Clinical SBAs
Clinical Hepato-biliary Surgery: (16 questions)

Questions

• 1
  A 54-year old man with alcoholic cirrhosis and bleeding oesophageal varices undergoes a treatment to reduce portal pressure but it increases his risk of developing encephalopathy. What treatment is this most likely to be?
  Difficulty: Medium     Topic: Portal hypertension treatment
  a

  Oral propranolol

  b

  Oral lactulose

  c

  Transjugular intrahepatic porto-systemic shunt (TIPSS)

  d

  Liver transplantation

  e

  Liver resection
  Explanation: TIPSS is where a shunt is passed through the hepatic vein and forced into one of the portal vein branches, allowing blood to bypass the hepatic circulation. This decreases portal pressure and the risk of variceal bleeding. However it increases the risk of encephalopathy due to the shunt. Oral propranolol is given as prophylactic treatment of varices to reduce risk of bleeding. Lactulose treats hepatic encephalopathy. Transplantation is the definitive treatment for cirrhosis. Resection is used for hepatocellular carcinoma but increases risk of decompensation in cirrhotic patients.
• 2
  An apyrexial 64-year old woman presents with generalised abdominal pain, distension and vomiting. AXR shows dilated central bowel loops and pneumobilia. She has not been in hospital in the last 5 years. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Abdominal pain and pnuemobilia
  a

  Acute cholecystitis

  b

  Sigmoid carcinoma

  c

  Ascending cholangitis

  d

  Gallstone ileus

  e

  Acute pancreatitis
  Explanation: This woman has a large gallstone impacted in her small bowel that has caused obstruction. The term 'ileus' is misleading because this is a mechanical cause of bowel obstruction. This condition occurs when chronic cholecystitis leads to formation of a fistula between the gall bladder and jejunum, allowing free passage of a stones into the bowel. If a stone >4cm forms then it can cause obstruction in the terminal ileum. Pneumobilia is the presence of air in the biliary tree, which can be caused by gallstone ileus. Other causes include anaerobic biliary tree infection, post-ERCP and surgery. This woman is apyrexial and has bowel obstruction, which makes cholecystitis and cholangitis unlikely. These conditions, as well as pancreatitis, may cause an ileus but would present with features of the primary diagnosis. Colorectal cancer frequently presents with bowel obstruction, however it is most likely to cause large bowel obstruction (with peripherally dilated bowel loops). CRC also would not account for pneumobilia.
• 3
  A 43-year old woman with right upper quadrant pain and a temperature of 38.9 degrees has the following blood tests: ALT 117 IU/L, ALP 540 IU/L, Br 64 mcrmol/L, Albumin 47g/L. What is the most likely diagnosis?
  Difficulty: Medium     Topic: RUQ pain and pyrexia 1
  a

  Hepatitis A infection

  b

  Acute cholecystitis

  c

  Chronic cholecystitis

  d

  Ascending cholangitis

  e

  Primary biliary cirrhosis
  Explanation: This woman has LFT consistent with obstructive jaundice: massively raised ALP, raised bilirubin and mildly raised ALT. Ascending cholangitis or PBC could fit this picture however albumin is normal, which favours an acute event. Patients with cirrhosis or chronic PBC will become hypoalbuminaemic, unlike ascending cholangitis. Hepatitis A causes an acute infection with markedly raised ALT (up to 1000IU/L) and moderately raised bilirubin. Cholecystitis does not cause a raised bilirubin.
• 4
  A 30-year old woman presents with constant right upper quadrant pain, pyrexia and leukocytosis. Which of the following signs is most likely to be present?
  Difficulty: Easy     Topic: RUQ pain and pyrexia 2
  a

  Rovsing's sign

  b

  Murphy's sign

  c

  Grey Turner's sign

  d

  Cullen's sign

  e

  Fox's sign
  Explanation: This woman has cholecystitis and Murphy's is appropriate. Pressure is placed in the RUQ and pain increases during inspiration as the gall bladder descends. Murphy's is positive if this is found on the right and not the left. Rovsing's is the presence of greater pain in the RIF than LIF when the left is pressed, in acute appendicitis. The remaining 3 options all refer to abdominal bruising that occurs due to retroperitoneal bleeding; the locations of the bruising are: Grey Turners' - flanks, Cullen's - umbilical, Fox's - inguinal ligament.
• 5
  A 45-year old woman with polycythaemia rubra vera presents with a 3 month history of RUQ pain, hepatomegaly and portal hypertension. What is the most likely diagnosis?
  Difficulty: Medium     Topic: RUQ pain and portal hypertension
  a

  RUQ pain and portal hypertension

  b

  Right heart failure (RHF)

  c

  Liver abscess

  d

  Portal vein thrombosis

  e

  Budd-Chiari syndrome
  Explanation: Budd-Chiari syndrome is occlusion of the hepatic vein, usually by a thrombus and is more common in hypercoagulability. Presentation can be acute or chronic with liver failure and non-cirrhotic portal hypertension. Doppler, CT or MRI are diagnostic and it is treated with stenting or venous bypass. Hepatitis A does not cause portal hypertension, nor do liver abscesses (except rarely by compression). RHF would give other signs e.g. oedema. Portal vein thrombosis doesn't cause hepatomegaly.
• 6
  A 71-year old man presents with progressive jaundice. USS shows a dilated common bile duct (CBD) and no masses in the head of the pancreas. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Progressive jaundice with normal pancreas
  a

  Chronic pancreatitis

  b

  Carcinoma in the tail of the pancreas

  c

  Peri-ampullary tumour

  d

  Primary biliary cirrhosis

  e

  Budd-Chiari syndrome
  Explanation: The progressive jaundice with a dilated common bile duct suggests compression of the distal biliary tree by a mass, usually cholangiocarcinoma or carcinoma of pancreatic head. Tumours at the ampulla of vater are rare adenocarcinomas with a moderately poor prognosis. Chronic pancreatitis rarely causes jaundice. Pancreatic tail masses don't compress the bile duct. Primary biliary cirrhosis only affects intrahepatic bile ducts. Budd-Chiari syndrome causes portal hypertension and liver failure, not obstructive jaundice.
• 7
  A 70-year old man presents with a 2 month history of painless progressive jaundice and weight loss. Which of the following is most likely to be the diagnostic investigation?
  Difficulty: Medium     Topic: Investigation of jaundice
  a

  Clotting studies

  b

  ERCP

  c

  Liver function tests

  d

  MRCP

  e

  Ultrasound scan
  Explanation: This man may have carcinoma of the pancreatic head. MRCP is most likely to be able to define the anatomy and illustrate the origin of obstruction. Clotting may be deranged from vitamin K deficiency due to lack of bile salts, which is non-specific to any cause of obstructive jaundice. ERCP will show obstruction of the common bile duct but will not differentiate pancreatic malignancy from cholangiocarcinoma. Liver function tests will show a non-specific picture consistent with obstructive jaundice. Ultrasound scan is unlikely to accurately visualise the pancreatic head due to overlying bowel, however it may show a dilated common bile duct.
• 8
  What condition is an exception to Courvoisier’s law?
  Difficulty: Easy     Topic: Courvoisier's law
  a

  Choledocholithiasis

  b

  Chronic pancreatitis

  c

  Gallstone ileus

  d

  Mirizzi's syndrome

  e

  Primary sclerosing cholangitis (PSC)
  Explanation: Courvoisier's law states that an obstructed jaundice is not due to gallstones if the gallbladder is palpable. A palpable gall bladder requires obstruction of the cystic duct to build up pressure and cause dilatation, but cystic duct occlusion alone usually does not cause jaundice. Also, a patient with gallstones is likely to have chronic cholecystitis with gall bladder fibrosis (which may be asymptomatic), which will not expand freely. However in Mirizzi's syndrome, a stone in the cystic duct causes extrinsic compression of the common bile duct, resulting in obstructive jaundice. Courvoisier's holds true for stones in the common bile duct (choledocholithiasis) and PSC. A gallstone ileus and chronic pancreatitis do not cause jaundice.
• 9
  A previously well 31-year old man becomes jaundiced while recovering from a hydrocele repair. LDH, ALT and ALP are normal, bilirubin is mildly raised. What other feature is most likely to be present?
  Difficulty: Easy     Topic: Jaundice with normal LFTs
  a

  Dilated biliary tree

  b

  Fragment red cells on peripheral blood film

  c

  Irregular hepatomegaly

  d

  Raised amylase

  e

  None of the above
  Explanation: This man has Gilbert's syndrome, a common inherited condition of reduced bilirubin conjugation ability from susceptibility of UGT-1 to down-regulation during stress. It causes unconjugated hyperbilirubinaemia without any other hepatic dysfunction. A dilated biliary tree suggests obstructive jaundice but this patient's ALP is normal. Fragmented red cells are found in haemolysis, but LDH is normal. Irregular hepatomegaly suggests metastases, which usually doesn't cause sudden onset jaundice. Pancreatitis causes a markedly raised amylase but ALP would be mildly raised if also jaundiced.
• 10
  A 68-year old woman presents with progressive jaundice and weight loss. Her common bile duct is dilated proximal to a dominant stricture. Which of the following statements about this condition is not true?
  Difficulty: Medium     Topic: Progressive jaundice with CBD stricture
  a

  It is strongly associated with primary biliary cirrhosis

  b

  Prognosis is poorer than oesophageal carcinoma

  c

  Less than 20% of patients are treated with surgery

  d

  It can be intra- or extra-hepatic

  e

  It can be mass-forming or infiltrative
  Explanation: Progressive jaundice and weight loss is most often due to pancreatic carcinoma or cholangiocarcinoma, as in this case, which is favoured by finding a dominant stricture. PBC is not a major risk factor but primary sclerosing cholangitis greatly increase risk. Prognosis is poor with median survival is <6 months as very few are resectable and it is relatively chemo-resistant. They can arise anywhere in the biliary tree. Mass-forming give obstructive symptoms earlier than infiltrative.
• 11
  Which of the following is not an independent risk factor for hepatocellular carcinoma (HCC)?
  Difficulty: Medium     Topic: Hepatocellular carcinoma
  a

  Cirrhosis

  b

  Iron accumulation

  c

  Hepatitis B virus

  d

  Hepatitis A virus

  e

  Aflatoxin exposure
  Explanation: HCC is the most common malignant primary liver tumour. It is associated with chronic liver inflammation whereas hepatitis A only causes an acute hepatitis. Almost all HCC occur on a background of cirrhosis, apart from some associated with chronic hepatitis B infection, which is strong independent risk factor. Iron overload (e.g. hereditary haemochromatosis, transfusions for thalassaemia) is toxic and pro-carcinogenic. Aflatoxin is a potent carcinogen produced by Aspergillus on stored grains in Asia and Africa.
• 12
  A 45-year old woman presents with colicky right upper quadrant pain, which most occurs after meals. Which of the following is not a complication of this condition?
  Difficulty: Easy     Topic: Colicky RUQ pain
  a

  Gall bladder carcinoma

  b

  Ileus

  c

  Cirrhosis

  d

  Jaundice

  e

  Raised amylase
  Explanation: Most gallstones are asymptomatic. Cirrhosis is caused by chronic liver inflammation not stones. The risk of gall bladder carcinoma is increased with gallstones, most in the presence of chronic cholecystitis. A gallstone ileus is a mechanical bowel obstruction that occurs when a large stone passes from the gall bladder into the small bowel via fistula. Jaundice occurs when stones are impacted in the common bile duct. Gallstones are the most common cause of pancreatitis.
• 13
  A 61-year old man presents with severe epigastric pain and vomiting with lipase 478U/L. Which of the following does not indicate severity of this condition?
  Difficulty: Easy     Topic: Epigastric pain and raised lipase
  a

  Hypocalcaemia

  b

  Hypoxia

  c

  Raised LDH

  d

  Raised amylase

  e

  CT appearance for Balthazar scoring
  Explanation: This man has pancreatitis - severe epigastric pain with nausea and a massively raised amylase or lipase is highly suggestive. Amylase can be used to help diagnose but does not indicate severity. Hypocalcaemia develops and may cause tetany. Hypoxia may occur due to pulmonary oedema or ARDS. Raised LDH or AST are poor prognostic markers. 'B-D' are all features that contribute to the Modified Glasgow scoring system for the severity of acute pancreatitis. The Balthazar scoring system uses CT appearance of pancreatic damage, especially the presence of necrosis and retroperitoneal haemorrhage, to predict severity.
• 14
  A 81-year old man presents with weight loss and malaise. He is anaemic and his liver contains multiple round masses, shown to be adenocarcinoma in origin. He reports no other symptoms. OGD and colonoscopy are normal. Where is the primary tumour most likely to be?
  Difficulty: Easy     Topic: Weight loss and liver metastases
  a

  Head of pancreas

  b

  Tail of pancreas

  c

  Common bile duct

  d

  Rectum

  e

  Ampulla of Vater
  Explanation: Adenocarcinoma of the tail of the pancreas presents more insidiously than that in the head. It does not cause obstructive jaundice and presents with metastases. It is the least common location for pancreatic tumours. Cancer of the pancreatic head, common bile duct (cholangiocarcinoma) or peri-ampullary tumours present with painless obstructive jaundice. Rectal tumour is unlikely because of a normal colonoscopy and a tumour advanced enough to metastasise are likely to cause change in bowel habit or bleeding par rectum.
• 15
  Adenocarcinoma of the tail of the pancreas presents more insidiously than that in the head. It does not cause obstructive jaundice and presents with metastases. It is the least common location for pancreatic tumours. Cancer of the pancreatic head, common bile duct (cholangiocarcinoma) or peri-ampullary tumours present with painless obstructive jaundice. Rectal tumour is unlikely because of a normal colonoscopy and a tumour advanced enough to metastasise are likely to cause change in bowel habit or bleeding par rectum.
  Difficulty: Medium     Topic: Portal hypertension treatment
  a

  Oral propranolol

  b

  Oral lactulose

  c

  Transjugular intrahepatic porto-systemic shunt (TIPSS)

  d

  Liver transplantation

  e

  Liver resection
  Explanation: TIPSS is where a shunt is passed through the hepatic vein and forced into one of the portal vein branches, allowing blood to bypass the hepatic circulation. This decreases portal pressure and the risk of variceal bleeding. However it increases the risk of encephalopathy due to the shunt. Oral propranolol is given as prophylactic treatment of varices to reduce risk of bleeding. Lactulose treats hepatic encephalopathy. Transplantation is the definitive treatment for cirrhosis. Resection is used for hepatocellular carcinoma but increases risk of decompensation in cirrhotic patients.
• 16
  An apyrexial 64-year old woman presents with generalised abdominal pain, distension and vomiting. AXR shows dilated central bowel loops and pneumobilia. She has not been in hospital in the last 5 years. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Abdominal pain and pnuemobilia
  a

  Acute cholecystitis

  b

  Sigmoid carcinoma

  c

  Ascending cholangitis

  d

  Gallstone ileus

  e

  Acute pancreatitis
  Explanation: This woman has a large gallstone impacted in her small bowel that has caused obstruction. The term 'ileus' is misleading because this is a mechanical cause of bowel obstruction. This condition occurs when chronic cholecystitis leads to formation of a fistula between the gall bladder and jejunum, allowing free passage of a stones into the bowel. If a stone >4cm forms then it can cause obstruction in the terminal ileum. Pneumobilia is the presence of air in the biliary tree, which can be caused by gallstone ileus. Other causes include anaerobic biliary tree infection, post-ERCP and surgery. This woman is apyrexial and has bowel obstruction, which makes cholecystitis and cholangitis unlikely. These conditions, as well as pancreatitis, may cause an ileus but would present with features of the primary diagnosis. Colorectal cancer frequently presents with bowel obstruction, however it is most likely to cause large bowel obstruction (with peripherally dilated bowel loops). CRC also would not account for pneumobilia.