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WorksheetsBiliary Neoplasms and Jaundice
Total questions: 15
Worksheet time: 15mins
42yoF presents 1 month after lap chole with RUQ pain, jaundice. T 39.4ºC, HR 105 bpm, BP 90/60. WBC 16.2, ALP 240, total bilirubin 5.5 mg/dL, Cr 2.2. Which of the following classifies her as severe (grade III) cholangitis?
White blood count greater than 12,000/µL
Temperature greater than 39ºC
Total bilirubin greater than 5 mg/dL
Alkaline phosphatase greater than 200 IU/L
Creatinine greater than 2 mg/dL
38yo Mexican American man with BMI 24.6 presents with abdominal pain. US shows a 2-cm stone lodged in his gallbladder neck, wall thickening, and pericholecystic fluid. He undergoes a lap chole. The path shows a 1.2-cm polyp with a focus of adenocarcinoma. Which of the following patient factors increase his risk of gallbladder cancer?
Male Gender
Ethnic Background
BMI
Gallstone Size
65yoM with DM, HLD, and CAD with stents presents with painless jaundice, weight loss, and vomiting for 1 month. He is found to have a mass in the lower CBD with a 3-cm lesion in segment VI and partial duodenal obstruction. Which of the following is the most appropriate next step?
Gastrojejunostomy
Pancreatoduodenectomy with wedge resection
Endoscopic duodenal stenting and consideration of later biliary decompression if the jaundice causes symptoms
PTC with drainage
ERCP with CBD stenting
55yoM has a lap chole. On a postop visit, path shows an adenocarcinoma invading the perimuscular connective tissue. Cystic duct margin is negative. Staging reveals no nodal or metastatic spread. What is the next step?
No further treatment necessary
Adjuvant chemotherapy
En bloc resection of segments IVb and V with portal lymphadenectomy
Resection of the gallbladder bed with negative margins
55yoM undergoes lap chole, path report shows a gallbladder adenocarcinoma invading the perimuscular connective tissue. What is the tumor stage?
Tis
T1
T2
T3
T4
75yoM has new-onset jaundice and pruritus x several weeks + unintentional weight. Abd US reveals dilated intrahepatic biliary ducts. Total bilirubin is 7 mg/dL with a direct of 5 mg/dL. What is the best next step?
Repeat ultrasound
CT of the abdomen with oral contrast only
Hepatobiliary iminodiacetic acid (HIDA) scan
CT of the chest
MRI of the abdomen with gadolinium
68yoM presents with a 4 weeks of worsening jaundice, pruritus, and dark urine. No fever or leukocytosis. RUQ US shows intra- and extrahepatic biliary ductal dilation. MRI demonstrates a focal enhancing stricture of the common hepatic duct, but no choledocholithiasis, lymphadenopathy, vascular invasion, or pancreatic mass. What is the best next step?
ERCP with brush cytology and stent placement
Multiphase liver CT and tumor markers
MRI–guided biopsy of the strictured segment
CT of the chest and tumor markers to complete staging followed by surgery
Percutaneous transhepatic cholangiography with biliary drainage
68yoF is diagnosed with a hilar cholangiocarcinoma (Bismuth Type I). Preop imaging has ruled out evidence of mets. Diagnostic lap reveals no peritoneal spread, so you proceed with resection. You perform a cholecystectomy and transect the common bile duct. What is the next series of steps?
Resect tumor proximally to negative margins, perform right hepatectomy, and reconstruct with Roux-en-Y hepaticojejunostomy.
Resect tumor proximally to negative margins and perform a pancreaticoduodenectomy.
Resect tumor proximally to negative margins, reconstruct with Roux-en-Y hepaticojejunostomy.
Resect tumor proximally to negative margins; and perform cholecystojejunostomy
Resect tumor proximally to negative margins; and reconstruct with choledochoduodenostomy.
75yoF with Child's B cirrhosis presents with painless jaundice and elevated bilirubin to 15. Imaging shows a mass in the distal CBD concerning for cholangiocarcinoma. After a full staging workup, the woman undergoes diagnostic lap and peritoneal mets are found. What is the next best step in treatment?
Whipple procedure for palliation
Whipple procedure followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with curative intent
Choledochotomy and placement of a stent for palliation
En bloc resection of the distal common bile duct with choledochoduodenostomy
Aborting the procedure and arranging for ERCP with stent placement, followed by discussion of systemic therapy options
You are performing a resection of a distal cholangiocarcinoma in a patient with known atherosclerosis and history of gastric bypass. After mobilizing the duodenum (Kocher maneuver) and exposing the pancreas, you realize that the tumor completely encases the superior mesenteric artery, superior mesenteric vein, and portal vein. What is the best next step?
Close the abdomen and place an implanted port for anticipated systemic therapy.
Perform a palliative, diverting hepaticojejunostomy
Consult a vascular specialist for intraoperative assistance with vascular reconstruction
Perform a side-to-side choledochoduodenostomy.
22yoF, asymptomatic, US showed 3mm polyp in gallbladder. What should you recommend?
follow up US in 6 months
EUS
CA19-9 and CA-125
ERCP
lap cholecystectomy
What is the first-line therapeutic option of choice for a partial (not circumferential) distal bile duct injury identified 48 hours after surgery?
Roux-en-Y hepaticojejunostomy
Choledochoduodenostomy
Primary repair of the injury over a T tube
Resection and end-to-end bile duct anastomosis
Endoscopic placement of a covered bile duct stent across the injury
Following uneventful laparoscopic cholecystectomy, the final pathology shows a T1a adenocarcinoma in the wall of the gallbladder opposite to the gallbladder fossa wall. Definitive surgical treatment includes
resection of a 2 cm rim of liver around the gallbladder fossa and a portal lymphadenectomy
hepatectomy including segments 4b and 5 and portal lymphadenectomy
portal lymphadenectomy alone
no additional therapy
radiation therapy to the gallbladder fossa and portal triad
Which of the following ultrasound findings best describe cholesterolosis of the gallbladder?
A single 13-mm hyperechoic, non-shadowing, polyp
A 10-mm mural mass with solid and cystic features
Hypoechoic, sessile, non-shadowing polyp
Multiple, hyperechoic, pedunculated, non-shadowing, non-mobile 4-mm masses
Multiple, hyperechoic, non-mobile 5-mm masses with posterior shadowing
When performing a choledochotomy during a laparoscopic or open bile duct exploration, how should the incision be made?
Transversely, above the insertion of the cystic duct
Transversely, below the insertion of the cystic duct
Longitudinally, above the insertion of the cystic duct
Longitudinally, below the insertion of the cystic duct
Transversely if above the insertion of the cystic duct and longitudinally if below the insertion of the cystic duct
