CHAPTER 7 Pancreas, Biliary Tract, Liver, and Spleen Valerie L. Katz and Akella Chendrasekhar Questions Copytight © 2007 by The MeGrevsHil Companies, Inc4. A 15-year-old female presents with RUQ abdominal pain. Workup reveals a choledochal cyst. Which of the following statements is TRUE? (A). Choledochal cysts are more common in men. (B) Laparoscopic cholecystectomy is the recommended treatment. (©) Patients with a choledochal cyst have an increased risk of cholangiocarcinoma, (D) All patients with a choledochal cyst have abdominal pain, a RUQ mass, and jaundice, (©) The etiology is infectious. 5, A 13-year-old female presenting with RUQ abdominal pain is suspected of having a chole- dochal cyst. Which of the following studies ‘would be least helpful in confirming the diag- nosis in this case? (A) Computed tomography (CT) scan (8) Percutaneous transhepatic cholangiography (© Endoscopic retrograde cholangiopancreatography (D) Magnetic resonance cholangiopancreatography (MRCP) (©) Upper Gl series 6. An intraoperative cholangiogram is performed during an elective laparoscopic cholecystec- tomy ona 30-year-old woman. She has no pre- vious surgical history. There is a 0.8-cm filling, defect in the distal common bile duet (CBD). ‘The surgeon should (A) Complete the laparoscopic cholecystectomy and check liver function tests (LFTs) postoperatively. If they are normal, no further treatment is needed. (B) Complete the laparoscopic cholecystectomy and repeat an ultrasound postoperatively. Observe the patient if no CBD stone is visualized (©) Periorm a CBD exploration either laparoscopically or open along with a cholecystectomy. (D) Complete the laparoscopic cholecystectomy, no further treatment is necessary. (E) Complete the laparoscopic cholecystectomy and plan for a postoperative hydroxy iminodiacetic acid (HIDA) scan. An 85-year-old man is brought to the hospital with a 2-day history of nausea and vomiting, He has not passed gas or moved his bowels for the last 5 days. Abdominal films show dilated small bowel, no air in the rectum and air in the biliary tree. Which of the following, statements is TRUE? (A). Air in the biliary tree associated with small-bowel obstruction suggests a diagnosis of gallstone ileus. (B) Anenterotomy should be distal to the site of obstruction and the stone should be removed. (©) Gallstone ileus is more common in the young adults. (D) Cholecystectomy is contraindicated E) Small-bowel obstruction usually occurs in the distal jejunum, 3. A.45-year-old man with hepatitis C undergoes an uneventful percutaneous liver biopsy. About 6-weeks later, he complains of RUQ pain, is clin- ically jaundiced, with a hemoglobin of 9.2 mg/dL and is fecal occult blood positive. Which diagnosis best explains this patient's symptoms? (A) Hepatocellular carcinoma (B) Chronic hepatitis C (© Colon carcinoma with liver metastasis (D) Hemobilia (E) Symptomatic cholelithiasis ). 40-year-old patient with a history of trauma to the RUQ presents with RUQ pain, clinical jaundice, and guaiac positive stools. Which one of the following studies would be most useful to confirm the patient's diagnosis? (A) Abdominal ultrasound (8) CT of the abdomen (© Angiography10. nL 12. 13. (D) HIDA scan (©) Diagnostic laparoscopy A 40-year-old female alcoholic is suspected of having a hepatic mass. Percutaneous ultrasound- guided liver biopsy is contraindicated in which of the following? (A) Hepatocellular carcinoma (B) Metastatic carcinoma (B) Cirthosis (D) Hepatitis C (E) Hepatic adenoma A20-year-old man is brought to the emergency department with a gunshot wound to the abdomen, His blood pressure is 70 systolic and his heart rate is 140 beats per minute (bpm). He is taken directly to the operating room for an exploratory laparotomy. A large, actively bleed- ing liver laceration is found. A pringle maneu- ver is performed as part of the procedure to control his bleeding. The pringle maneuver compresses which structures? (A) Portal vein, hepatic vein, and hepatic artery (8) Portal vein, hepatic artery, and cystic artery (©) Portal vein and hepatic artery (D) Portal vein, hepatic artery, and CBD (E) Cystic artery, cystic duct, and CBD A 22-year-old medical student is seen by the student health service prior to beginning school, Routine labs are drawn, The medical student immunized against hepatitis Bin child- hood will have which hepatitis profile? (A) HbsAb+, HbsAgt, HbcAbt (B) HbsAb+, HbsAgt, HbcAb- (C) HbsAb-, HbsAg-, HbcAb- (D) HbsAb+, HbsAg-, HbcAb- (E) HbsAb-, HbsAg, HebAb- A 36-year-old man presents to the emergency department after a motor vehicle crash. He is complaining of left-sided chest pain and abdom- inal pain. His blood pressure is 130/80 mm He. Anelectrocardiogram shows sinus rhythm with ve 15. a heart rate of 95 bpm. A chest x-ray shows left 8,9, and 10 rib fractures. An abdominal com- puted axial tomography (CAT) scan is obtained, Itshows a 3-cm laceration in the upper pole of the spleen with a small amount of blood around the spleen. No other injury is identified. Which of the following statements is TRUE? (A) This is a class I injury and it may be treated nonoperatively. (B) This is a class Il injury and it may be treated nonoperatively. (C) This is a class Il injury and it requires immediate laparotomy. (D) The patient should be prophylactically transfused in anticipation of continued blood loss. (E) Delayed splenic rupture is not possible with this injury, A38-year-old man undergoes excisional biopsy of a cervical lymph node. Pathology reveals Hodgkin’s lymphoma. Which of the following, statements about Hodgkin's disease is TRUE? (A) Splenectomy is always required for accurate staging (8) Staging laparotomy involves liver biopsy, biopsy of the spleen, and periaortic lymph node dissection. (©) Stage Il disease involves disease on both sides of the diaphragm. (D) Ifthe spleen is involved, the patient has stage IV disease. (E) Splenectomy is sometimes indicated for thrombocytopenia. A50-year-old woman complains of weakness, profuse watery diarrhea, and crampy abdom- inal pain. She reports a 10-Ib weight loss. Her serum potassium is 2.8 mEq/L. Select the most likely diagnosis. (A) Watery, diarrhea, hypokalemia, and achlorhydria (WDHA) syndrome (B) Somatostatinoma (©) Glucagonoma (D) Insulinoma (E) Multiple endocrine neoplasia type 1(MEN-1)