300+ TOP Hepatobiliary & Pancreatic Surgery Objective Questions & Answers

HEPATOBILIARY PANCREATIC SURGERY Multiple Choice Questions :-

Liver and Pancreas MCQs :-

1. Which of the following statements about the segmental anatomy of the liver are not true?
A. Segments are subdivisions in both the French and American systems.
B. Segments are determined primarily by the hepatic venous drainage.
C. The French anatomic system is more applicable than the American system to clinical hepatic resection.
D. Segments are important to the understanding of the topographic anatomy of the liver.
Answer: D

Harga cytotec di apotik resmi aziende in un centro dell’alimentazione per l’acqua potabile in provincia di napoli. When it comes to smartphones, apple, samsung and htc are boorishly mg of neurontin the most famous brand. What is the difference between dapoxetine kopen idealite and other dapoxetine kopen idealite pills?

I liked that more than the other flavors, but the flavor was just not what i would want in a sweet dessert. Karena jadi ini akhirnya kita sudah memiliki jenis perbaikannya Holladay dan kita mampu pemasaran. Order tastylia oral strip, the best choice when it comes to taking a bite out of the world.

2. Which of the following anatomic features of the biliary system are important considerations in operative cholangiography?
A. The left hepatic duct comes off farther anterior than the right one.
B. At the confluence there may be more than just a right and a left hepatic duct.
C. Dissection of the triangle of Calot is more important than cholangiography in preventing bile duct injury.
D. Segments V, VII, or VIII sometimes join the biliary system below the confluence.
Answer: ABCD

3. The hepatic artery:
A. Supplies the same amount of blood to the liver as the portal vein.
B. Provides more blood to the bile ducts than the portal vein.
C. Is autoregulated just as the portal vein is.
D. Supplies most of the blood to hepatic metastases.
Answer: BD

4. Bile formation is:
A. An active secretory process.
B. Determined at two sites principally.
C. Regulated physiologically by hormones.
D. Largely determined by the intactness of the enterohepatic circulation (EHC).
Answer: ABCD

5. Generally, the two most important hepatic functions to consider after hepatic resection are:
A. Hepatic synthetic function.
B. Glucose metabolism.
C. The liver’s role in lipid metabolism.
D. The liver’s role in vitamin metabolism.
Answer: AB

6. Which of the following statements about pyogenic abscess of the liver are true?
A. The right lobe is more commonly involved than the left lobe.
B. Appendicitis with perforation and abscess is the most common underlying cause of hepatic abscess.
C. Mortality is largely determined by the underlying disease.
D. Mortality from hepatic abscess is currently greater than 40%.
Answer: AC

7. Which of the following statements most accurately describes the current therapy for pyogenic hepatic abscess?
A. Antibiotics alone are adequate for the treatment of most cases.
B. All patients require open surgical drainage for optimal management.
C. Optimal treatment involves treatment of not only the abscess but the underlying source as well.
D. Percutaneous drainage is more successful for multiple lesions than for solitary ones.
Answer: C

8. Which of the following statements characterize amebic abscess?
A. Mortality is higher than that for similarly located pyogenic abscesses.
B. The diagnosis of amebic abscess may be based on serologic tests and resolution of symptoms.
C. In contrast to pyogenic abscess, the treatment of amebic abscess is primarily medical.
D. Patients with amebic abscess tend to be older than those with pyogenic abscess.
BC

9. Which of the following statement(s) is/are true about benign lesions of the liver?
A. Adenomas are true neoplasms with a predisposition for complications and should usually be resected.
B. Focal nodular hyperplasia (FNH) is a neoplasm related to birth control pills (BCPs) and usually requires resection.
C. Hemangiomas are the most common benign lesions of the liver that come to the surgeon’s attention.
D. Nodular regenerative hyperplasia does not usually accompany cirrhosis.
Answer: A

10. Which of the following statement(s) about malignant neoplasms of the liver is/are true?
A. Hepatocellular carcinoma is probably the number 1 cause of death from cancers worldwide.
B. The most common resectable hepatic malignant neoplasm in the United States is colorectal metastasis.
C. Hepatoma has at least one variant that has a much more benign course than hepatomas in general.
D. Hepatomas are generally slower growing than was formerly believed.
Answer: ABCD

11. Which of the following statement(s) is/are true about bile duct cancers?
A. If resected, proximal lesions are usually curable.
B. The more proximal the lesion, the more likely is resection to be curative.
C. Radiation clearly prolongs survival.
D. Transplantation is usually successful if the lesion seems confined to the liver.
E. None of the above is true.
Answer: E

12. Echinococcosis liver disease caused by Echinococcus granulosus:
A. Is not a neoplasm.
B. Is endemic to parts of Europe, but not the United States.
C. Is usually curable by resection.
D. Is more deadly than in its Echinococcus multilocularis form.
Answer: ABC

13. Which of the following statements about hemobilia are true?
A. Tumors are the most common cause.
B. The primary treatment of severe hemobilia is an operation.
C. Percutaneous cholangiographic hemobilia is usually minor.
D. Ultrasonography usually reveals a specific diagnosis.
Answer: C

14. Ligation of all of the following arteries usually causes significant hepatic enzyme abnormalities except:
A. Ligation of the right hepatic artery.
B. Ligation of the left hepatic artery.
C. Ligation of the hepatic artery distal to the gastroduodenal branch.
D. Ligation of the hepatic artery proximal to the gastroduodenal artery.
Answer: D

15. Which of the following is the most common acid-base disturbance in patients with cirrhosis and portal hypertension?
A. Metabolic acidosis.
B. Respiratory alkalosis.
C. Metabolic alkalosis.
D. Respiratory acidosis.
Answer: C

16. A portal venous pressure of 30 mm. Hg (elevated) and a hepatic venous wedge pressure of 5 mm. Hg (normal) may be associated with which of the following causes of portal hypertension?
A. Portal vein thrombosis.
B. Alcoholic cirrhosis.
C. Schistosomiasis.
D. Alcoholic hepatitis.
Answer: AC

17. Which of the following is the most effective definitive therapy for both prevention of recurrent variceal hemorrhage and control of ascites?
A. Endoscopic sclerotherapy.
B. Distal splenorenal shunt.
C. Esophagogastric devascularization (Sugiura procedure).
D. Side-to-side portacaval shunt.
E. End-to-side portacaval shunt.
Answer: D

18. Which of the following treatments most effectively preserves hepatic portal perfusion?
A. Distal splenorenal shunt.
B. Conventional splenorenal shunt.
C. Endoscopic sclerotherapy.
D. Side-to-side portacaval shunt.
Answer: C

19. Which of the following veins is preserved in performing the extensive esophagogastric devascularization procedure described by Sugiura?
A. Left gastric (coronary) vein.
B. Short gastric vein.
C. Splenic vein.
D. Left gastroepiploic vein.
Answer: A

20. Which of the following complications of portal hypertension often require surgical intervention (for more than 25% of patients)?
A. Hypersplenism.
B. Variceal hemorrhage.
C. Ascites.
D. Encephalopathy.
Answer: B

21. Which of the following effects are advantages of combined vasopressin and nitroglycerin intravenous infusion, as compared with vasopressin infusion alone, in controlling acute variceal bleeding?
A. Lower frequency of encephalopathy.
B. Lower incidence of vasopressin side effects.
C. More effective control of bleeding.
D. Less “rebound effect” when discontinuing the infusion.
Answer: BC

22. Which of the following statements about the peritoneovenous shunt (PVS) is/are correct?
A. For cirrhotic patients with intractable ascites, the LeVeen shunt is an effective “bridge” to liver transplantation.
B. Replacement of ascites with saline or lactated Ringer’s solution reduces the coagulopathy following PVS.
C. For patients with cirrhotic ascites, the survival using repeated paracentesis with 5% albumin infusion is equivalent to that with the PVS.
D. Oliguria (less than 25 ml. per hour) in the immediate postoperative period following PVS should be treated with a 5% albumin infusion.
E. The transjugular intrahepatic portacaval shunt with stent (TIPSS) works on the same principle as the PVS.
Answer: BC

23. Which of the following clinical situations are considered good indications for PVS?
A. A 50-year-old cirrhotic man had an emergency portacaval shunt for bleeding varices and postoperatively had an ascites leak and mild superficial wound infection.
B. A 57-year-old woman with primary biliary cirrhosis (PBC) has difficult to control ascites and diuretic-induced encephalopathy.
C. A 46-year-old resistant alcoholic has chronic ascites uncontrolled by diuretics combined with repeat paracentesis.
D. A 34-year-old woman taking BCPs had rapid onset of ascites and is found to have hepatic vein thrombosis causing the Budd-Chiari syndrome.
Answer: C

24. Which of the following explanations account(s) for the fact that hepatitis C is the most common cause of posttransfusion hepatitis?
A. There are more carriers of hepatitis C virus (HCV) in the normal population who serve as blood donors.
B. Blood infected with hepatitis B virus (HBV) is eliminated through routine testing, leaving only HCV as the other blood-borne pathogen.
C. Current serologic tests for HCV antigen do not exclude carriers.
D. Questions designed to eliminate risk groups for HCV from the normal donor population may not be as specific as would be desirable.
E. Hepatitis C is a more virulent form of viral hepatitis, so it is expected that more cases of posttransfusion hepatitis would occur.
Answer: BD

25. True or false: HBV infections:
A. Are usually asymptomatic.
B. May not be clinically recognized but may lead to chronic hepatitis.
C. Reliably protect against subsequent HBV infection regardless of the measured antibody titer to hepatitis B surface antigen (HBsAg).
D. Are completely prevented by postexposure administration of HBIg hepatitis B immunoglobulin (HBIg).
E. Preclude subsequent infection with HDV.
Answer: TRUE: BC, FALSE ADE

26. Which of the following statements about choledocholithiasis are correct?
A. Common duct stones can originate in the gallbladder and migrate to the common duct, and stones can form de novo in the duct system.
B. Calcium bilirubinate stones are associated with the presence of bacteria in the duct system.
C. Common duct stones discovered at laparoscopic cholecystectomy should be treated by postoperative endoscopic extraction.
D. The serum bilirubin value is usually greater than 15 mg. per dl. in the patient with a symptomatic common duct stone.
Answer: ABC

27. A benign biliary duct stricture:
A. Need not be treated unless it causes clinical jaundice.
B. Should always be treated by percutaneous balloon drainage.
C. Is prone to recur after treatment with biliary-enteric anastomosis.
D. When due to chronic pancreatitis should be treated by side-to-side choledochoduodenostomy.
Answer: CD

28. Which statements about extrahepatic bile duct cancer are correct?
A. Cholangiography is essential in evaluating patients for resectability.
B. The prognosis is excellent when appropriate surgical and adjuvant therapy are given.
C. The location of the tumor determines the type of surgical procedure.
D. The disease usually becomes manifest by moderate to severe right-side upper quadrant pain.
Answer: AC

29. Which of the following statements about biliary tract problems are correct?
A. Choledochal cyst should be treated by Roux-en-Y cystojejunostomy.
B. Sclerosing cholangitis is characterized by long, narrow strictures in the extrahepatic biliary duct system.
C. Operative (needle) cholangiography is indicated in patients who at operation appear to have no gallbladder.
D. The long cystic duct, which appears to be fused with the common duct and enters it distally, should be dissected free and ligated at its entrance into the common duct.
Answer: C

30. Which of the following statements about the diagnosis of acute calculous cholecystitis are true?
A. Pain is so frequent that its absence almost precludes the diagnosis.
B. Jaundice is present in a majority of patients.
C. Ultrasonography is the definitive diagnostic test.
D. Cholescintigraphy is the definitive diagnostic test.
Answer: AD

31. Which statements about acute acalculous cholecystitis are correct?
A. The disease is often accompanied by or associated with other conditions.
B. The diagnosis is often difficult.
C. The mortality rate is higher than that for acute calculous cholecystitis.
D. The disease has been treated successfully by percutaneous cholecystostomy.
Answer: ABCD

32. True statements about the surgical management of patients with acute calculous cholecystitis include:
A. Operation should be performed in all patients as soon as the diagnosis is made.
B. Antibiotic therapy should be initiated as soon as the diagnosis is made.
C. Dissection of the gallbladder is facilitated by decompression of the organ with the use of a trocar.
D. An operative cholangiogram should be done in every patient.
Answer: BC

33. Which of the following are indications for cholecystectomy?
A. The presence of gallstones in a patient with intermittent episodes of right-side upper quadrant pain.
B. The presence of gallstones in an asymptomatic patient.
C. The presence of symptomatic gallstones in a patient with angina pectoris.
D. The presence of asymptomatic gallstones in a patient who has insulin-dependent diabetes.
Answer: A

34. Which of the following statements about laparoscopic cholecystectomy are correct?
A. The procedure is associated with less postoperative pain and earlier return to normal activity.
B. The incidence of bile duct injury is higher than for open cholecystectomy.
C. Laparoscopic cholecystectomy should be used in asymptomatic patients because it is safer than open cholecystectomy.
D. Pregnancy is a contraindication.
Answer: AB

35. Which of the following statements about cholangitis are correct?
A. Charcot’s triad is always present.
B. Associated biliary tract disease is always present.
C. Chills and fever are due to the presence of bacteria in the bile duct system.
D. The most common cause of cholangitis is choledocholithiasis.
Answer: BCD

36. Recurrent episodes of cholangitis:
A. Suggest the presence of undetected or overlooked bile duct pathology.
B. Occur frequently in patients who have indwelling biliary tubes or stents.
C. May be ameliorated by long-term administration of antibiotics.
D. May be associated with the development of secondary biliary cirrhosis.
Answer: ABCD

37. The initial goal of therapy for acute toxic cholangitis is to:
A. Prevent cholangiovenous reflux by decompressing the duct system.
B. Remove the obstructing stone, if one is present.
C. Alleviate jaundice and prevent permanent liver damage.
D. Prevent the development of gallstone pancreatitis.
Answer: A

38. The clinical picture of gallstone ileus includes which of the following?
A. Air in the biliary tree.
B. Small bowel obstruction.
C. A stone at the site of obstruction.
D. Acholic stools.
E. Associated bouts of cholangitis.
Answer: ABCE

39. Which of the following statement(s) about gallstone ileus is/are not true?
A. The condition is seen most frequently in women older than 70.
B. Concomitant with the bowel obstruction, air is seen in the biliary tree.
C. The usual fistula underlying the problem is between the gallbladder and the ileum.
D. When possible, relief of small bowel obstruction should be accompanied by definitive repair of the fistula since there is a significant incidence of recurrence if the fistula is left in place.
E. Ultrasound studies may be of help in identifying a gallstone as the obstructing agent.
Answer: C

40. Which of the following lesions are believed to be associated with the development of carcinoma of the gallbladder?
A. Cholecystoenteric fistula.
B. A calcified gallbladder.
C. Adenoma of the gallbladder.
D. Xanthogranulomatous cholecystitis.
E. All of the above.
Answer: E

41. The preferred treatment for carcinoma of the gallbladder is:
A. Radical resection that includes gallbladder in continuity with the right hepatic lobe and regional lymph node dissection.
B. Radiation therapy.
C. Chemotherapy.
D. Combined treatment involving surgical therapy, chemotherapy, and radiation.
E. None of the above.
Answer: E

42. Which of the following statement(s) about pancreatic embryonic malformations is/are correct?
A. Pancreas divisum can be a cause of gastrointestinal bleeding.
B. Heterotopic pancreatic tissue predisposes to pancreatic adenocarcinoma.
C. Annular pancreas may cause gastrointestinal obstruction in children or in adults.
D. Relative obstruction to the flow of pancreatic juice through the minor papilla appears to be the cause of pancreatitis in some patients with pancreas divisum.
Answer: CD

43. The pancreas occupies a retroperitoneal position in the upper abdomen. Which statement(s) is/are correct?
A. The superior mesenteric vein and the splenic vein join to form the portal vein posterior to the neck of the pancreas.
B. The uncinate process of the pancreas extends posterior to the inferior vena cava.
C. The tail of the pancreas extends to the left of the aorta, toward the splenic hilum.
D. The head of the pancreas is jointly supplied by arterial blood from the celiac axis and the superior mesenteric artery.
Answer: ACD

44. Both endocrine and exocrine tissue comprise the pancreas. Which statement(s) is/are true?
A. The islets of Langerhans total 1 million per gland and drain their secretions via intercalated duct cells through the ampulla of Vater.
B. Islet alpha cells produce glucagon.
C. Islet sigma cells produce somatostatin.
D. The acini and ductal systems constitute the exocrine portion of the pancreas.
Answer: BD

45. Pancreatic exocrine secretory products include a bicarbonate-rich electrolyte solution as well as digestive enzymes. Which of the following statement(s) is/are true?
A. Cholecystokinin (CCK) is the most potent endogenous stimulant of pancreatic enzyme secretion.
B. The chloride and bicarbonate concentrations of pancreatic juice vary and depend on the secretory flow rate.
C. Secretin is the most potent endogenous stimulant of pancreatic water and electrolyte secretion.
D. The peptidases synthesized by acinar cells are released into the pancreatic duct system in active form.
Answer: ABC

46. Which of the following parameters is/are not included in the Ranson’s prognostic signs useful in the early evaluation of a patient with acute pancreatitis?
A. Elevated blood glucose.
B. Leukocytosis.
C. Amylase value greater than 1000 U per dl.
D. Serum lactic dehydrogenase (LDH) greater than 350 IU per dl.
E. Alanine aminotransferase greater than 250 U per dl.
Answer: CE

47. Standard supportive measures for patients with mild pancreatitis include the following:
A. Intravenous fluid and electrolyte therapy.
B. Withholding of analgesics to allow serial abdominal examinations.
C. Subcutaneous octreotide therapy.
D. Nasogastric decompression.
E. Prophylactic antibiotics.
Answer: A

48. Which of the following statements about chronic pancreatitis is/are correct?
A. Chronic pancreatitis is the inevitable result after repeated episodes of acute pancreatitis.
B. Patients with chronic pancreatitis commonly present with jaundice, pruritus, and fever.
C. Mesenteric angiography is useful in the evaluation of many patients with chronic pancreatitis.
D. Total pancreatectomy usually offers the best outcome in patients with chronic pancreatitis.
E. For patients with disabling chronic pancreatitis and a dilated pancreatic duct with associated stricture formation, a longitudinal pancreaticojejunostomy (Peustow procedure) is an appropriate surgical option.
Answer: E

49. Which of the following statements about pancreatic ascites is/are correct?
A. Patients typically present with painful ascites, reflecting the release of toxic pancreatic enzymes into the peritoneal cavity.
B. The standard evaluation of a patient with new-onset ascites includes abdominal paracentesis. In cases of pancreatic ascites, the peritoneal fluid contains high concentrations of both amylase and protein.
C. Pancreatic ascites can follow an episode of acute pancreatitis.
D. Patients with pancreatic ascites may fail to improve with nonoperative therapy and require surgical procedures. At abdominal exploration an acceptable approach to the pancreatic duct disruption involves suture ligation with omental patching.
Answer: BC

50. Which of the following statements about adenocarcinoma of the pancreas is/are correct?
A. It is the fifth most common cause of cancer death in the U.S.
B. Most cases occur in the body and tail of the pancreas, making distal pancreatectomy the most commonly performed resectional therapy.
C. For cancers of the head of the pancreas resected by pancreaticoduodenectomy, prognosis appears to be independent of nodal status, margin status, or tumor diameter.
D. The most accurate screening test involves surveillance of stool for carbohydrate antigen (CA 19–9).
Answer: A

51. A 35-year-old woman presents with episodes of obtundation, somnolence, and tachycardia. An insulinoma is suspected based on a random serum glucose test value of 38 mg. per dl. Which of the following statements is/are true?
A. The most important diagnostic study for insulinoma is an oral glucose tolerance test.
B. It may be helpful to perform ERCP in an effort to localize the tumor.
C. Most patients with insulinoma present with extensive disease, rendering them only rarely resectable or curable.
D. An important component of the preoperative evaluation in patients with presumed insulinoma involves confirming elevated C-peptide or proinsulin levels and screening for anti-insulin antibodies.
Answer: D

52. Which of the following statements about gastrinoma (Zollinger-Ellison syndrome) is/are correct?
A. As many as 75% of gastrinoma patients have sporadic disease; 25% have gastrinoma associated with multiple endocrine neoplasia type 1 (MEN 1).
B. Extrapancreatic gastrinomas are common, and exploration should include careful assessment of the duodenum and peripancreatic lymph nodes.
C. Diarrhea may be a prominent presenting feature of some patients with gastrinoma.
D. Before elective operation acid-reducing medications such as omeprazole should be administered.
Answer: ABCD

53. With regard to the control of pancreatic exocrine function, which of the following statement(s) is/are correct?

a. Cholecystokinin, a hormone released from the duodenal mucosa, is the predominant stimulus for pancreatic enzyme secretion
b. Gastrin is a major stimulant for pancreatic bicarbonate secretion
c. Secretin is released from the duodenum upon mucosal acidification and stimulates pancreatic bicarbonate secretion
d. Acetylcholine, released from pancreatic nerves, stimulates enzyme secretion
Answer: a, c, d

54. In the performance of a pancreaticoduodenectomy (Whipple procedure), the superior mesenteric vein is an important landmark. Which of the following statements is/are true with regard to the superior mesenteric vein?

a. Small venous branches enter the superior mesenteric vein anteriorly as it courses beneath the neck of the pancreas
b. The superior mesenteric vein joins the splenic vein at the superior border of the pancreas to form the portal vein
c. Small venous branches enter the superior mesenteric vein laterally as it courses beneath the neck of the pancreas
d. The superior mesenteric vein courses anterior to the neck of the pancreas
Answer: b, c

55. Pancreas divisum results from incomplete fusion of the ventral pancreatic duct with the dorsal pancreatic duct during embryologic development. Which of the following statements correctly describes pancreas divisum?

a. The body and tail of the pancreas drain via an accessory ampulla distal to the ampulla of Vater. The uncinate process drains via the ampulla of Vater
b. The entire pancreatic ductal system drains via the ampulla of Vater
c. The entire pancreatic ductal system drains via an accessory ampulla proximal to the ampulla of Vater
d. The body and tail of the pancreas are absent. The uncinate process drains via the ampulla of Vater
Answer: c

56. Which of the following statements is/are correct with regard to the blood supply of the pancreas?

a. The inferior pancreaticoduodenal artery, a branch of the celiac artery, divides into anterior and posterior branches to supply the pancreatic head
b. The body and tail of the pancreas are supplied by branches of the splenic artery
c. The superior pancreaticoduodenal artery is a branch of the gastroduodenal artery
d. The body and tail of the pancreas are supplied by branches derived from the left renal artery
Answer: b, c

57. Orally administered glucose provokes a greater insulin response than an equivalent amount of intravenously administered glucose. The incremental response to ingested glucose is due to the effects of which of the following hormones?

a. Gastric inhibitory peptide
b. Somatostatin
c. Pancreatic polypeptide
d. Secretin
Answer: a

58. The islets of Langerhans contain four major endocrine cell types that secrete which of the following hormones?

a. Insulin, somatostatin, glucagon, secretin
b. Insulin, somatostatin, cholecystokinin, pancreatic polypeptide
c. Insulin, somatostatin, glucagon, pancreatic polypeptide
d. Insulin, secretin, glucagon, cholecystokinin
Answer: c

59. A 50-year-old man develops acute pancreatitis due to alcohol abuse. Hyperamylasemia resolves by the third day after admission. By the eighth hospital day, the patient is noted to have recurrent fever (38.5°C), progressive leukocytosis (18,500 WBC/mm3), and tachypnea. The most appropriate management includes which as the next step?

a. Laparotomy with pancreatic debridement
b. CT guided aspiration of peripancreatic fluid collections
c. ERCP with sphincterotomy and placement of biliary stent
d. Intravenous amphotericin B
Answer: b

60. The patient in the above question is treated by observation for 8 weeks. He continues to be symptomatic with epigastric pain. A repeat abdominal CT scan reveals a persistent 6 cm pseudocyst in the region of the body of the pancreas. The pseudocyst is unilocular and demonstrates a well-defined rim of fibrous tissue. The gastric antrum is displaced anteriorly. Using CT guidance, 300 ml of fluid is aspirated from the lesion which is shown to be collapsed radiographically. No further intervention is performed. What is the risk of pseudocyst recurrence after simple aspiration?

a. 80–85%
b. 60–65%
c. 40–45%
d. 20–25%
Answer: d

61. In prospective, randomized trials which of the following agents or therapeutic measures has/have been demonstrated to accelerate recovery from acute pancreatitis?

a. Peritoneal lavage
b. Anticholinergic blockade
c. Octreotide
d. H2 receptor blockade
e. None of the above
Answer: e

62. Which of the following medical procedures has/have been associated with an increased risk of post-procedure acute pancreatitis?

a. Common bile duct exploration
b. Endoscopic retrograde cholangiopancreatography
c. Coronary bypass grafting
d. Distal gastrectomy
Answer: a, b, c, d

63. A 42-year-old male develops acute pancreatitis in the setting of acute alcohol abuse. One week after onset of symptoms, computed tomography of the abdomen reveals a pancreatic phlegmon and associated pseudocyst. Which of the following factors, if present, would decrease the likelihood of spontaneous resolution of the pseudocyst?

a. Size greater than 5 cm
b. Diffuse calcification of the pancreatic gland
c. Multilocularity
d. Location in the pancreatic tail
Answer: a, b, c

64. Which of the following is/are prognostic signs reported by Ranson to predict outcomes associated with acute pancreatitis?

a. Age greater than 60 years
b. Hematocrit decrease of 105 within 48 hours of hospital admission
c. Serum amylase value greater than 4 times upper limit of normal
d. Serum glucose greater than 200 mg/dL on admission
e. Ca2+ level less than 8 mg/dL within 48 hours of hospital admission
Answer: b, d, e

65. A 36-year-old woman is admitted to a the hospital with upper abdominal pain, hyperamylasemia, elevation of serum alkaline phosphatase and ultrasound evidence of cholelithiasis. With intravenous hydration and analgesia, symptoms rapidly resolved. After 48 hours, serum amylase and alkaline phosphatase values had returned to normal and physical examination revealed lessening tenderness in the right upper quadrant of the abdomen. Appropriate management consists of which of the following as the next step?

a. Cholecystectomy and intraoperative cholangiography before hospital discharge
b. Elective cholecystectomy at approximately 8 weeks
c. Endoscopic sphincterotomy before discharge followed by cholecystectomy at approximately 8 weeks
d. Observation
Answer: a

66. For the patient in the preceding question, symptomatic recurrence at 3 weeks after aspiration is confirmed ultrasonographically. Endoscopic retrograde pancreatography does not demonstrate communication of a major pancreatic duct with the pseudocyst. Appropriate management includes which of the following?

a. Pancreatectomy to include the pseudocyst
b. Cystgastrostomy
c. Repeat aspiration followed by injection of sodium morrhuate into the pseudocyst cavity
d. Pancreatic debridement followed by external drainage
Answer: b

67. With regard to acute pancreatitis: which of the following statements is/are correct?

a. The majority of patients presenting with acute pancreatitis of biliary type are female
b. The majority of patients presenting with acute pancreatitis of alcoholic type are female
c. The most common cause of acute pancreatitis in the United States is alcohol use
d. Patients with alcohol-induced pancreatitis tend to be older than those with biliary-induced disease
Answer: a, c

68. Which of the following statement(s) relating to chronic pancreatitis is/are correct?

a. In the United States, the most common cause of chronic pancreatitis is alcohol abuse
b. Approximately 50% of chronic alcoholics develop chronic pancreatitis
c. Clinically significant chronic pancreatitis develops on average after five years of alcohol abuse in men
d. The risk of alcohol-induced chronic pancreatitis can be decreased by consumption of a high-protein diet
Answer: a

69. The most appropriate test to confirm a clinical diagnosis of early chronic pancreatitis is which of the following?

a. Serum amylase determination
b. Calculation of urinary amylase clearance
c. Measurement of para-aminobenzoic acid absorption
d. Endoscopic retrograde cholangiopancreatography
Answer: d

70. A 52-year-old male, known to be alcoholic, is evaluated because of chronic abdominal pain. The clinical diagnosis of chronic pancreatitis is supported by ERCP findings of pancreatic ductal ectasia with alternating areas of stricture and dilatation. Several pancreatic ductal stones are also noted. With chronic pain as the operative indication, the most appropriate procedure would be:

a. 80% distal pancreatectomy with splenectomy
b. Longitudinal pancreaticojejunostomy
c. Distal pancreatectomy with end pancreaticojejunostomy
d. Total pancreatectomy
Answer: b

71. For the patient in the preceding question, the most appropriate long-term management is which of the following?

a. Endoscopic stenting of the distal common bile duct
b. Choledochoduodenostomy
c. Pancreaticoduodenectomy (Whipple procedure)
d. Percutaneous transhepatic drainage of the common hepatic duct
Answer: b

72. Which of the following is the most common cause of obstructive jaundice in patients with chronic pancreatitis?

a. Adenocarcinoma of the head of the pancreas
b. Choledocholithiasis
c. Fibrotic stricture of the common bile duct
d. Pancreatic pseudocyst formation
Answer: c

73. Alcohol-induced and hereditary chronic pancreatitis are the two most common etiologies observed in North American patients. Most of the remaining patients fall into which of the following categories?

a. Chronic pancreatitis secondary to hyperparathyroidism
b. Chronic pancreatitis caused by protein-calorie malnutrition
c. Chronic pancreatitis secondary to congenital pancreatic ductal obstruction
d. Idiopathic chronic pancreatitis
Answer: d

74. Which of the following statements regarding prognosis in chronic pancreatitis is/are correct?

a. Patients with chronic pancreatitis have decreased long-term survival compared with the general population
b. Patients with chronic pancreatitis exhibit no excess mortality relative to the general population
c. Excess mortality in patients with chronic pancreatitis is related to cancers of the aerodigestive system, complications of diabetes, and complications of cirrhosis
d. Excess mortality in patients with chronic pancreatitis is due to development of adenocarcinoma of the pancreas and to the complications of recurrent pancreatitis
Answer: a, c

75. Which of the following is the most common clinical manifestation of chronic pancreatitis?

a. Epigastric pain with radiation to the hypogastrium
b. Diabetes mellitus
c. Steatorrhea
d. Epigastric pain with radiation to the upper lumbar vertebrae
Answer: d

76. For the patient in the preceding question, appropriate management includes which of the following?

a. Distal pancreatectomy
b. Cystjejunostomy
c. Percutaneous drainage
d. Primary radiotherapy and chemotherapy
Answer: a

77. A 72-year-old man develops jaundice and is demonstrated to have a 2.5 mass in the pancreatic head by computed tomography. There are no signs of unresectability on CT examination. Fine needle aspiration cytology is positive for adenocarcinoma. Which of the following intraoperative findings would indicate unresectability?

a. Fibrotic reaction in the body and tail of the pancreas
b. Microscopic tumor cells in perigastric lymph nodes on frozen section
c. Inability to develop an avascular plane anterior to the superior mesenteric vein
d. Cholelithiasis
Answer: b, c

78. A 67-year-old male presents with complaints of itching, dark urine, and epigastric pain. Physical examination reveals jaundice. Initial laboratory tests show total bilirubin of 6.5 mg/dL, alkaline phosphatase elevated at 3 the upper limit of normal, and mild elevations in serum transaminases. Appropriate management includes which diagnostic test next?

a. Abdominal ultrasonography
b. Computed tomography of the abdomen
c. Magnetic resonance imaging of the abdomen
d. Endoscopic retrograde cholangiography
Answer: a

79. Which of the following statements regarding ductal adenocarcinoma of the pancreas is/are correct?

a. For ductal adenocarcinoma, 60–70% of tumors arise in the head of the gland, 15% in the body, and 10% in the tail, the remainder are diffuse
b. Fifty percent of pancreatic adenocarcinomas involve the gland diffusely at the time of diagnosis
c. For ductal adenocarcinomas, tumors of the body and tail are usually larger at the time of diagnosis than those arising in the head of the gland
d. Pancreatic adenocarcinomas occur with equal frequency within the head, body, and tail of the gland
Answer: a, c

80. The most common cause of death in the postoperative period following pancreaticoduodenectomy is which of the following?

a. Myocardial infarction
b. Intraperitoneal hemorrhage
c. Pulmonary embolism
d. Pneumonia
Answer: b

HEPATOBILIARY & PANCREATIC SURGERY Objective Type Questions with Answers ::

81. For the above patient, ultrasonography reveals dilated extrahepatic and intrahepatic bile ducts and the absence of gallstones within the gallbladder. A 2 cm mass within the pancreatic head is visualized. Computed tomography of the abdomen is performed. Which of following CT findings indicate probable unresectability?

a. Common bile duct diameter of 2 cm
b. Ascites
c. Infiltration of the transverse colonic mesentery
d. Dilatation of the main pancreatic duct to 1.5 cm
Answer: b, c

82. Which of the following have been shown to be risk factors for development of adenocarcinoma of the pancreas?

a. Cigarette smoking
b. Coffee drinking
c. Adult-onset diabetes mellitus
d. Chronic coumadin usage
e. Prior gastrectomy
Answer: a, e

83. Which of the following surgical procedures has the lowest incidence of recurrent jaundice when used in the context of unresectable carcinoma of the head of the pancreas?

a. Choledochoduodenostomy
b. Cholecystojejunostomy
c. Cholecystoduodenostomy
d. Choledochojejunostomy
Answer: d

84. A 45-year-old woman is evaluated for epigastric and back pain. Physical examination is normal. Computed tomography of the abdomen reveals a 8 cm cystic lesion in the region of the tail of the pancreas. The cyst demonstrates internal septations and papillary projections from its walls. Which of the following diagnoses is most likely in this patient?

a. Pancreatic lymphoma
b. Retroperitoneal liposarcoma
c. Pancreatic pseudocyst
d. Pancreatic mucinous cystadenoma
Answer: d

85. A 45-year-old woman develops upper gastrointestinal hemorrhage. Evaluation by upper endoscopy reveals three ulcers in the second portion of the duodenum. Bleeding is controlled using an endoscopic heat probe. Further investigation reveals a serum gastrin value of 240 pg/mL. Which of the following would support the presumptive diagnosis of gastrinoma?

a. An increase of 320 pg/mL in serum gastrin upon intravenous infusion of secretin
b. Gastric acid analysis demonstrating fasting acid secretion of 3 mEq/h
c. Enlarged gastric rugae on upper gastrointestinal contrast study
d. An increase of 150 pg/mL in serum gastrin upon intravenous infusion of cholecystokinin
Answer: a, c

86. For the patient in the preceding question, an insulin/glucose ratio of 0.5 was documented at 28 hours of fasting. Symptoms of mental obtundation developed concurrently and were reversed by oral glucose administration. Endoscopic ultrasonography demonstrated a 1.2 cm mass in the head of the pancreas. Appropriate management consists of which of the following?

a. Surgical enucleation of the tumor
b. Total pancreatectomy
c. Long-term octreotide administration
d. Primary radiotherapy
Answer: a

87. A 35-year-old woman is evaluated for seizure disorder, mental obtundation, and personality change. Physical examination is normal. Fasting serum glucose is 44 mg/dL. Other serum values are normal. Subsequent investigations should include which of the following?

a. Oral glucose tolerance test
b. Determination of fasting insulin/glucose ratios
c. Assay of serum C-peptide levels
d. Determination of serum prolactin levels
Answer: b, c

88. The most common location(s) for development of gastrinoma is/are which of the following?

a. Pancreas to the right of the superior mesenteric vein
b. Pancreatic body and tail
c. Gastric antrum
d. Duodenum
Answer: a, d

89. Neoplastic hypersecretion of the hormone vasoactive intestinal peptide is associated with which of the following features?

a. Hypokalemia, hypochlorhydria, diarrhea
b. Hyperglycemia, necrolytic rash, hypoaminoacidemia
c. Constipation, gallstones, hyperglycemia
d. Hyperkalemia, necrolytic rash, diarrhea
Answer: a

90. A patient with biochemically confirmed gastrinoma undergoes computed tomography for tumor localization. CT reveals a 2 cm mass in the head of the pancreas and multiple nodules within right and left lobes of the liver. Appropriate management includes which of the following?

a. Omeprazole administration
b. Radiotherapy
c. Pancreaticoduodenectomy
d. Proximal gastric vagotomy
Answer: a

91. The following statement(s) is/are true concerning the widely accepted French or Couinaud’s nomenclature for liver anatomy.

a. The liver is divided into eight discrete segments based on portal pedicle branches and hepatic venous drainage
b. This anatomy is particularly useful in allowing less than lobar segmental anatomical resections that minimize blood loss and loss of hepatic reserve
c. Enumeration of the system begins from right to left
d. Segments II and III are synonymous with the left lateral segment based on English nomenclature
Answer: a, b, d

92. In the patient described above, which of the following are important operative steps in the performance of a right hepatic lobectomy?

a. The use of an ultrasonic dissector is essential for division of the hepatic parenchyma
b. If temporary portal inflow occlusion is used (Pringle maneuver), it is not necessary to reestablish blood flow during the course of the parenchymal division
c. The greater omentum may be used to buttress the transected liver edge
d. Control of the main right hepatic vein should eliminate all forms of venous drainage
Answer: c

93. Intraoperative ultrasound is now commonly used by the hepatic surgeon. Which of the following statement(s) is/are true concerning intraoperative ultrasound and hepatic surgery?

a. An intraoperative ultrasound offers no advantage to conventional transcorporial ultrasound in detection of hepatic lesions
b. Portal structures can be differentiated from hepatic veins by the extension of Glisson’s capsule surrounding these structures
c. It is difficult on ultrasound to differentiate a vascular structure from a mass
d. The short hepatic veins are difficult to detect with intraoperative ultrasound
Answer: b

94. The following statement(s) is/are true concerning hepatic anatomical nomenclature.

a. In the traditional English system, the right lobe is divided into anterior and posterior segments by an intersegmental line with no topographic landmarks or interparenchymal septi
b. The caudate lobe in the French or Couinaud’s nomenclature is referred to as segment I
c. The right lobe of the liver by English nomenclature is subdivided in the French system into segments V–VIII
d. In the English system, the left lobe of the liver is divided into the medial segment and lateral segment by the falciform ligament
Answer: a, b, c, d

95. A 57-year-old man with a history of Duke’s C colon cancer is being evaluated for a rising CEA. Which of the following statement(s) is/are correct concerning the use of CT scanning for this indication?

a. Conventional CT scanning will detect lesions well below 1 cm in size
b. CT arterio-portography involves immediate CT scanning after direct injection into both the common hepatic artery and superior mesenteric artery
c. A double helical (spiral) CT scan may eliminate the need for invasive angiography
d. Magnetic resonance imaging of the liver will add little to the workup of this patient
Answer: b, c, d

96. A solitary 6 cm lesion is identified in the right hepatic lobe in the patient described above. Which of the following statement(s) is/are true concerning the initial operative management?

a. To facilitate mobilization and assessment with intraoperative ultrasound, complete mobilization including dividing the left and right triangular ligaments would be necessary
b. In dividing the right triangular ligament, care must be taken to avoid injury to accessory right hepatic veins draining directly into the vena cava
c. Unless a considerable length of hepatic vein is found outside the hepatic parenchyma, early hepatic vein ligation should be avoided
d. Ligation of the portal arterial structures is always necessary before proceeding with hepatic lobectomy
Answer: a, b, c

97. Which of the following statement(s) is/are true concerning the arterial venous anatomy of the liver?

a. Most commonly, the right, left, and middle hepatic veins join the inferior vena cava as a separate trunk
b. Most frequently, the entire length of each hepatic vein is within the parenchyma of the liver
c. A replaced right hepatic artery may be placed in jeopardy during performance of a pancreaticoduodenectomy
d. There is little collateral arterial circulation between the right and left hepatic lobes
Answer: b, c

98. The liver plays a vital role in carbohydrate metabolism and regulation of blood glucose. The following statement(s) is/are true concerning carbohydrate metabolism by the liver.

a. Glycogen, a complex polymer of glucose, is synthesized by the hepatocyte in a remarkably energy efficient process
b. Glucagon stimulates glycogenesis
c. Glycolysis, the process by which glucose is converted to two molecules of pyruvate, occurs in the liver mitochondria
d. If glycogen stores become depleted, the liver is capable of synthesizing new glucose by the process of gluconeogenesis, which is stimulated by insulin
Answer: a

99. Transport of substances from the blood into the hepatocyte occurs through the sinusoidal membrane. The following statement(s) is/are true concerning this plasma membrane.

a. The high lipid content of this phospholipid bilayer allows lipid-soluble molecules to enter the cell by simple diffusion
b. Carrier proteins within the phospholipid bilayer bind to a solute in blood and by conformational change allow it to be transported into the cell
c. Large glycoprotein molecules of the sinusoidal membrane known as receptors always transport the binding ligand into the cell
d. The transmission of a signal to the interior of the cell by receptor-ligand binding which generates intracellular second messengers is known as signal transduction
Answer: a, b, d

100. The liver is an important site of protein metabolism. Which of the following statement(s) is/are true concerning protein metabolism by the liver?

a. Amino acids are taken up by hepatocytes by active transport mechanisms and are generally stored long-term for later synthetic activity
b. Under certain conditions the amine group is removed from the amino acids in the liver and the carbon chain used for carbohydrate, lipid, or nonessential amino acid synthesis
c. The most important route of detoxification of ammonia formed as the result of deamination of amino acids is via excretion of ammonia into the urine
d. Proteins synthesized by the liver include albumin, transferrin, fibrinogen, and apolipoproteins
e. Albumin is a sensitive indicator of hepatic synthetic function
Answer: b, d

101. The following statement(s) is/are true concerning hepatic blood flow.

a. Although constituting only 2.5% of total body weight, the liver receives 25% of the cardiac output
b. Hepatic blood flow is equally derived from the portal vein and hepatic artery
c. The liver serves as a physiologic blood reservoir either releasing blood back into the systemic circulation at times of acute blood loss or in situations of volume overload serving as a site of extra blood storage
d. An important function of the liver is to filter particulate debris which is performed by phagocytic Kupffer cells which line the hepatic sinusoidal endothelium
Answer: a, c, d

102. The liver synthesizes key metabolites essential for the production of fuel substrates for other organs. These key metabolites include:

a. Glucose-6-phosphate (G6P)
b. Acetyl CoA
c. Pyruvate
d. Oxaloacetate
Answer: a, b, c

103. The following statement(s) concerning hepatic bile formation/secretion is/are true.

a. The adult human liver secretes less than 1000 cc of bile daily
b. Most bile is secreted by hepatocytes (canalicular bile)
c. Primary bile acids include cholic acid, chenodeoxycholic acid, and deoxycholic acid
d. The enterohepatic circulation is tremendously efficient in reabsorption of intestinal bile acids
e. Bile acids are the primary determinant of bile flow
Answer: b, d, e

104. The following statement(s) is/are true containing lipid metabolism in the liver.

a. Hepatic mitochondrial hydrolysis of fatty acids is a tremendous source of ATP
b. Significant hepatic storage of triglyceride or fatty infiltration can cause hepatic fibrosis or necrosis
c. Approximately 90% of cholesterol synthesis occurs in the liver
d. Most cells in the body are capable of phospholipid synthesis, therefore the liver plays a minimal role in this process
Answer: a, c

105. Hepatic biotransformation is defined as the intracellular metabolism of endogenous and exogenous organic compounds. Which of the following is/are enzyme families responsible for hepatic bile transformation?

a. Cytochromes P-450
b. UDB-glucuronyl transferases
c. Glutathione-transferases
d. Sulfotransferases
Answer: a, b, c, d

106. The following statement(s) is/are true concerning the differential diagnosis between an amoebic and a pyogenic liver abscess.

a. The clinical presentation is often clearly distinguishable
b. A history of travel or origin from a high risk area might suggest an amebic liver abscess
c. Routine liver chemistries frequently can distinguish pyogenic from amoebic liver abscess
d. Serologic testing for the presence of antibody to entamoeba histolyctica is the only specific and sensitive way to confirm the diagnosis of amoebic liver abscess
e. Distinguishing pyogenic from hepatic abscesses preoperatively is not important since surgical drainage is imperative for both
Answer: b, d

107. A patient is found to develop evidence of hepatitis approximately eight weeks after receiving blood transfusions during a surgical procedure. Which of the following statement(s) is/are true?

a. The virus responsible is most likely hepatitis C
b. A chronic carrier state will ultimately develop in most patients
c. There is no role for interferon in the treatment of chronic hepatitis C viral infection
d. Chronic infection with hepatitis C is not associated with an increased risk of developing hepatocellular carcinoma
Answer: a, b

108. A surgeon is suspected of having contacted hepatitis B virus via needle stick. Which of the following statement(s) is/are true concerning his diagnosis and outcome?

a. Incubation of hepatitis B virus is about two weeks
b. Jaundice is the first serologic indicator of hepatitis B infection
c. The patient has about a 10% chance of developing a chronic carrier state
d. All susceptible household of the surgeon should receive hepatitis B viral vaccine
e. The surgeon should receive hepatitis B immunoglobulin as soon as possible after the accidental needle stick
Answer: c, d, e

109. The following statement(s) is/are true concerning the diagnosis and treatment of hydatid cysts.

a. Percutaneous aspiration is an important aspect of diagnosis and treatment of a hydatid cyst
b. CT scan will oftentimes show the classic findings of a cystic liver lesion with a calcific rim
c. At operation, care must be taken to protect the operative field from spillage of the cyst fluid
d. The use of a scoleocide has become obsolete with current surgical techniques
Answer: b, c

110. Which of the following statement(s) is/are true concerning treatment of pyogenic liver abscess?

a. Antibiotic therapy alone may be advisable in patients with multiple small abscesses
b. Percutaneous drainage provides comparable results to surgical drainage in patients with unilocular large abscesses
c. Sufficient antibiotic coverage for most hepatic abscesses includes coverage for gram-positive aerobic bacteria only
d. In patients with a primary biliary origin for the hepatic abscess, treatment must also be addressed at underlying biliary pathology such as choledocholithiasis or biliary ductal obstruction
Answer: a, b, d

111. Which of the following statement(s) is/are true concerning acute, fulminant hepatic failure?

a. The most frequent cause of acute hepatic failure world-wide is hepatitis B infection
b. Higher grades of encephalopathy are associated with a worse prognosis
c. Hypoglycemia is a common complication of all liver diseases
d. Liver transplantation would appear indicated in all patients with hepatic coma secondary to acute liver failure
Answer: b

112. Which of the following statement(s) is/are true concerning the natural history and clinical features of alcoholic cirrhosis?

a. In patients with compensated cirrhosis, the probability of survival at 10 years approaches 50%
b. The development of clinical evidence of hepatic decompensation reduces five year survival to less than 20%
c. Continued consumption of alcohol worsens prognosis
d. The risk of death after variceal hemorrhage depends more on the severity of underlying liver disease than the type of therapy
Answer: a, b, c, d

113. Which of the following statement(s) is/are true concerning the morphologic and histologic findings of cirrhosis?

a. Micronodular cirrhosis is a pattern typical of chronic alcoholic liver disease
b. Mallory bodies and megamitochondria are typical findings of alcoholic cirrhosis
c. Bile leaks caused by rupture of bile ducts with extravasation of bile into portal triads is a common finding in post-necrotic cirrhosis secondary to hepatitis
d. Large regenerating nodules separated by coarse irregular scars in piecemeal parenchyma necrosis is common in liver disease secondary to chronic active hepatitis
Answer: a, b, d

114. The following statement(s) is/are true concerning the management of ascites associated with chronic liver disease.

a. Spontaneous bacterial peritonitis is an insignificant complication
b. Large volume paracentesis is unsafe due to excessive volume loss from the intervascular space
c. Peritoneovenous shunting is a trivial surgical procedure with minimal perioperative morbidity and mortality
d. Transjugular intrahepatic portosystemic shunts (TIPS) can effectively treat ascites in patients refractory to conventional medical therapy
Answer: d

115. Which of these statement(s) is/are true concerning the etiologic factors in the development of cirrhosis?

a. Viral hepatitis of any type (A, B, or non-A, non-B) can all progress to cirrhosis
b. Acetaminophen can cause acute liver failure and necrosis but will not lead to cirrhosis
c. Alcohol exerts toxic effects on the liver via reactive intermediates such as acetaldehyde
d. Long-standing congestive heart failure can lead to cirrhosis secondary to centrilobular congestion, hemorrhage, and necrosis
Answer: c, d

116. Important spontaneous portosystemic collaterals which develop in the face of portal hypertension include:

a. The hemorrhoidal veins
b. Left renal vein
c. The paraumbilical venous plexus
d. The coronary, short gastric, and paraesophageal veins
Answer: a, b, c, d

117. Which of the following statement(s) is/are true concerning the pathophysiology of variceal hemorrhage?

a. All patients with portal hypertension will develop esophageal varices
b. All patients with esophageal varices eventually bleed
c. Variceal size can predict the incidence of variceal hemorrhage
d. Control of acid secretion by H2 blockade can decrease the incidence of rebleeding after esophageal hemorrhage
e. None of the above
Answer: e

118. Which of the following statement(s) is/are true concerning the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of variceal bleeding?

a. This procedure effectively creates an end-to-side portocaval shunt
b. Procedure-related mortality is generally in excess of 20%
c. TIPS has been used successfully as a pretransplant procedure to reduce portal pressure
d. The placement of a TIPS is not associated with the development of encephalopathy
Answer: c

119. Hepatic encephalopathy is a common systemic manifestation of chronic liver disease. Which of the following statement(s) is/are true concerning this condition?

a. Blood ammonia levels correlate well with the stage of hepatic encephalopathy
b. Alterations in central nervous system neurotransmitters such as the neurotransmitter g- aminobutyric acid (GABA) have been proposed in the pathogenesis of hepatic encephalopathy
c. Lactulose can be used to decrease intestinal ammonia absorption
d. Patients can be expected to have an increased sensitivity to benzodiazepines
Answer: b, c, d

120. Which of the following statement(s) is/are true concerning the management of gastroesophageal variceal hemorrhage?

a. Vasopressin decreases portal pressure through the process of splanchnic vasoconstriction
b. Somatostatin is as effective as vasopressin but without the cardiac side effects
c. Balloon tamponade provides good long-term control of bleeding esophageal varices
d. Endoscopic sclerotherapy is more effective than conservative medical therapy in the treatment of bleeding esophageal varices
e. Sclerotherapy, although excellent for the control of bleeding short-term, does not prolong overall survival
Answer: a, b, d

121. Which of the following statement(s) is/are true concerning the surgical management of bleeding esophageal varices.

a. A side-to-side portacaval shunt may be associated with the development of hepatofugal blood flow
b. Selective shunts preserve prograde (hepatopedal) blood flow while decompressing esophageal varices or reducing portal pressure
c. The presence of intractable ascites is a contraindication to the Warren shunt
d. If the patient is considered a liver transplant patient, an interposition mesocaval shunt is a suitable alternative
Answer: a, b, c, d

122. Which of the following statement(s) is/are true concerning the results of portosystemic shunting?

a. When comparing shunts with nonshunting procedures, only minor differences in long-term survival are reported, but the mode of death usually changes
b. Distal splenorenal shunts are associated with the development of less hepatic encephalopathy
c. Survival statistics following distal splenorenal shunt in good risk patients (Child’s Class A) are in excess of 80%
d. None of the above
Answer: a, b, c

123. Which of the following statement(s) is/are true concerning radiologic examinations used for the assessment of hepatic neoplasms?

a. Magnetic resonance imaging is considered the test of choice for distinguishing hemangiomas from other mass lesions
b. Dynamic CT scanning is the dominant imaging modality for routine screening and diagnosis
c. Radionucleotide imaging plays an important role in modern screening and detection for liver lesions
d. CT angio-portography (CTAP) is the gold standard for early detection of metastatic hepatic lesions
Answer: a, b, d

124. A 45-year-old woman undergoes an ultrasound because of vague right upper quadrant pain and epigastric fullness. A 7 cm cystic lesion is detected. Which of the following statement(s) is/are true concerning the patient’s diagnosis and management?

a. Simple aspiration is indicated for treatment and diagnosis
b. Bile stained fluid suggests underlying biliary pathology
c. The cyst is likely lined by cuboidal epithelium
d. Laparoscopic unroofing of the cyst can provide satisfactory treatment
Answer: c, d

125. Which of the following statement(s) is/are true concerning biopsy techniques for hepatic masses?

a. A fine needle aspiration (FNA for cytology is contraindicated for patients with hypervascular masses)
b. Percutaneous biopsy should be performed only if results may obviate the need for exploratory laparotomy
c. Needle track seeding of tumor is not a risk associated with percutaneous biopsy
d. Laparoscopy and biopsy play little role in the management of liver lesions
Answer: b

126. A 55-year-old woman presents with vague right upper quadrant pain and a palpable liver. Laboratory tests are normal and a noncontrast CT scan (patient has a history of contrast allergy) reveals an 8 cm right hepatic mass. Which of the following statement(s) is/are correct concerning the patient’s diagnosis and management.

a. A gadilinium-enhanced MRI would be indicated to define the extent of the lesion and confirm the diagnosis of hemangioma
b. A fine needle aspiration should be performed regardless of radiographic workup
c. Hepatic embolization is the treatment of choice
d. The lesion should be resected because of concern for malignant degeneration
Answer: a

127. Which of the following statement(s) is/are true concerning the pathogenesis of hepatocelluar carcinoma?

a. Hepatocellular carcinoma is associated with infection with hepatitis A, hepatitis B, and hepatitis C
b. The risk of developing hepatocellular carcinoma related to hepatitis B viral infection is related to the chronicity of the infection
c. Hepatocellular carcinoma only develops in cirrhosis associated with hepatitis
d. Alfatoxin B1 is a potent carcinogen in the development of hepatocellular carcinoma
Answer: b, d

128. A 38-year-old woman with a 17 year history of oral contraceptive use presents with right upper quadrant pain. A CT scan demonstrates a 4 cm lesion in the right lobe of the liver. Which of the following statement(s) is/are true concerning the patient’s diagnosis and management?

a. The lesion is likely premalignant
b. A 99mTc sulfur colloid scan will distinguish this benign lesion from a malignant hepatoma
c. The lesion, although benign, may be associated with life-threatening hemorrhage
d. The lesion would be expected to be hypervascular on angiographic study
Answer: c, d

129. Which of the following statement(s) is/are true concerning focal nodular hyperplasia (FNH)?

a. The lesion predominantly affects young women
b. The lesion is associated with the use of oral contraceptives and other estrogens
c. Radionucleotide scanning can be useful in the specific diagnosis of FNH
d. Excisional biopsy is indicated in almost all cases because of the risk of bleeding
Answer: a, c

130. Which of the following statement(s) is/are true concerning the prognosis of patients with hepatic metastases and colorectal carcinoma?

a. Over half of these patients will survive one year without treatment
b. Five year survivals following hepatic resection for an isolated metastasis is in excess of 25%
c. Survival beyond five years after resection suggests a high probability of cure
d. Survival rates are improved with a margin of resection greater than 1 cm
e. The size of a liver metastasis is not a significant factor in predicting recurrence if adequate margins can be obtained
Answer: b, c, d, e

131. Which of the following statement(s) is/are true concerning the treatment and prognosis of hepatocellular carcinoma?

a. The fibrolamellar variant of hepatocellular carcinoma has a distinctly better prognosis than other forms of the disease
b. Patients with untreated hepatocellular carcinoma rarely survive a year
c. Multiagent chemotherapy is extremely effective in hepatocellular carcinoma and should be considered for the treatment for most patients
d. Hepatic artery ligation or embolization has been demonstrated to be highly effective for hepatocellular carcinoma
Answer: a, b

132. The following statement(s) is/are true concerning the relationship of the biliary tree and the hepatic artery and portal vein.

a. The common hepatic and common bile duct lie immediately anterior to the portal vein
b. The cystic artery, which usually arises from the right hepatic artery, crosses behind the hepatic duct in most cases
c. A replaced right hepatic artery arising from the superior mesenteric artery system will run to the right of the common bile duct
d. The arterial supply of the extrahepatic biliary ducts is derived from major trunks running along the medial and lateral walls of the common duct at the 3 o’clock and 9 o’clock position
Answer: a, b, c, d

133. An understanding of the anatomy of the extrahepatic biliary tree is essential in performing biliary tract surgery. Which of the following statement(s) is/are true concerning biliary ductal anatomy?

a. The majority of patients have the “classic” anatomical description
b. The common hepatic duct unites with the cystic duct to form the common bile duct
c. An accessory right hepatic duct occurs in 5% of patients
d. A common channel or “Y” configuration of the distal bile duct and pancreatic ducts occur in approximately 70% of patients
Answer: b, c, d

134. A 35-year-old female presents with typical biliary colic symptoms, however her sonogram shows no gallstones. Which of the following statement(s) is/are true concerning her diagnoses?

a. Chronic acalculous cholecystitis or gallbladder dyskinesia is seldom associated with classic biliary colic symptoms
b. The most specific test for diagnosing gallbladder dyskinesia is CCK-enhanced cholescintigraphy with assessment of gallbladder ejection fraction
c. An ejection fraction greater than 75% is considered abnormal and indicative of gallbladder dyskinesia
d. Cholecystectomy is not indicated for chronic acalculous cholecystitis
Answer: b

135. The following statement(s) is/are true concerning the embryology of the biliary tree.

a. The primordial anlagen of the liver and biliary tract arises from the entoderm
b. Superior and inferior caudal buds form as the hepatic diverticulum develops
c. The development of the liver is a separate process from that of the gallbladder and distal biliary tree
d. The biliary tree develops in association with the dorsal pancreas
Answer: a, b

136. The following statement(s) is/are true concerning biliary motor function.

a. The contracted sphincter of Oddi impairs bile flow into the duodenum and directs it into the gallbladder
b. In the postprandial state about 70% of hepatic bile flows into the gallbladder before reaching the duodenum
c. During the interdigestive period, only a small fraction of gallbladder bile enters the duodenum
d. Gallbladder emptying during fasting is associated with phase III of the interdigestive migrating motor complex (MMC)
e. After a meal, the gallbladder empties by a steady tonic contraction thought to be due to release of endogenous motilin from the mucosa of the small intestine
Answer: a, b, c

137. The following statement(s) is/are true concerning the anatomy of the gallbladder.

a. The gallbladder lies between the right, left, and quadrate hepatic lobes or hepatic segments IV and V
b. The cystic duct contains the spiral valve of Heister which serves an important valvular function for the gallbladder
c. The cystic artery arises from the right hepatic artery in 95% of cases
d. The cystic artery crosses anterior to the hepatic duct in the majority of cases
Answer: a, c

138. The gallbladder plays an important role in altering bile composition by absorption and secretion. Which of the following statement(s) is/are true concerning this mucosal function?

a. The absorption of water by the gallbladder can result in concentration of the solute components of bile from 2-to 10-fold
b. Gallbladder mucosal absorption can occur by both active and passive mechanisms
c. Cyclic adenosine monophosphate (cAMP) stimulates NaCl-coupled transport and may also influence tight junction permeability
d. Secretory products of the gallbladder include bicarbonate and glycoproteins
Answer: a, b, d

139. Abnormalities of the sphincter of Oddi have been recently recognized to cause symptoms which are referable to the biliary tree or pancreas. The following statement(s) is/are true concerning sphincter of Oddi motor function.

a. The sphincter’s basal resting pressure is 10 to 15 mm Hg above duodenal pressure
b. Contraction of the sphincter occurs with CCK stimulation
c. Vagal stimulation results in relaxation of the sphincter
d. Manometry of the sphincter of Oddi may be performed at the time of ERCP to characterize basal pressure, amplitude, frequency of contraction, and direction of propagation of contractile waves
e. Stenosis of the sphincter of Oddi is characterized by abnormally elevated basal pressure on sphincter of Oddi manometrics
Answer: a, c, d, e

140. A 32-year-old woman with symptomatic gallstones wishes to discuss nonsurgical options for her gallstones. Which of the following statement(s) are true?

a. The best commercially available oral dissolution agent, ursodeoxycholic acid, is associated with a complete dissolution rate of less than 50%
b. If the gallstones dissolve, there is minimal risk of gallstone recurrence
c. Contact dissolution is applicable regardless of stone type
d. Extracorporial shock wave lithotripsy (ESWL) in combination with oral dissolution agents is an appropriate technique for most patients and can result in complete stone fragment clearance in over 90% of patients by one year
Answer: a

141. A 48-year-old woman presents with several hours of acute right upper quadrant pain, low grade fever, and nausea and vomiting. Which of the following statement(s) is/are true concerning her diagnosis and management?

a. A mild elevation of her bilirubin (< 3 mg/dl) would strongly suggest a common bile duct stone
b. A positive bile culture can be expected in virtually 100% of patients with this scenario
c. Laparoscopic cholecystectomy is clearly contraindicated
d. Appropriate antibiotic coverage should include coverage for gram-negative aerobes
Answer: d

142. Laparoscopic cholecystectomy has become the procedure of choice for the management of symptomatic gallstones. Which of the following statement(s) is/are true concerning laparoscopic cholecystectomy?

a. Injury to biliary tree occurs more frequently with laparoscopic cholecystectomy than open cholecystectomy
b. Laparoscopic cholecystectomy is contraindicated in patients with acute cholecystitis
c. Bile duct injuries are more likely to occur during the surgeon’s early operative experience with the procedure
d. Previous upper abdominal surgery is an absolute contraindication to laparoscopic cholecystectomy
Answer: a, c

143. Which of the following statement(s) is/are true concerning gallstone ileus?

a. The diagnosis may be suggested by plain abdominal radiograph
b. Primary surgical management consists of relief of obstruction and cholecystectomy
c. Gallstone ileus accounts for less than 5% of all causes of intestinal obstruction
d. Typical patients are elderly with long-standing gallstone disease
Answer: a, c, d

144. The pathogenesis of cholesterol gallstones is multifactorial. A number of key processes, however, appear to interact closely in the formation of cholesterol gallstones. These include:

a. Cholesterol supersaturation
b. Gallbladder stasis
c. Accelerated nucleation
d. High bilirubin concentration
Answer: a, b, c

145. Which of the following statement(s). is/are true concerning the diagnosis of biliary tract disease?

a. Nonvisualization of the gallbladder on oral cholecystogram is diagnostic of biliary calculous disease
b. Ultrasonography has a diagnostic accuracy and sensitivity for cholelithiasis in excess of 95%
c. Ultrasonography is the preferred test to distinguish chronic from acute cholecystitis
d. Hepatobiliary scintigraphy is primarily indicated to confirm the clinical diagnosis of acute cholecystitis
Answer: b, d

146. Which of the following statement(s) is/are true concerning the solubilization of cholesterol in bile?

a. Cholesterol is highly soluble in both serum and bile
b. Mixed micelles are the primary transport mechanism for biliary cholesterol
c. Most cholesterol found in bile is the result of excretion from serum
d. Biliary vesicles are composed primarily of biliary phospholipid
Answer: d

147. Appropriate options for management of common bile duct stones identified at laparoscopic cholecystectomy include:

a. Conversion to open cholecystectomy and common duct exploration
b. Transcystic duct dilatation and exploration
c. Laparoscopic choledochotomy
d. Complete the laparoscopic cholecystectomy with postoperative ERCP and stone removal
Answer: a, b, d

148. Risk factors associated with development of gallstones include:

a. Increasing age
b. Obesity
c. Rapid weight loss
d. Cirrhosis
e. Diabetes mellitus
Answer: a, b, c, d, e

149. Which of the following statement(s) is/are true concerning a 35-year-old woman found to have asymptomatic gallstones?

a. The patient should undergo attempts at medical dissolution
b. Cholecystectomy should only be performed if the laparoscopic technique is an available option
c. The patient has less than 10% chance of developing significant symptoms over the next five years
d. The risk of gallbladder cancer with stones detected at such a young age, warrants cholecystectomy
Answer: c

150. In which of the following clinical situations is pigment rather than cholesterol gallstones a more common problem?

a. Alcoholic cirrhosis
b. Morbid obesity
c. Diabetes mellitus
d. Hereditary spherocytosis
e. Biliary tract infection
Answer: a, d, e

151. The following statement(s) is/are true concerning the mode of spread of gallbladder cancer.

a. The most common mode of spread for gallbladder cancer is to the liver by hematogenous spread
b. Lymphatic drainage of the gallbladder can extend from the cystic duct lymph node to periportal lymph nodes and the celiac and superior mesenteric lymph nodes
c. Gallbladder cancers rarely extend past the cystic duct
d. Direct extension to the liver, particularly liver segments IV and V, is the most common mode of spread for gallbladder cancer
e. Most patients with gallbladder cancer present with a very limited extent of disease
Answer: b, d

152. A 55-year-old woman undergoes cholecystectomy for symptomatic gallstones. The final pathology returns one week after the operation showing gallbladder carcinoma. Which of the following statement(s) is/are true concerning this patient’s prognosis and management?

a. If the gallbladder carcinoma is limited to the mucosa and/or submucosa, cholecystectomy alone is adequate treatment
b. If the carcinoma involves deeper layers of the gallbladder wall, the prognosis will be significantly worse
c. If reoperation is performed, the chance of finding residual disease will be low
d. If a full thickness tumor had been recognized at the time of cholecystectomy, an “extended cholecystectomy” may have been appropriate
Answer: a, b, d

153. Gallbladder cancer accounts for 3% to 4% of all gastrointestinal tumors. Which of the following statement(s) is/are true concerning the incidence of gallbladder cancer?

a. Gallbladder cancer is much more frequent in men
b. Southwest Native Americans, Alaskans, Mexicans, and Hispanics have a greater incidence of gallbladder cancer than the general population
c. The majority of patients with gallbladder cancer have gallstones
d. The association of gallstones with gallbladder cancer is greater in patients with multiple small stones
Answer: b, c

154. The following statement(s) is/are true concerning the prognosis for gallbladder cancer.

a. Average survival is in the range of one year
b. Five year survival rates approach 50%
c. The combination of postoperative adjuvant radiation and chemotherapy have been associated with overall improved survival
d. For most patients, the goal of treatment is palliation
Answer: d

155. Which of the following statement(s) is/are true concerning gallbladder polyps?

a. Sonographic findings of a gallbladder polyp include a filling defect which does not move with change in position
b. Benign gallbladder polyps can cause symptoms similar to those caused by gallstones
c. Ultrasonography can readily distinguish benign from malignant gallbladder lesions
d. An asymptomatic gallbladder polyp 1 cm in size can usually be followed with serial ultrasounds and does not require cholecystectomy
Answer: a, b

156. The following statement(s) is/are true concerning the surgical therapy of cholangiocarcinomas.

a. A resectable distal bile duct carcinoma is best treated by a Whipple procedure
b. Klatskin tumors may require hepatic resection in attempt for potential cure
c. Regardless of the surgical resection for proximal biliary tumors, stenting of the biliary anastomosis is important
d. Complete hepatic resection with hepatic transplantation has been associated with overall good results
Answer: a, b, c

157. The following statement(s) is/are true concerning carcinoma of the bile ducts.

a. Carcinoma of the bile ducts is more common than gallbladder carcinoma
b. Similar to gallbladder cancer, bile duct cancer is more common in females
c. Unlike gallbladder cancer, there is no association of bile duct cancer and gallstones
d. Ulcerative colitis is associated with an increased incidence of bile duct cancer
e. Choledochal cysts may be associated with the development of bile duct cancer
Answer: d, e

158. Which of the following statement(s) is/are true concerning the association of gallstones with gallbladder cancer?

a. The association of gallbladder cancer with gallstones is such that young patients with asymptomatic gallstones should undergo routine cholecystectomy
b. Calcification of the wall of the gallbladder is associated with an increased incidence of gallbladder cancer
c. Larger gallstones are associated with a greater risk of gallbladder cancer than smaller gallstones
d. The 20 year risk of developing gallbladder carcinoma in patients in the general population with gallstones is approximately 1%
Answer: b, c

159. A 65-year-old man presents with obstructive jaundice. The patient’s workup begins with a CT scan. Which of the following statement(s) is/are true concerning his diagnosis?

a. A CT scan demonstrating intrahepatic biliary obstruction with a decompressed gallbladder and a nondilated extrahepatic biliary tree will be consistent with a Klatskin tumor
b. The presence of biliary obstruction seen on the CT scan requires further evaluation with invasive cholangiography either percutaneously or endoscopically
c. Percutaneous transhepatic cholangiography would be the preferred technique for a suspected proximal cholangiocarcinoma in that it will better visualize the proximal extent of the tumor in the biliary tree
d. The placement of a transhepatic biliary catheter can prove useful in surgical management of proximal bile duct cancers
e. There is little role for angiography in the evaluation of a patient with suspected cholangiocarcinoma
Answer: a, b, c, d

160. Benign gallbladder and bile duct tumors are extremely rare. Which of the following statement(s) is/are true concerning benign biliary tumors?

a. Cholesterol polyps are due to foamy macrophages filled with cholesterol
b. Inflammatory polyps and cholesterol polyps are not considered to be premalignant
c. Gallbladder adenomas, like adenomas in other gastrointestinal organs, are considered premalignant
d. Most gallbladder adenomas are associated with gallstones
e. An adenomyoma is a mucosal lesion of the gallbladder not considered to be premalignant
Answer: a, b, c

161. Which of the following statement(s) concerning bile duct strictures due to chronic pancreatitis is/are true?

a. Most patients present with progressive jaundice
b. Strictures are classically long and tapered involving the entire intrapancreatic bile duct
c. Patients may be asymptomatic and diagnosed only by persistent elevation of serum alkaline phosphatase
d. An excellent option for surgical management is choledochoduodenostomy
Answer: b, c, d

162. If a bile duct injury is suspected at laparoscopic cholecystectomy, appropriate management includes which of the following?

a. Conversion to open cholecystectomy and intraoperative cholangiography
b. Small ducts (< 3 mm) demonstrated by cholangiography to drain a single liver segment can be ligated
c. If the injured segment is greater than 1 cm. in length an end-to-end ductal anastomosis is the procedure of choice
d. Postoperative external drainage should be avoided
Answer: a, b

163. Which of the following statement(s) is/are true concerning the incidence of bile duct injury following cholecystectomy?

a. Data from the pre-laparoscopic cholecystectomy era would suggest the incidence of bile duct injury during open cholecystectomy to be 0.1–0.2%
b. The current incidence of bile duct injury during laparoscopic cholecystectomy is greater than 1%
c. The experience of the surgeon performing laparoscopic cholecystectomy can be correlated with the incidence of bile duct injury
d. Intraoperative cholangiography during laparoscopic cholecystectomy will prevent bile duct injury in virtually all cases
Answer: a, c

164. Primary sclerosing cholangitis has a number of treatment options—both medical and surgical. Which of the following statement(s) is/are true?

a. A number of immunosuppressive oral agents can provide specific effective treatment for primary sclerosing cholangitis
b. Biliary reconstruction with long-term transanastomotic stents can be useful in selected patients with focal strictures at the hepatic duct bifurcation
c. Biliary reconstruction should be reserved only for patients with established biliary cirrhosis
d. Hepatic transplantation for primary sclerosing cholangitis can be associated with survival rates similar to other indications for transplantation
Answer: b, d

165. The following statement(s) regarding the elective repair of a bile duct stricture is/are true:

a. A transanastomotic stent is necessary for a successful result
b. Long-term stenting for approximately one year is necessary for an anastomosis performed at the distal common hepatic duct
c. A Roux-en-Y hepaticojejunostomy provides the best route for restoring biliary-enteric continuity
d. Preoperatively-placed biliary catheters facilitate dissection and identification of the stricture and are useful in placement of transanastomotic stents when employed
Answer: c, d

166. The vast majority of benign bile duct strictures occur following operations in or near the right upper quadrant. Other causes of benign bile duct strictures include:

a. Chronic pancreatitis
b. Ulcerative colitis
c. Primary sclerosing cholangitis
d. Intrahepatic arterial infusion of 5-fluorouracil
Answer: a, c, d

167. A 37-year-old female presents with obstructive jaundice due to a mid-bile duct stricture four months after laparoscopic cholecystectomy. Which of the following statement(s) are true:

a. Surgical reconstruction is the only option for management of this patient
b. Excellent long-term results can be expected in approximately 80% of patients following surgical biliary reconstruction
c. One year follow-up after successful repair is satisfactory regardless of the method of management
d. Surgical reconstruction offers a better chance of long-term success than either percutaneous or endoscopic dilatation
Answer: b, d

168. Most patients with postoperative bile duct strictures after cholecystectomy present early after their initial operation. Patients may present in which of the following manner(s)?

a. Obstructive jaundice
b. An external biliary fistula
c. Progressive accumulation of bile in the peritoneal cavity (bile ascites)
d. Biliary cirrhosis
Answer: a, b, c

169. Nonoperative dilatation, performed either endoscopically or percutaneously, can be successfully employed in which of the following etiologies of bile duct strictures?

a. Postoperative bile duct strictures following a hepaticojejunostomy used for reconstruction during a Whipple procedure
b. Complete transection of the bile duct during laparoscopic cholecystectomy (the so-called “classic laparoscopic cholecystectomy injury”)
c. Primary sclerosing cholangitis
d. Oriental cholangiohepatitis
Answer: a, c

170. The gold standard for evaluation of patients with bile duct strictures is cholangiography. The two routes for cholangiography are percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiography (ERC). Which of the following statement(s) is/are true?

a. PTC is generally more valuable than ERC in defining the proximal biliary tree to be used in reconstruction
b. ERC is technically easier in patients with bile leaks because the biliary tree is usually not dilated
c. Parenteral antibiotics should be administered prior to either procedure to prevent cholangitis
d. Biliary stents can be placed via either technique to control biliary leaks
Answer: a, b, c, d

171. The management of a suspected bile duct injury depends on a number of factors, most importantly the mode and timing of presentation. Which of the following statement(s) is/are true concerning a patient presenting with a suspected bile leak after laparoscopic cholecystectomy?

a. Laparotomy should be performed immediately
b. Cholangiography should be performed to determine the nature of the injury
c. Operatively-placed drains should be removed to allow the fistula to close
d. The patient should be discharged to home to allow the leak to close spontaneously
Answer: b

HEPATOBILIARY PANCREATIC SURGERY Questions and Answers pdf Download