Post-Test Questions

 

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Article 1 (253–258)

1. Bilirubin is derived from the catabolism of hemecontaining proteins, the majority of which originates from senescent red blood cells

   • True

   • False

2. All of the following produce a cholestatic pattern to abnormal liver function tests EXCEPT:

   • Primary biliary cirrhosis

   • Viral hepatitis

   • Autoimmune cholangitis

   • Hemochromatosis

   • Primary sclerosing cholangitis

3. Clinical signs of jaundice occur when

   • The serum bilirubin level exceeds 2.5 to 3 mg/dL

   • Indirect serum bilirubin level exceeds 1.5 mg/dL

   • Alkaline phosphatase level exceeds 100 IU/L

   • All of the above cause clinical signs of jaundice

   • There is no threshold

   Article 2 (259–267)

4. In patients with malignant biliary obstruction, covered self-expanding metal stents typically become occluded prior to patient death?

   • True

   • False

5. Which of the following is CORRECT regarding drainage procedures for malignant biliary obstruction?

   • Percutaneous techniques are preferred as the initial procedure.

   • Recanalization techniques are more successful with percutaneous techniques than with endoscopic techniques.

   • Cholangitis is more common following endoscopic drainage because of the stents crossing the ampulla.

   • Bismuth IV obstructions are best treated by percutaneous techniques.

   • None of the above are correct.

6. Goals for imaging patients with biliary obstruction are all of the following EXCEPT:

   • Distinction between benign and malignant strictures

   • Guidance of tissue sampling

   • Assessment of the extent of local disease

   • Exclusion of distant metastases

   • All of the above are goals for imaging

   Article 3 (268–276)

7. In Western societies, what is the most common site of bile duct stone formation?

   • Gallbladder

   • Intrahepatic bile duct

   • Extrahepatic bile duct

   • Pancreatic duct

8. Noninvasive imaging of the biliary tree is accomplished with which of the following?

   • Endoscopic retrograde cholangiopancreatography (ERCP)

   • Percutaneous transhepatic cholangiography (PTC)

   • Endoscopic ultrasound (EUS)

   • Magnetic resonance cholangiopancreatography (MRCP)

9. Which of the following is the most common method for the management of choledocholithiasis?

   • Endoscopic

   • Open surgical

   • Laparoscopic surgical

   • Percutaneous

   Article 4 (277–282)

10. The most accurate diagnostic test for diagnosing acute acalculous cholecystitis is:

    • Ultrasound

    • Computed tomography

    • Nuclear medicine HIDA scan

    • Magnetic resonance cholangiopancreatography

11. The most sensitive modality for evaluating biliary collections in a postoperative patient is:

    • Computed tomography

    • Ultrasound

    • Magnetic resonance cholangiopancreatography

    • Nuclear medicine HIDA scan

12. Malignant obstruction of the biliary system can be inferred on CT with the presence of

    • Biliary ductal dilation

    • Filling defects within the biliary tree

    • Short segment narrowing

    • Enhancing soft tissue within or encircling the bile duct

    Article 5 (283–290)

13. Which of the following is associated with a LEFT-sided approach to percutaneous transhepatic cholangiography?

    • Increased risk of pneumothorax

    • Increased radiation exposure to the operator

    • Easier manipulation into the common duct

    • Tract maturation prior to intervention

    • Mandatory use of ultrasound

14. Management of malignant strictures is generally preferred with which of the following?

    • Plastic stents due to superior patency compared to metal stents

    • Only bare metal stents due to ease of relocation and removal

    • Only PTFE-covered metal stents

    • Either uncovered or covered metal stents

    • Stent selection is inconsequential

15. A 72-year-old man with suspected biliary cancer awaiting tissue diagnosis is admitted to your service. He had a cholecystectomy at the age of 36 years. After a failed ERCP, the patient complains of abdominal pain and becomes febrile, hypotensive, and confused. Laboratory results reveal signifi cant leukocytosis, hyperbilirubinemia, and transaminitis. In addition to starting antibiotics and IV fl uids, which of the following is the best next step in management?

    • Immediate cholangioscopy for visualization of the stricture

    • External biliary decompression and possible reintervention for stent placement

    • Radiation oncology consultation for intraluminal brachytherapy

    • Percutaneous stone extraction for suspected gallstone impaction

    • Exfoliative cytology prior to stent placement

    Article 6 (291–296)

16. Which of the following is not an indication for percutaneous cholecystostomy?

    • Severe (grade 3) acalculous cholecystitis

    • Moderate (grade 2) calculous cholecystitis

    • Acute cholangitis

    • Mild (grade 1) calculous cholecystitis

17. When deciding between transhepatic and transperitoneal approaches for percutaneous cholecystostomy, the transperitoneal route is preferred in which of the following scenarios:

    • The patient has known ascites

    • The patient has diff use hepatic metastases

    • Ultrasound demonstrates interposed bowel between the abdominal wall and gallbladder

    • The gallbladder wall is emphysematous or friable

18. The most common overall complication of percutaneous cholecystostomy is:

    • Tube dislodgement

    • Bleeding requiring transfusion

    • Bile leak

    • Bowel perforation

    Article 7 (297–306)

19. Which of the following is true regarding the epidemiology of biliary strictures?

    • IgG4 sclerosing cholangitis is the most common cause of benign biliary strictures.

    • Iatrogenic injury is the most common cause of benign strictures in the United States.

    • Cholangiocarcinoma is a rare cause of malignant biliary strictures.

    • Diff erentiation of benign from malignant causes is always easily accomplished using imaging and clinical data.

    • The majority of all biliary strictures are benign.

20. Which of the following is true regarding iatrogenic biliary strictures?

    • Strictures occur in up to 50% of orthotopic liver transplant patients.

    • Strictures occur in up to 10% of patients following cholecystectomy.

    • Anastomotic strictures following liver transplant occur due to hepatic venous compromise.

    • Hepatic arterial ischemia causes nonanastomotic strictures in liver transplant patients.

    • The most common form of iatrogenic biliary injury resulting in biliary obstruction is ligation of the common bile duct during cholecystectomy.

21. Which of the following is true regarding the treatment of benign biliary strictures?

    • PTC with PBD is considered first-line therapy in patients with normal, nonsurgical anatomy.

    • Plastic stents have a greater long-term patency rate than fully covered metallic stents.

    • Fully covered self-expandable metallic stents are not indicated in the treatment of benign strictures.

    • Bare metal stents are preferred over plastic stents due to higher patency rates.

    • Percutaneous therapy generally consists of balloon dilation with sequential catheter upsizing.

    Article 8 (307–312)

22. The use of hepatobiliary cholescintigraphy and MRCP as diagnostic imaging modalities can be useful for the detection of biliary leaks. Which of the following is an advantage of cholescintigraphy in detecting bile leaks?

    • Cholescintigraphy is able to demonstrate active physiologic leakage of bile and show continuity of intra-abdominal fluid collections with the biliary system.

    • Cholescintigraphy is a much quicker exam compared to MRCP.

    • Cholescintigraphy alone has better special resolution compared to MRCP.

    • Precise location of biliary leaks is better determined with cholescintigraphy.

23. All of the following are relative contraindications to performing PTC/PTBD placement, EXCEPT:

    • Large volume ascites.

    • Cholangitis

    • Coagulopathy

    • Iodine contrast medium allergy

24. Which of the following is an advantage of using CT-guided biliary drainage compared to ultrasound?

    • Decreased radiation exposure

    • Detailed information of surrounding intra-abdominal anatomy

    • Use of real-time imaging capability and easier identifi cation of nearby superfi cial vascular structures.

    • Easier to maintain access point with patients who move

    Article 9 (313–323)

25. In which of the following patients would there be a clear preference for percutaneous intervention over ERCP?

    • DA neonate with cholestatic jaundice and nondiagnostic MRCP

    • A 12-year-old girl with jaundice and pruritus secondary to a common bile duct stricture

    • A 2-year-old girl who presents with obstructive jaundice secondary to biliary rhabdomyosarcoma

    • A 6-year-old boy with history of Kasai portoenterostomy who presents with biliary obstruction and cholangitis

26. In which of the following patients would there be a clear preference for medical management over percutaneous cholecystostomy?

    • A critically ill 12-year-old boy with severe burns, CT evidence of acute acalculous cholecystitis, and deteriorating clinical status

    • A 4-year-old boy with a pancreatic head mass causing biliary obstruction in whom attempts at biliary drainage by ERCP and PTC have been unsuccessful

    • A 12-year-old girl with EBV infection, findings of acalculous cholecystitis on right upper quadrant sonography, and no signs of peritonitis

    • A 9-year-old boy admitted to the intensive care unit following motor vehicle accident trauma who develops acute acalculous cholecystitis and is considered a poor surgical candidate

27. Which of the following measures would be preferred in a 12-year-old boy with non-Hodgkin lymphoma who is felt to have a favorable prognosis and presents with jaundice due to porta hepatis lymphadenopathy?

    • Chemotherapy

    • ERCP with plastic stent placement

    • Percutaneous cholecystostomy

    • PTC with metallic stent placement

    Article 10 (324–331)

28. Potential causes of hemobilia include:

    • Blunt liver trauma

    • Iatrogenic injury

    • Inflammatory conditions

    • Neoplasm

    • All of the above

29. Endovascular therapy in the treatment of hemobilia is successful in what percentage of cases?

    <10%

    20–40%

    40–60%

    75–100%

30. Which of the following is TRUE regarding biliary tract bleeding?

    • The clinical triad of jaundice, upper abdominal pain, and obscure upper GI bleeding is known as Quincke triad.

    • Only 10% of patients will have all three symptoms of Quincke triad.

    • The biliary tract derives approximately 50% of its vascular supply from the portal vein.

    • Biliary tract bleeding is more commonly from the cystic artery than intraparenchymal hepatic artery branches.

    • All of the above are true

    Article 11 (332–336)

31. What is the female:male predominance of gallstone disease?

    • 1:1

    • 3:1

    • 4.5:1

    • 10:1

32. What is the cause of Mirizzi syndrome?

    • Internal compression of the gallbladder

    • Extrinsic compression of the hepatic duct by gallstone

    • Extrinsic compression of the cystic duct by gallstones

    • Idiopathic degeneration of the common hepatic duct

33. Which of the following statements about Mirizzi syndrome is FALSE?

    • Mirizzi syndrome has been associated with an increased frequency of gallbladder cancer.

    • Most patients present with jaundice, fever, and right upper quadrant pain.

    • Mirizzi syndrome occurs when a gallstone becomes impacted within the common hepatic duct.

    • Surgery is the mainstay of therapy for Mirizzi syndrome.