Department of SurgeryUST Faculty of Medicine & Surgery

General Review Guidelines General Review Guidelines

Adequate content coverageAdequate content coverage Time managementTime management TestmanshipTestmanship

Testmanship Testmanship

Too encompassing/absolute Too encompassing/absolute statements statements

One or more completion types One or more completion types

(A - 1,2,3, correct; C - 2,4 correct (A - 1,2,3, correct; C - 2,4 correct etc…)etc…)

All of the above/none of the aboveAll of the above/none of the above Try to anticipate what is in the Try to anticipate what is in the

mind of the examinermind of the examiner

Hepatocallular CarcinomaHepatocallular Carcinoma

55thth most common most common

1 M new cases annually1 M new cases annually

Asia: 30-65/100TAsia: 30-65/100T

USA - 2/100TUSA - 2/100T

Risk Factors:Risk Factors:

CirrhosisCirrhosis

Viral HepatitisViral Hepatitis

CholangiocarcinomaCholangiocarcinoma

22ndnd most common liver malignancy most common liver malignancy Hilar – Hilar – KlatskinKlatskin tumor tumor

Treatment Options for Liver Treatment Options for Liver CancerCancer

Hepatic resection mortality rates < 5%; 5 yr recurrence 50%Hepatic resection mortality rates < 5%; 5 yr recurrence 50% Liver transplantationLiver transplantation

Ablation techniques Ablation techniques

     Radiofrequency ablation Radiofrequency ablation 

   Ethanol ablation Ethanol ablation     Cryoablation   Cryoablation   Microwave ablationMicrowave ablation

Regional liver therapies  Regional liver therapies   Chemoembolization/embolization  Chemoembolization/embolization   Hepatic artery pump chemoperfusion  Hepatic artery pump chemoperfusion   Internal radiation therapy (yttrium 90 internal radiation)Internal radiation therapy (yttrium 90 internal radiation) External beam radiation therapy External beam radiation therapy      Stereotactic radiosurgery (CyberKnife, Trilogy, Synergy) Stereotactic radiosurgery (CyberKnife, Trilogy, Synergy)      Intensity-modulated radiation therapySystemic Intensity-modulated radiation therapySystemic chemotherapyMultimodality approachchemotherapyMultimodality approach

Right hepatic lobestomyRight hepatic lobestomy

Left hepatic lobectomyLeft hepatic lobectomy

Gall BladderGall Bladder30-50cc30-50cc

300 cc distended300 cc distended

Triangle of CalotTriangle of Calot

Gall stonesGall stones

pigmentpigment

CholecystolithiasisCholecystolithiasis

CholecystitisCholecystitis

CholedocholithisisCholedocholithisis

CholangitisCholangitis

Courvosieur’sCourvosieur’s

PancreasPancreasPsuedocystsPsuedocysts

Periampullary lesionsPeriampullary lesions

Pancreatic carcinomaPancreatic carcinoma

Duodenal carcinomaDuodenal carcinoma

InsulinomasInsulinomas

Whipple’s triadWhipple’s triad

symptomatic symptomatic hypoglycemiahypoglycemia

glucose levels below50 glucose levels below50

relieved by glucoserelieved by glucose

Whipple’s procedureWhipple’s procedure

pancrearicoduodenectomypancrearicoduodenectomy

Serous cystadenomasSerous cystadenomas

SplenectomySplenectomyTraumaTrauma

Hematologic Hematologic

EXC: G6PDEXC: G6PD

hereditary elliptocytosishereditary elliptocytosis

stagingstaging

OSPIOSPI

- strep pneumoniae- strep pneumoniae

- hemophilus influenza- hemophilus influenza

- meningococcus- meningococcus

A 55 y/o man who is extremely obese A 55 y/o man who is extremely obese reports weakness, sweating, reports weakness, sweating, tachycardia, confusion and headache tachycardia, confusion and headache whenever he fast for more than a few whenever he fast for more than a few hours. He has prompt relief of hours. He has prompt relief of symptoms when he eats. These symptoms when he eats. These symptoms are most suggestive of which symptoms are most suggestive of which of the following disorders?of the following disorders?

A.A. Diabetes mellitusDiabetes mellitusB.B. InsulinomaInsulinomaC.C. Zollinger-Ellison syndromeZollinger-Ellison syndromeD.D. Carcinoid syndromeCarcinoid syndrome

Most likely cause of UGI bleeding in Most likely cause of UGI bleeding in patient with cirrhosis is:patient with cirrhosis is:

A.A. Acute erosive gastritisAcute erosive gastritisB.B. Bleeding esophageal varicesBleeding esophageal varicesC.C. Bleeding peptic ulcerBleeding peptic ulcerD.D. Zollinger-Ellison syndromeZollinger-Ellison syndrome

The following are causes of The following are causes of extrahepatic portal venous system extrahepatic portal venous system obstruction, EXCEPT:obstruction, EXCEPT:

A.A. InfectionInfectionB.B. TraumaTraumaC.C. TumorTumorD.D. SchistosomiasisSchistosomiasis

The most important tributary of the The most important tributary of the portal vein after it is formed by the portal vein after it is formed by the confluence of the superior confluence of the superior mesenteric and splenic veins is the: mesenteric and splenic veins is the:

A.A. Right gastric vein Right gastric vein B.B. Coronary vein Coronary vein C.C. Duodenal vein Duodenal vein D.D. Cystic vein Cystic vein

Two months after laparoscopic Two months after laparoscopic cholecystectomy, a patient is determined cholecystectomy, a patient is determined to have obstructive jaundice, secondary to to have obstructive jaundice, secondary to a 1.5 cm stone in the distal common bile a 1.5 cm stone in the distal common bile duct. The best approach to the removal duct. The best approach to the removal of this stone is:of this stone is:

A.A. Endoscopic papillotomy and Endoscopic papillotomy and extraction of the stoneextraction of the stone

B.B. Laparotomy and CBD exploration Laparotomy and CBD exploration C.C. Administration of oral bile acids Administration of oral bile acids D.D. Endoscopic introduction of litholytic Endoscopic introduction of litholytic

agents agents

The origin of the cystic artery is:The origin of the cystic artery is:

A.A. VariableVariable

B.B. Almost always from the right Almost always from the right hepatic artery hepatic artery

C.C. Frequently from the left hepatic Frequently from the left hepatic artery artery

D.D. Usually from the common Usually from the common hepatic artery hepatic artery

As a therapeutic modality, As a therapeutic modality, splenectomy might be indicated for a splenectomy might be indicated for a patient who had the following, EXCEPT:patient who had the following, EXCEPT:

A.A. Hereditary spherocytosisHereditary spherocytosis

B.B. Sickle cell anemiaSickle cell anemia

C.C. Idiopathic autoimmune hemolytic Idiopathic autoimmune hemolytic anemiaanemia

D.D. Glucose-6-phosphate deficiencyGlucose-6-phosphate deficiency

A liver function study in a jaundiced A liver function study in a jaundiced patient reveals conjugated patient reveals conjugated hyperbilirubinemia. All of the following hyperbilirubinemia. All of the following conditions should be considered in the conditions should be considered in the differential diagnosis, Except: differential diagnosis, Except:

A.A. CBD obstruction secondary to CBD obstruction secondary to choledocholithiasis choledocholithiasis

B.B. Periampullary carcinoma Periampullary carcinoma C.C. Hemolysis secondary to Hemolysis secondary to

spherocytosis spherocytosis D.D. Intrahepatic cholestasis without Intrahepatic cholestasis without

hepatocyte damage hepatocyte damage

A patient undergoing an ERCP A patient undergoing an ERCP (endoscopic retrograde (endoscopic retrograde pancreatogram) is noted to have a pancreatogram) is noted to have a pancreas divisum. What pancreas divisum. What consequence will arise because of consequence will arise because of this abnormality: this abnormality:

A.A. Pancreatic carcinoma Pancreatic carcinoma B.B. Acute pancreatitis Acute pancreatitis C.C. Biliary obstruction Biliary obstruction D.D. No pathology will necessarily No pathology will necessarily

developdevelop

Following a splenectomy in pediatric Following a splenectomy in pediatric patients, what is the most common patients, what is the most common etiologic agent in severe post-etiologic agent in severe post-splenectomy sepsis: splenectomy sepsis:

A.A. Streptococcus penumoniae Streptococcus penumoniae B.B. Staphylococcus aureus Staphylococcus aureus C.C. Group B hemolytic Group B hemolytic

streptococcus streptococcus D.D. Hemophilus ducreyiHemophilus ducreyi

A 50-year old known alcoholic and A 50-year old known alcoholic and cirrhotic man develops moderate cirrhotic man develops moderate ascites. How should he be treatedascites. How should he be treated::

A.A. Spironolactone and salt restriction Spironolactone and salt restriction B.B. Intermittent paracentesis Intermittent paracentesis

abdominis abdominis C.C. Use a peritoneo-venous shunt Use a peritoneo-venous shunt D.D. Porto-systemic shunting while his Porto-systemic shunting while his

risk status is goodrisk status is good

A post-operative t-tube chonagiogram done A post-operative t-tube chonagiogram done 12 days after cholectystectomy with 12 days after cholectystectomy with common bile duct exploration reveals a 0.5 common bile duct exploration reveals a 0.5 cm residual stone in the common bile duct. cm residual stone in the common bile duct. In this patient: In this patient:

A.A. Endoscopic papillotomy with stone Endoscopic papillotomy with stone retrieval is the best treatment retrieval is the best treatment

B.B. Litholytic agents should be instilled into Litholytic agents should be instilled into the CBD the CBD

C.C. Immediate reexploration should be Immediate reexploration should be done done

D.D. The stone can be removed through the The stone can be removed through the t- tube tract when the tract is mature t- tube tract when the tract is mature

A 30-year old woman who has undergone A 30-year old woman who has undergone appendectomy for ruptured appendicitis appendectomy for ruptured appendicitis develops upper abdominal pain and fever. develops upper abdominal pain and fever. A CT scan reveals a 6-cm complex mass A CT scan reveals a 6-cm complex mass in the infero-posterior aspect of segment in the infero-posterior aspect of segment 6 of the liver. How should she be treated:6 of the liver. How should she be treated:

A.A. Percutaneous aspiration alone Percutaneous aspiration alone B.B. Appropriate antibiotics Appropriate antibiotics C.C. Exploratory laparotomy and Exploratory laparotomy and

drainage drainage D.D. Antibiotics plus percutaneous Antibiotics plus percutaneous

aspiration aspiration

Several months after a laparoscopic Several months after a laparoscopic cholecystectomy for cholelithiasis, a 50-cholecystectomy for cholelithiasis, a 50-year old obese woman develops year old obese woman develops obstructive jaundice. In this patient:obstructive jaundice. In this patient:

A.A. If a common bile stone is diagnosed, If a common bile stone is diagnosed, a CBD exploration should be done a CBD exploration should be done

B.B. An ERCP should be performed An ERCP should be performed C.C. Bile duct ultrasonography is the best Bile duct ultrasonography is the best

diagnostic procedure diagnostic procedure D.D. Bile duct imaging should be Bile duct imaging should be

performed performed

The anatomical anomaly known as The anatomical anomaly known as pancreas divisum is associated with:pancreas divisum is associated with:

A.A. Wirsung’s duct does not drain into Wirsung’s duct does not drain into the ampulla of Vater the ampulla of Vater

B.B. An almost 100% incidence of An almost 100% incidence of pancreatitis pancreatitis

C.C. Santorini’s duct serves as the main Santorini’s duct serves as the main drainage channel for pancreatic drainage channel for pancreatic juicejuice

D.D. The presence of an annular pancreas The presence of an annular pancreas

A poor-risk 65-year old patient with A poor-risk 65-year old patient with obstructive jaundice secondary to obstructive jaundice secondary to pancreatic head carcinoma pancreatic head carcinoma associated with hepatic associated with hepatic insufficiency is best managed by: insufficiency is best managed by:

A.A. Choledocho-enterostomyCholedocho-enterostomyB.B. Cholecysto-enterostomyCholecysto-enterostomyC.C. Endoscopic bile-duct stentingEndoscopic bile-duct stentingD.D. Percutaneous trans-hepatic Percutaneous trans-hepatic

bile duct drainage bile duct drainage

Everything else being equal, of the Everything else being equal, of the periampullary carcinomas, the periampullary carcinomas, the poorest prognosis is associated with poorest prognosis is associated with carcinoma of the:carcinoma of the:

A.A. Body and tail of the pancreas Body and tail of the pancreas B.B. Distal common bile duct Distal common bile duct C.C. Head of the pancreas Head of the pancreas D.D. DuodenumDuodenum

Two months after an apparently straight Two months after an apparently straight forward/laparoscopic cholecystectomy, forward/laparoscopic cholecystectomy, the patient develops jaundice and highly the patient develops jaundice and highly colored urine. In this patient:colored urine. In this patient:

A.A. Both a liver function study and Both a liver function study and ERCP should be done ERCP should be done

B.B. A liver function study is indicated A liver function study is indicated C.C. A biliary imaging procedure should A biliary imaging procedure should

be done be done D.D. An ERCP is indicatedAn ERCP is indicated

Six months after blunt trauma to the Six months after blunt trauma to the abdomen which was managed non-abdomen which was managed non-operatively, a young man operatively, a young man complaining of vague upper complaining of vague upper abdominal discomfort is discovered abdominal discomfort is discovered to have a 10-cm cystic mass in the to have a 10-cm cystic mass in the spleen on ultrasonography. In this spleen on ultrasonography. In this patient: patient:

A.A. Marsupialization is a reasonable Marsupialization is a reasonable alternative to spelenctomy alternative to spelenctomy

B.B. Splenectomy should be done Splenectomy should be done C.C. Malignancy should be suspected Malignancy should be suspected D.D. Percutaneous aspiration of the Percutaneous aspiration of the

cyst is the best treatmentcyst is the best treatment

Two years after an uncomplicated, Two years after an uncomplicated, apparently straight forward laparoscopic apparently straight forward laparoscopic cholecystectomy, a 50-year old woman cholecystectomy, a 50-year old woman develops jaundice associated with upper develops jaundice associated with upper abdominal discomfort and pruritus. The abdominal discomfort and pruritus. The stools are described as pasty grayish. Which stools are described as pasty grayish. Which of the following procedures should be done: of the following procedures should be done:

A.A. ERCPERCPB.B. Ultrasound of the liver and biliary treeUltrasound of the liver and biliary tree C.C. Percutaneous transhepatic Percutaneous transhepatic

cholangiography cholangiography D.D. Bile duct imaging using a radioactive Bile duct imaging using a radioactive

tracertracer

Two weeks after penetrating Two weeks after penetrating abdominal trauma, in which repair of abdominal trauma, in which repair of a deep laceration of the right lobe of a deep laceration of the right lobe of the liver was done, a patient the liver was done, a patient develops fever, jaundice and GI develops fever, jaundice and GI bleeding. In this patient, the most bleeding. In this patient, the most useful diagnostic procedure is: useful diagnostic procedure is:

A.A. Selective arteriographySelective arteriography B.B. PTCPTCC.C. Upper GI endoscopy Upper GI endoscopy D.D. ERCP ERCP

A 72 year old female previously A 72 year old female previously diagnosed to have sigmoid diverticulitis diagnosed to have sigmoid diverticulitis now presents with tender now presents with tender hepatomegaly and fever. US of the hepatomegaly and fever. US of the liver showed multiple complex masses liver showed multiple complex masses in the ® lobe. The initial treatment of in the ® lobe. The initial treatment of choice is: choice is:

A.A. Parenteral antibiotics aloneParenteral antibiotics aloneB.B. Open surgical evacuation Open surgical evacuation C.C. Percutaneous aspiration Percutaneous aspiration D.D. Laparoscopic drainage Laparoscopic drainage

A 22 year old male sought consult A 22 year old male sought consult because of RUQ pain, fever, and because of RUQ pain, fever, and bloody diarrhea. At US of the liver bloody diarrhea. At US of the liver there was a solitary 10 cm complex there was a solitary 10 cm complex mass at the (L) lobe. The initial mass at the (L) lobe. The initial treatment of choice is: treatment of choice is:

A.A. Open surgical drainageOpen surgical drainageB.B. Percutaneous aspiration Percutaneous aspiration C.C. Antibiotic alone Antibiotic alone D.D. Laparoscopic drainage Laparoscopic drainage

The most important diagnostic tool The most important diagnostic tool for this 38 year old male from Samar for this 38 year old male from Samar with Schistosomiasis presenting with with Schistosomiasis presenting with massive splenomegaly w/o any other massive splenomegaly w/o any other clinical signs of portal hypertension is:clinical signs of portal hypertension is:

A.A. UGIEUGIEB.B. UGIS UGIS C.C. Splenoportography Splenoportography D.D. AortographyAortography

A 50 year old female who on A 50 year old female who on routine abdominal US for annual routine abdominal US for annual check up was found to have a 9 cm check up was found to have a 9 cm solitary hepatic cystic lesion at the solitary hepatic cystic lesion at the ® lobe. Treatment of choice is : ® lobe. Treatment of choice is :

A.A. Laparoscopic cystectomy Laparoscopic cystectomy B.B. Open surgical drainage Open surgical drainage C.C. Percutaneous US guided Percutaneous US guided

aspiration with sclerotherapyaspiration with sclerotherapyD.D. None of the aboveNone of the above

At CBDE, a tightly impacted distal At CBDE, a tightly impacted distal common duct stone could not be common duct stone could not be removed through a supraduodenal removed through a supraduodenal choledochotomy. Assuming that the choledochotomy. Assuming that the OR is not equipped with a OR is not equipped with a choledochoscope, the next procedure choledochoscope, the next procedure of choice is: of choice is:

A.A. Transduodenal sphinctorotomy Transduodenal sphinctorotomy with sphincteroplastywith sphincteroplasty

B.B. T-Tube drainage then T-Tube drainage then postoperative ERCP postoperative ERCP

C.C. Intraoperative ERCP Intraoperative ERCP D.D. Choledochoduodenostomy and Choledochoduodenostomy and

leave the stoneleave the stone

A 33 year old female presents with A 33 year old female presents with fever and jaundice, and ® upper fever and jaundice, and ® upper quadrant pain. At US, the GB was quadrant pain. At US, the GB was distended, with thickened wall but distended, with thickened wall but without evidence of calculus. Both without evidence of calculus. Both SGPT and SGOT are markedly SGPT and SGOT are markedly elevated. She is HbsAg reactive. elevated. She is HbsAg reactive. Treatment of choice:Treatment of choice:

A.A. Open cholecystectomy Open cholecystectomy B.B. Laparoscopic cholecystectomy Laparoscopic cholecystectomy C.C. Supportive medical therapy aloneSupportive medical therapy alone D.D. CholecystostomyCholecystostomy

After an elective cholecystectomy, After an elective cholecystectomy, the final histopathologic report of the final histopathologic report of the GB came in as a T2 the GB came in as a T2 adenocarcinoma at the fundus. adenocarcinoma at the fundus. The definitive therapy is:The definitive therapy is:

A.A. Hepatic resection Hepatic resection B.B. Already completed Already completed C.C. Cholecystectomy and postop Cholecystectomy and postop

chemotherapy chemotherapy D.D. Cholecystectomy and postop Cholecystectomy and postop

radiotherapyradiotherapy

A 37 year old male has postnecrotic A 37 year old male has postnecrotic cirrhosis and liver function of Child’s-cirrhosis and liver function of Child’s-Pugh Class C. He has relative in Hong Pugh Class C. He has relative in Hong kong who is offering the possibility of kong who is offering the possibility of liver transplant. But he bleed liver transplant. But he bleed profusely but was resuscitated. The profusely but was resuscitated. The best management option is:best management option is:

A.A. Non-shunt devascularization Non-shunt devascularization B.B. TIPS TIPS C.C. Medical supportive therapy alone Medical supportive therapy alone D.D. Porto-systemic shunting procedurePorto-systemic shunting procedure

A 44 year old female with no A 44 year old female with no previous abdominal surgery previous abdominal surgery presents with signs and symptoms presents with signs and symptoms of intestinal obstruction. Flat of intestinal obstruction. Flat plate showed aerobilia with plate showed aerobilia with multiple air-fluid levels. This is multiple air-fluid levels. This is most likely:most likely:

A.A. PPUD PPUD B.B. Gallstone ileus Gallstone ileus C.C. Perforated GI malignancy Perforated GI malignancy D.D. Biliary ascariasisBiliary ascariasis

Asymptomatic cholecystolithiasis Asymptomatic cholecystolithiasis is best managed by:is best managed by:

A.A. Observation alone Observation alone B.B. Open cholecystectomy Open cholecystectomy C.C. Laparoscopic Laparoscopic

cholecystectomy cholecystectomy D.D. ESWLESWL

Biliary ascariasis in cholangitis Biliary ascariasis in cholangitis without evidence of biliary calculi is without evidence of biliary calculi is best managed by:best managed by:

A.A. Open cholecystectomy with Open cholecystectomy with CBDECBDE

B.B. Antiparasitic drugs aloneAntiparasitic drugs alone

C.C. ERCP ERCP

D.D. ERCP followed by laparoscopic ERCP followed by laparoscopic cholecystectomy cholecystectomy

A 42 year old female sought consult for A 42 year old female sought consult for your opinion. A month ago she your opinion. A month ago she underwent ERCP for a successful underwent ERCP for a successful retrieval of what appears to be a retrieval of what appears to be a secondary common duct stone. She is secondary common duct stone. She is now scheduled though asymptomatic for now scheduled though asymptomatic for cholecystectomy. You will recommend:cholecystectomy. You will recommend:

A.A. Observation aloneObservation aloneB.B. Open cholecystectomyOpen cholecystectomyC.C. Laparoscopic cholecystectomy Laparoscopic cholecystectomy D.D. Additional work upAdditional work up

What is the most likely etiologic diagnosis What is the most likely etiologic diagnosis in this 67 year old male presenting with in this 67 year old male presenting with significant weight loss accompanied by significant weight loss accompanied by progressive jaundice, anorexia, tea-progressive jaundice, anorexia, tea-colored urine and who at PE has a colored urine and who at PE has a palpable slightly tender GB and a smooth palpable slightly tender GB and a smooth liver:liver:

A.A. Acute cholecystitisAcute cholecystitisB.B. HepatomaHepatomaC.C. Pancreatic head tumor Pancreatic head tumor D.D. Cirrhosis of the liverCirrhosis of the liver

In order to confirm your clinical In order to confirm your clinical impression in the above case your impression in the above case your initial work up is:initial work up is:

A.A. Upper abdominal USUpper abdominal USB.B. Upper abdominal CT-ScanUpper abdominal CT-ScanC.C. Upper GI endoscopy Upper GI endoscopy D.D. Upper GI seriesUpper GI series

In order to plan the appropriate In order to plan the appropriate therapy, assess the extent of disease, therapy, assess the extent of disease, and prognosticate probable outcome, and prognosticate probable outcome, the following can be done:the following can be done:

A.A. LaparoscopyLaparoscopyB.B. Abdominal CT-ScanAbdominal CT-ScanC.C. Exploratory laparotomy Exploratory laparotomy D.D. AllAll

Eight months after an acute episode of Eight months after an acute episode of pancreatitis, this 54 year old female pancreatitis, this 54 year old female presented with a virtually presented with a virtually asymptomatic, gradually expanding, asymptomatic, gradually expanding, firm, nodular mass at the LUQ. The firm, nodular mass at the LUQ. The interval history was unremarkable save interval history was unremarkable save for intermittently recurring epigastric for intermittently recurring epigastric discomfort. Your clinical impression for discomfort. Your clinical impression for the case is:the case is:

A.A. Ampullary cholangiocarcinoma Ampullary cholangiocarcinoma B.B. Pancreatic CAPancreatic CAC.C. True pancreatic cyst True pancreatic cyst D.D. Pseudocyst of the pancreasPseudocyst of the pancreas

From the above-given data, where From the above-given data, where do you think is the location of the do you think is the location of the lesion?:lesion?:

A.A. Head Head B.B. BodyBodyC.C. Neck Neck D.D. TailTailE.E. None of the aboveNone of the above

Assuming that the patient with the Assuming that the patient with the above lesion does not present with above lesion does not present with signs of infection and the size of the signs of infection and the size of the lesion is about 10 cm, the lesion is about 10 cm, the recommended treatment is:recommended treatment is:

A.A. Internal drainage Internal drainage B.B. Percutaneous drainagePercutaneous drainageC.C. External drainage External drainage D.D. Observation aloneObservation alone

The severe, progressive and continuous, The severe, progressive and continuous, abdominal pain that radiates at the back abdominal pain that radiates at the back accompanied by vomiting of this healthy accompanied by vomiting of this healthy 38 year old who, does not drink alcohol 38 year old who, does not drink alcohol nor a diabetic may be due to:nor a diabetic may be due to:

A.A. PUD PUD B.B. Acute cholecystitisAcute cholecystitisC.C. Acute pancreatitis Acute pancreatitis D.D. Any of the above Any of the above

Indication/s for surgical intervention Indication/s for surgical intervention in cases of pancreatitis:in cases of pancreatitis:

A.A. Necrotizing complicationsNecrotizing complicationsB.B. Acute hemorrhagic Acute hemorrhagic

complicationscomplicationsC.C. Infected pancreatic necrosis Infected pancreatic necrosis D.D. AllAll

The most common cause/s of death The most common cause/s of death among patients with complications of among patients with complications of pancreatitis is/are:pancreatitis is/are:

A.A. Acute Renal Failure (ARF)Acute Renal Failure (ARF)B.B. Acute Respiratory Distress Acute Respiratory Distress

Syndrome (ARDS)Syndrome (ARDS)C.C. Acute Compartment Syndrome Acute Compartment Syndrome

(ACS) (ACS) D.D. A and BA and B

Non surgical therapy of simple Non surgical therapy of simple pancreatitis consist of:pancreatitis consist of:

A.A. Adequate pain controlAdequate pain controlB.B. Resuscitation and maintenance of Resuscitation and maintenance of

fluid and electrolyte balancefluid and electrolyte balanceC.C. Rest of the exocrine function of Rest of the exocrine function of

the pancreas the pancreas D.D. AllAll

Sudden hematemesis of a 38 year Sudden hematemesis of a 38 year old male presenting with jaundice, old male presenting with jaundice, RUQ pain and fever, your primary RUQ pain and fever, your primary consideration is: consideration is:

A.A. Bleeding from an upper GI Bleeding from an upper GI tumor tumor

B.B. Peptic ulcer disease Peptic ulcer disease C.C. Hemobilia Hemobilia D.D. Deulafouy Deulafouy

One week after a blunt abdominal One week after a blunt abdominal trauma, this 26 y/o male vomited fresh trauma, this 26 y/o male vomited fresh blood. But at UGI endoscopy the blood. But at UGI endoscopy the esophagus, stomach, and duodenum esophagus, stomach, and duodenum appeared normal. The most likely appeared normal. The most likely source of blood is: source of blood is:

A.A. JejunumJejunumB.B. Biliary treeBiliary treeC.C. Liver Liver D.D. PancreasPancreas

A 55 year old asymptomatic male A 55 year old asymptomatic male presents with a solitary, solid 5 cm presents with a solitary, solid 5 cm mass at the ® lobe of the liver. mass at the ® lobe of the liver. He most likely has: He most likely has:

A.A. Amoebic abscess Amoebic abscess B.B. Metastatic malignancyMetastatic malignancyC.C. Hepatocellular carcinoma Hepatocellular carcinoma D.D. Liver adenoma Liver adenoma

The single most important The single most important diagnostic test for a solid, 4 cm, diagnostic test for a solid, 4 cm, single liver mass at the ® lobe is: single liver mass at the ® lobe is:

A.A. CT-Scan CT-Scan B.B. FNABFNABC.C. Serum CEASerum CEAD.D. Serum AFP Serum AFP

Given a 7 cm solitary, hypoechoic Given a 7 cm solitary, hypoechoic mass at the (L) lobe of the liver, mass at the (L) lobe of the liver, assuming availabilityof full diagnostic assuming availabilityof full diagnostic complement, your next step towards complement, your next step towards the management of this 54 year old the management of this 54 year old male is:male is:

A.A. FNABFNABB.B. Abdominal CT-ScanAbdominal CT-ScanC.C. Surgical resectionSurgical resectionD.D. AngiographyAngiography

A 45 year old female who on A 45 year old female who on routine company check up was routine company check up was found to have cholecystolithiasis found to have cholecystolithiasis by US. You will recommend: by US. You will recommend:

A.A. Laporatomy cholecystectomyLaporatomy cholecystectomy

B.B. Observation aloneObservation alone

C.C. Open cholecystectomyOpen cholecystectomy

D.D. ESWLESWL

Obstructive biliary tract disease in Obstructive biliary tract disease in an otherwise healthy 30 year old an otherwise healthy 30 year old male is most likely due to: male is most likely due to:

A.A. CholangiocarcinomaCholangiocarcinomaB.B. CholedocholithiasisCholedocholithiasisC.C. Early ampulalary malignancyEarly ampulalary malignancyD.D. Hepatobiliary TBHepatobiliary TB

Curative treatment for a 6cm solid, Curative treatment for a 6cm solid, solitary liver mass with serum AFP solitary liver mass with serum AFP level of 600 IU/ml is: level of 600 IU/ml is:

A.A. Hepatic resectionHepatic resectionB.B. Alcohol injectionAlcohol injectionC.C. Radiofrequency therapyRadiofrequency therapyD.D. ChemoembolizationChemoembolization

Extrahepatic biliary duct obstruction Extrahepatic biliary duct obstruction by US with curvousier’s GB in a 62 by US with curvousier’s GB in a 62 y/o jaundiced (but not in cholangitis) y/o jaundiced (but not in cholangitis) female clinically means: female clinically means:

A.A. Periampullary malignancyPeriampullary malignancyB.B. Distal CBD stonesDistal CBD stonesC.C. Biliary ascariasisBiliary ascariasisD.D. Hepatobiliary TBHepatobiliary TB

Progressive jaundice in a Progressive jaundice in a hyposthenic patient with untreated hyposthenic patient with untreated pulmonary tuberculosis presenting pulmonary tuberculosis presenting with RUQ colicky pain, intermittent with RUQ colicky pain, intermittent low grade fever with chills and by US low grade fever with chills and by US showed multiple hepatic showed multiple hepatic calcifications is: calcifications is:

A.A. Pyogenic liver abscessPyogenic liver abscessB.B. Hepatobiliary TBHepatobiliary TBC.C. Metastatic liver malignancyMetastatic liver malignancyD.D. Biliary ascariasisBiliary ascariasis

The procedure of choice for The procedure of choice for extrahepatic biliary obstruction extrahepatic biliary obstruction suspected of hepatobiliary TB is: suspected of hepatobiliary TB is:

A.A. PTCPTCB.B. ERCPERCPC.C. TIPSTIPSD.D. FNAB of hepatic calcificationsFNAB of hepatic calcifications

At cholangiogram the typical image At cholangiogram the typical image HB Tuberculosis will make is: HB Tuberculosis will make is:

A.A. Fusiform CBD dilatationFusiform CBD dilatationB.B. Rosary-bead ductal deformityRosary-bead ductal deformityC.C. An elongated-luminal-tubular An elongated-luminal-tubular

structure w/in the CBD structure w/in the CBDD.D. Multiple radioluscent filling Multiple radioluscent filling

defects along the ducts defects along the ducts

Upper GI bleeding on the background of Upper GI bleeding on the background of stigmata of liver cirrhosis, HbsAg stigmata of liver cirrhosis, HbsAg reactive, and splenomegaly, clinically reactive, and splenomegaly, clinically means: means:

A.A. Hepatoma with hemobiliaHepatoma with hemobiliaB.B. Variceal bleeding due to portal Variceal bleeding due to portal

hypertensionhypertensionC.C. Complicated primary hypersplenismComplicated primary hypersplenismD.D. Acute erosive gastritis Acute erosive gastritis

For this 48 y/o male who possesses the For this 48 y/o male who possesses the above-mentioned clinical picture and who above-mentioned clinical picture and who is not in hypovolemic shock, the first line is not in hypovolemic shock, the first line of treatment: of treatment:

A.A. Emergency shunting procedureEmergency shunting procedureB.B. Endoscopic sclerotherapy or Endoscopic sclerotherapy or

bandingbandingC.C. Supportive therapy alone Supportive therapy alone D.D. Emergency devascularization Emergency devascularization

procedure procedure

If the variceal bleeding is controlled or If the variceal bleeding is controlled or spontaneously stopped your spontaneously stopped your recommended definitive treatment is: recommended definitive treatment is:

A.A. Elective shunting procedureElective shunting procedureB.B. Propanolol therapy with serial Propanolol therapy with serial

endoscopic sclerotherapyendoscopic sclerotherapyC.C. Elective devascularization Elective devascularization

surgery surgery D.D. Liver transplantation Liver transplantation

High grade fever preceded by High grade fever preceded by alternating constipation & diarrhea 1-alternating constipation & diarrhea 1-2 weeks ago now presenting with 2 weeks ago now presenting with tender hepatomegaly in a 23 y/o tender hepatomegaly in a 23 y/o male is most likely due to: male is most likely due to:

A.A. Amoebic abscess Amoebic abscess B.B. Pyogenic abscessPyogenic abscessC.C. Biliary TB Biliary TB D.D. Biliary ascariasis Biliary ascariasis

Acutely excruciating, colicky RUQ Acutely excruciating, colicky RUQ pain with cholangitis in a 15 y/o pain with cholangitis in a 15 y/o male who did not show any stone male who did not show any stone in the biliary tree by US require an in the biliary tree by US require an immediate: immediate:

A.A. ERCP ERCP B.B. PTCPTCC.C. CT-Scan CT-Scan D.D. MRI MRI

In the absence of a history of In the absence of a history of abdominal trauma, repeated abdominal trauma, repeated hemobilia in a 70 y/o female with a hemobilia in a 70 y/o female with a negative abdominal US merits negative abdominal US merits a/an: a/an:

A.A. Contrast CT-Scan Contrast CT-Scan B.B. ERCPERCPC.C. MRI-ANGIO MRI-ANGIO D.D. Selective angiographySelective angiography