ABSITE - Biliary – Questions & Answers
100% Accurate!
A 44-year-old woman with a body mass index of 38 presents to the emergency
department with fever, nausea, vomiting, and right upper quadrant pain. A right upper
quadrant ultrasound shows an obstructing cystic duct stone and a normal-appearing
common bile duct. You undertake a laparoscopic cholecystectomy but the case is
difficult, requiring conversion to an open approach due to severe chronic inflammation
and fibrosis in the hepatocystic triangle and porta hepatis. You unintentionally enter the
duodenum during your dissection and close it in two layers. It appeared to be in
continuity with the gallbladder, which is then removed. Four days later the nasogastric
tube output is persistently elevated. An aqueous contrast upper gastrointestinal series
with small bowel follow-through shows no proximal stricture or leak, but contrast does
not reach the cecum after 12 hours. A CT scan shows a high-grade obstruction in the di
- ANSWERSMeticulous intraoperative examination of the small bowel
Correct.
When a cholecystoenteric fistula is known or encountered at operation, it is important to
carefully examine the entire small bowel at the time of surgery to ensure that any and all
stones are removed.
Reproduction of biliary colic with which of the following tests best identifies patients
likely to benefit from transduodenal sphincteroplasty?
A. Secretin stimulation test
B. Morphine-neostigmine (Nardi) test
C. Glucagon stimulation test
D. Cholecystokinin (CCK) test
E. Corticotropin stimulation test - ANSWERSMorphine-neostigmine (Nardi) test
Correct.
Reproduction of pain with morphine (resulting in sphincter contraction) and neostigmine
(resulting in biliary contraction) has been historically used to identify patients with
sphincter of Oddi dysfunction that would benefit from transduodenal sphincterectomy.
A 68-year-old man with a history of chronic pancreatitis presents with painless jaundice,
weight loss, fatigue, and back pain. A right upper quadrant ultrasound demonstrates
intrahepatic ductal dilation without any hepatic masses. A pancreas protocol CT scan
shows mild scattered calcifications in the pancreas and dilated biliary ducts but no
definite mass. The next best step is:
A. Diagnostic laparoscopy followed by Whipple procedure
B. ERCP with endoscopic ultrasound
C. Whole body PET scan
D. Repeat pancreas protocol CT scan in 3 months
, E. HIDA scan - ANSWERSERCP with endoscopic ultrasound
Correct.
While the patient's history is suggestive of an obstructing periampullary neoplasm or
possibly a pancreatic duct stricture, no definitive diagnosis has been made. ERCP
permits identification and biopsy of periampullary tumors and will further define ductal
anatomy. In this setting, EUS with FNA has a sensitivity of about 90% for pancreatic
cancer. Choice A is not indicated because no definite mass is seen. Choice C is not
indicated because it is not sensitive or specific for periampullary neoplasm, and no
definitive diagnosis has been made yet. Choice D is incorrect because this scenario
requires further diagnostic workup. Choice E is not indicated because it does not
establish a diagnosis in this scenario, and at best would demonstrate biliary obstruction,
which is already evident from the patient's jaundice and intrahepatic ductal dilation.
The incidence of recurrent pancreatitis or other gallstone-related complications during
the 6-week period following an episode of gallstone pancreatitis in patients who do not
undergo cholecystectomy is:
A. zero
B. 5%
C. 25%
D. 50%
E. 100% - ANSWERS25%
Correct.
There is an approximate 25% incidence of recurrent pancreatitis and gallstone-related
complications in patients with biliary pancreatitis whose cholecystectomy is delayed
even 2 weeks after hospital discharge. Therefore, cholecystectomy should be
performed during the same hospitalization for most patients with mild gallstone
pancreatitis.
In patients with gallstone pancreatitis, studies have shown that early ERCP with stone
extraction and sphincterotomy benefits the subset of patients who have which of the
following:
A. Obstructive jaundice and/or cholangitis
B. Pancreatic pseudocyst
C. Acute cholecystitis
D. Mild elevations of transaminases
E. Infected peripancreatic necrosis - ANSWERSObstructive jaundice and/or cholangitis
Correct.
There is both theoretical and experimental rationale to believe that removal of
gallstones impacted at the ampulla of Vater early in the course of an episode of acute
gallstone pancreatitis might limit disease severity. The efficacy of early ERCP to
accomplish this goal has been subjected to prospective, randomized clinical trials.
These studies show that early ERCP with stone extraction and sphincterotomy benefits
the subset of patients with gallstone pancreatitis who have obstructive jaundice and/or
100% Accurate!
A 44-year-old woman with a body mass index of 38 presents to the emergency
department with fever, nausea, vomiting, and right upper quadrant pain. A right upper
quadrant ultrasound shows an obstructing cystic duct stone and a normal-appearing
common bile duct. You undertake a laparoscopic cholecystectomy but the case is
difficult, requiring conversion to an open approach due to severe chronic inflammation
and fibrosis in the hepatocystic triangle and porta hepatis. You unintentionally enter the
duodenum during your dissection and close it in two layers. It appeared to be in
continuity with the gallbladder, which is then removed. Four days later the nasogastric
tube output is persistently elevated. An aqueous contrast upper gastrointestinal series
with small bowel follow-through shows no proximal stricture or leak, but contrast does
not reach the cecum after 12 hours. A CT scan shows a high-grade obstruction in the di
- ANSWERSMeticulous intraoperative examination of the small bowel
Correct.
When a cholecystoenteric fistula is known or encountered at operation, it is important to
carefully examine the entire small bowel at the time of surgery to ensure that any and all
stones are removed.
Reproduction of biliary colic with which of the following tests best identifies patients
likely to benefit from transduodenal sphincteroplasty?
A. Secretin stimulation test
B. Morphine-neostigmine (Nardi) test
C. Glucagon stimulation test
D. Cholecystokinin (CCK) test
E. Corticotropin stimulation test - ANSWERSMorphine-neostigmine (Nardi) test
Correct.
Reproduction of pain with morphine (resulting in sphincter contraction) and neostigmine
(resulting in biliary contraction) has been historically used to identify patients with
sphincter of Oddi dysfunction that would benefit from transduodenal sphincterectomy.
A 68-year-old man with a history of chronic pancreatitis presents with painless jaundice,
weight loss, fatigue, and back pain. A right upper quadrant ultrasound demonstrates
intrahepatic ductal dilation without any hepatic masses. A pancreas protocol CT scan
shows mild scattered calcifications in the pancreas and dilated biliary ducts but no
definite mass. The next best step is:
A. Diagnostic laparoscopy followed by Whipple procedure
B. ERCP with endoscopic ultrasound
C. Whole body PET scan
D. Repeat pancreas protocol CT scan in 3 months
, E. HIDA scan - ANSWERSERCP with endoscopic ultrasound
Correct.
While the patient's history is suggestive of an obstructing periampullary neoplasm or
possibly a pancreatic duct stricture, no definitive diagnosis has been made. ERCP
permits identification and biopsy of periampullary tumors and will further define ductal
anatomy. In this setting, EUS with FNA has a sensitivity of about 90% for pancreatic
cancer. Choice A is not indicated because no definite mass is seen. Choice C is not
indicated because it is not sensitive or specific for periampullary neoplasm, and no
definitive diagnosis has been made yet. Choice D is incorrect because this scenario
requires further diagnostic workup. Choice E is not indicated because it does not
establish a diagnosis in this scenario, and at best would demonstrate biliary obstruction,
which is already evident from the patient's jaundice and intrahepatic ductal dilation.
The incidence of recurrent pancreatitis or other gallstone-related complications during
the 6-week period following an episode of gallstone pancreatitis in patients who do not
undergo cholecystectomy is:
A. zero
B. 5%
C. 25%
D. 50%
E. 100% - ANSWERS25%
Correct.
There is an approximate 25% incidence of recurrent pancreatitis and gallstone-related
complications in patients with biliary pancreatitis whose cholecystectomy is delayed
even 2 weeks after hospital discharge. Therefore, cholecystectomy should be
performed during the same hospitalization for most patients with mild gallstone
pancreatitis.
In patients with gallstone pancreatitis, studies have shown that early ERCP with stone
extraction and sphincterotomy benefits the subset of patients who have which of the
following:
A. Obstructive jaundice and/or cholangitis
B. Pancreatic pseudocyst
C. Acute cholecystitis
D. Mild elevations of transaminases
E. Infected peripancreatic necrosis - ANSWERSObstructive jaundice and/or cholangitis
Correct.
There is both theoretical and experimental rationale to believe that removal of
gallstones impacted at the ampulla of Vater early in the course of an episode of acute
gallstone pancreatitis might limit disease severity. The efficacy of early ERCP to
accomplish this goal has been subjected to prospective, randomized clinical trials.
These studies show that early ERCP with stone extraction and sphincterotomy benefits
the subset of patients with gallstone pancreatitis who have obstructive jaundice and/or
