks are the commonest bile leaks after cholecystectomy. Draining the collection and reducing pressure in the bile duct with an ERCP stent allows the leak to heal in nearly all cases. Surgery is needed only if there is generalised bile peritonitis or a major duct injury.
Why not the others? Hepaticojejunostomy is for major transection injuries, not stump leaks.
References
Eight weeks after acute pancreatitis, a patient has a 7-cm well-defined pseudocyst next to the stomach. She is eating normally with no pain. What is the management?
- Observation; intervention only for symptoms (pain, gastric outlet obstruction, infection) or complications
- External drainage
- Pancreatectomy
- Total parenteral nutrition
- Immediate drainage because of the size
Show the answer and explanation
Answer: A. Observation; intervention only for symptoms (pain, gastric outlet obstruction, infection) or complications. Many pseudocysts resolve, and size alone is not an indication for drainage. Symptomatic or complicated pseudocysts are drained, usually endoscopically into the stomach (cystgastrostomy), which has replaced most surgical drainage.
Why not the others? External drainage risks a persistent pancreatic fistula.
References
A 42-year-old with chronic pancreatitis has severe, daily pain requiring opioids. Imaging shows a dilated main pancreatic duct with stones in the head. According to the ESCAPE trial, what is better than prolonged medical and endoscopic treatment?
- Coeliac plexus block only
- Total pancreatectomy as first choice
- Pancreatic enzymes alone
- Increasing opioid doses indefinitely
- Early surgery (for example a drainage or Frey procedure)
Show the answer and explanation
Answer: E. Early surgery (for example a drainage or Frey procedure). In painful chronic pancreatitis with a dilated duct, the ESCAPE trial showed that early surgery gave better pain relief, with fewer interventions, than an endoscopy-first approach. Stopping alcohol and smoking is essential.
Why not the others? Long-term opioids carry dependence and do not treat the obstruction.
References
CT shows a pancreatic head adenocarcinoma with 180° contact with the superior mesenteric vein and less than 180° contact with the superior mesenteric artery, with no metastases (borderline resectable). The patient is fit. What is the usual approach?
- Biliary bypass and stop
- Radiotherapy alone
- Immediate pancreatoduodenectomy without chemotherapy
- Neoadjuvant chemotherapy (for example FOLFIRINOX), then restaging and resection if there is no progression
- Palliative care only
Show the answer and explanation
Answer: D. Neoadjuvant chemotherapy (for example FOLFIRINOX), then restaging and resection if there is no progression. In borderline resectable pancreatic cancer, neoadjuvant chemotherapy treats micrometastatic disease, selects patients whose tumours do not progress, and increases margin-negative resection. A biliary stent is placed if jaundice needs drainage during chemotherapy.
Why not the others? Upfront surgery risks a margin-positive resection with early recurrence.
References
A 55-year-old has compensated cirrhosis from hepatitis C. What surveillance for hepatocellular carcinoma is recommended?
- CT every 5 years
- No surveillance
- Liver ultrasound every 6 months (with or without AFP)
- AFP alone every 2 years
- Liver biopsy every year
Show the answer and explanation
Answer: C. Liver ultrasound every 6 months (with or without AFP). Patients with cirrhosis have a high risk of HCC. Surveillance by ultrasound every 6 months detects tumours early, when resection, ablation or transplantation can cure them. CT or MRI is used when ultrasound is inadequate.
Why not the others? AFP alone misses many tumours.
References
Two weeks after a pancreatoduodenectomy, a patient with a drain has a small bleed from the drain, which stops, then a few hours later a large bleed with hypotension. What is the most likely cause and the best investigation?
- Normal postoperative bleeding; observe
- Anastomotic leak only; no imaging
- Pseudoaneurysm (for example of the gastroduodenal artery stump) after a “sentinel bleed”; urgent CT angiography and angiographic embolisation or stenting
- Haemorrhoids; banding
- Gastric ulcer; oral PPI and discharge
Show the answer and explanation
Answer: C. Pseudoaneurysm (for example of the gastroduodenal artery stump) after a “sentinel bleed”; urgent CT angiography and angiographic embolisation or stenting. Late haemorrhage after pancreatic surgery is often caused by erosion of an artery by pancreatic juice from a leak, forming a pseudoaneurysm. A small “sentinel bleed” often precedes a major bleed, so it must be investigated urgently. Interventional radiology is first-line; relaparotomy is for failure.
Why not the others? Dismissing a sentinel bleed can be fatal.
References
Ultrasound for another reason shows gallstones in a 50-year-old who has never had abdominal pain. What do you advise?
- Lithotripsy
- Ursodeoxycholic acid
- ERCP
- Cholecystectomy in every case
- No treatment; cholecystectomy is not recommended for asymptomatic gallstones in most people
Show the answer and explanation
Answer: E. No treatment; cholecystectomy is not recommended for asymptomatic gallstones in most people. Most people with asymptomatic gallstones never develop symptoms, and the risk of complications is low. Cholecystectomy is advised once symptoms develop. A few groups (for example a porcelain gallbladder or large polyps) may be considered for surgery.
Why not the others? Surgery for asymptomatic stones exposes patients to risk without much benefit.
References
A woman who is 20 weeks pregnant has her third attack of biliary colic, and now has acute cholecystitis. What do you advise?
- Laparoscopic cholecystectomy is safe in pregnancy and is preferred to repeated conservative management
- Open surgery only
- ERCP for all
- Wait until after delivery in every case
- Termination of pregnancy
Show the answer and explanation
Answer: A. Laparoscopic cholecystectomy is safe in pregnancy and is preferred to repeated conservative management. Laparoscopic cholecystectomy can be performed safely in any trimester. Conservative management of symptomatic gallstones in pregnancy has high recurrence, more admissions and a risk of pancreatitis, which is more dangerous for the fetus than surgery.
Why not the others? Pregnancy is not a contraindication to laparoscopy.
References
A 60-year-old with painless jaundice has a hilar cholangiocarcinoma that may be resectable with an extended right hepatectomy. The future liver remnant is small. What preparation is commonly needed?
- Immediate resection without preparation
- Liver transplantation for every case
- Drainage of the future liver remnant and portal vein embolisation of the side to be removed, to grow the remnant before resection
- Chemotherapy alone
- Cholecystectomy only
Show the answer and explanation
Answer: C. Drainage of the future liver remnant and portal vein embolisation of the side to be removed, to grow the remnant before resection. Major hepatectomy for hilar cholangiocarcinoma carries a risk of liver failure if the remnant is too small or jaundiced. Draining the remnant and embolising the portal vein on the tumour side make the remnant grow before surgery.
Why not the others? Operating with a small, jaundiced remnant risks postoperative liver failure.
References
A 35-year-old man from an endemic area has fever, right upper quadrant pain and a single 6-cm liver abscess. Amoebic serology is positive. What is the treatment?
- Albendazole
- Immediate surgical drainage
- Liver resection
- Metronidazole, followed by a luminal agent (for example paromomycin); drainage only if there is no response or a risk of rupture
- No treatment
Show the answer and explanation
Answer: D. Metronidazole, followed by a luminal agent (for example paromomycin); drainage only if there is no response or a risk of rupture. Amoebic liver abscesses respond to metronidazole in most cases, even when large. A luminal agent then clears intestinal cysts to prevent relapse. Aspiration is reserved for failure to respond, diagnostic doubt, or large left-lobe abscesses at risk of rupture into the pericardium.
Why not the others? Albendazole is for hydatid disease.
References
According to the revised Atlanta classification, what defines severe acute pancreatitis?
- Pancreatic necrosis on any CT
- Organ failure that persists for more than 48 hours
- Pain lasting more than 3 days
- An amylase more than 3 times normal
- Any fluid collection
Show the answer and explanation
Answer: B. Organ failure that persists for more than 48 hours. Mild pancreatitis has no organ failure or complications; moderately severe has transient organ failure (under 48 hours) or local complications; severe has persistent organ failure beyond 48 hours. Persistent organ failure is the main predictor of death.
Why not the others? The level of amylase does not reflect severity.
References
A 40-year-old with poorly controlled diabetes has acute pancreatitis. He does not drink alcohol and ultrasound shows no gallstones. Which test should be checked early?
- Tumour markers
- Serum copper
- Urinary 5-HIAA
- Thyroid antibodies
- Serum triglycerides (above about 11.3 mmol/L, or 1000 mg/dL, suggests hypertriglyceridaemia as the cause)
Show the answer and explanation
Answer: E. Serum triglycerides (above about 11.3 mmol/L, or 1000 mg/dL, suggests hypertriglyceridaemia as the cause). Hypertriglyceridaemia is the third most common cause of acute pancreatitis after gallstones and alcohol. Triglycerides should be measured early because levels fall with fasting. Treatment includes insulin infusion and lipid-lowering therapy, and plasmapheresis in selected cases.
Why not the others? Calcium should also be checked, as hypercalcaemia is another metabolic cause.
References
A fit patient has symptomatic gallstones and a proven common bile duct stone. Which statement is correct about management?
- Leave the duct stone, as it always passes
- ERCP alone without cholecystectomy for all fit patients
- Cholecystectomy alone is enough
- Either ERCP clearance before laparoscopic cholecystectomy, or a single-stage laparoscopic cholecystectomy with bile duct exploration, is acceptable, depending on local expertise
- Open bile duct exploration is the only option
Show the answer and explanation
Answer: D. Either ERCP clearance before laparoscopic cholecystectomy, or a single-stage laparoscopic cholecystectomy with bile duct exploration, is acceptable, depending on local expertise. Both strategies clear bile duct stones with similar success. The single-stage approach can shorten hospital stay but requires expertise. Fit patients should also have their gallbladder removed, because leaving it in place leads to recurrent biliary events.
Why not the others? ERCP alone is reasonable only for frail patients.
References
A patient has gallstone pancreatitis together with fever, jaundice and rising bilirubin (cholangitis). When should ERCP be done?
- Only if CT shows necrosis
- Never in pancreatitis
- Only if the amylase normalises
- Urgently, within 24 hours
- Only after 6 weeks
Show the answer and explanation
Answer: D. Urgently, within 24 hours. In gallstone pancreatitis with cholangitis, urgent ERCP to clear the bile duct is recommended. Without cholangitis or ongoing biliary obstruction, early ERCP does not improve outcomes, and medical treatment is preferred.
Why not the others? Routine early ERCP in every gallstone pancreatitis adds risk without benefit.
References