GALLBLADDER DISEASES

Question 1

What is the predominant type of gallstones found in Western industrialized countries?

A. Pigment stones
B. Mixed stones
C. Cholesterol stones
D. Calcium phosphate stones

Answer 1

Correct Answer: C. Cholesterol stones
Rationale: Cholesterol stones account for >90% of all gallstones in Western industrialized countries.

Question 2

What is a key distinguishing feature of cholesterol gallstones?

A. Composed primarily of calcium bilirubinate
B. Contains >50% cholesterol monohydrate
C. Always associated with chronic infection
D. Contains <20% cholesterol

Answer 2

Correct Answer: B. Contains >50% cholesterol monohydrate
Rationale: Cholesterol gallstones contain >50% cholesterol monohydrate and may also include calcium salts, bile pigments, proteins, and fatty acids.

Question 3

Which type of gallstone is most commonly associated with chronic biliary infection?

A. Cholesterol stones
B. Black pigment stones
C. Brown pigment stones
D. Mixed stones

Answer 3

Correct Answer: C. Brown pigment stones
Rationale: Brown pigment stones are primarily composed of calcium bilirubinate and are associated with chronic biliary infection.

Question 4

Which condition is most commonly associated with the development of black pigment gallstones?

A. Chronic biliary infection
B. Chronic hemolytic states
C. High dietary cholesterol
D. Acute cholecystitis

Answer 4

Correct Answer: B. Chronic hemolytic states
Rationale: Black pigment stones are primarily composed of calcium bilirubinate and are associated with chronic hemolytic states due to increased conjugated bilirubin in bile.

Question 5

In which of the following patients are black pigment gallstones most likely to form?

A. A patient with a history of chronic biliary infections
B. A patient with Gilbert’s syndrome
C. A patient with high dietary cholesterol intake
D. A patient with obesity and no underlying conditions

Answer 5

Correct Answer: B. A patient with Gilbert’s syndrome
Rationale: Black pigment stones are common in patients with conditions like Gilbert’s syndrome, which is associated with altered bilirubin metabolism.

Question 6

What is the primary composition of black pigment gallstones?

A. Cholesterol monohydrate
B. Calcium bilirubinate or polymer-like complexes
C. Fatty acids and bile pigments
D. Calcium phosphate

Answer 6

Correct Answer: B. Calcium bilirubinate or polymer-like complexes
Rationale: Black pigment stones are composed of pure calcium bilirubinate or polymer-like complexes with calcium and mucin glycoproteins.

Question 7

What is the most characteristic symptom of gallstone disease?

A. Intermittent left lower quadrant pain
B. Severe, steady epigastric or right upper quadrant pain
C. Vague epigastric fullness and flatulence
D. Severe pain relieved by biliary contractions

Answer 7

Correct Answer: B. Severe, steady epigastric or right upper quadrant pain
Rationale: The hallmark symptom of gallstone disease is biliary colic, a severe and steady ache in the epigastrium or RUQ, often radiating to the right scapula or shoulder.

Question 8

What is Murphy’s sign, and what does its presence indicate?

A. Pain radiating to the left shoulder during deep breathing; indicates pancreatitis
B. Pain or inspiratory arrest during subcostal palpation of the right upper quadrant; indicates acute cholecystitis
C. Rebound tenderness in the right lower quadrant; indicates appendicitis
D. Jaundice with deep palpation; indicates liver disease

Answer 8

Correct Answer: B. Pain or inspiratory arrest during subcostal palpation of the right upper quadrant; indicates acute cholecystitis
Rationale: Murphy’s sign is specific to gallbladder inflammation and is elicited when the patient experiences pain or arrests inspiration during palpation of the right upper quadrant.

Question 9

Which imaging modality is most commonly used for diagnosing acute cholecystitis?

A. CT scan
B. MRI
C. Ultrasound
D. Radionuclide biliary scan (HIDA scan)

Answer 9

Correct Answer: C. Ultrasound
Rationale: Ultrasound is the first-line imaging modality for diagnosing acute cholecystitis. It detects gallstones in 90–95% of cases and signs of inflammation, such as gallbladder wall thickening, pericholecystic fluid, and bile duct dilation.

Question 10

What is the hallmark triad of acute cholecystitis?

A. Fever, jaundice, and RUQ tenderness
B. Sudden onset of RUQ tenderness, fever, and leukocytosis
C. Progressive jaundice, hypotension, and confusion
D. Nausea, vomiting, and abdominal rigidity

Answer 10

Correct Answer: B. Sudden onset of RUQ tenderness, fever, and leukocytosis
Rationale: The combination of RUQ tenderness, fever, and leukocytosis strongly suggests acute cholecystitis.

Question 11

Which of the following is a primary risk factor for emphysematous cholecystitis?

A. Young age and obesity
B. Advanced age and diabetes mellitus
C. Female gender and pregnancy
D. Chronic liver disease

Answer 11

Correct Answer: B. Advanced age and diabetes mellitus
Rationale: Emphysematous cholecystitis occurs most frequently in elderly men and patients with diabetes mellitus due to impaired immune response and vascular compromise.

Question 12

Which organisms are most commonly associated with emphysematous cholecystitis?

A. Staphylococcus aureus and Streptococcus pyogenes
B. Clostridium species and E. coli
C. Klebsiella species and Pseudomonas aeruginosa
D. Salmonella species and Campylobacter jejuni

Answer 12

Correct Answer: B. Clostridium species and E. coli
Rationale: Emphysematous cholecystitis is caused by gas-producing organisms, including anaerobes such as Clostridium welchii or C. perfringens and aerobes such as E. coli.

Question 13

What is the preferred treatment for emphysematous cholecystitis?

A. Observation and supportive care
B. Antibiotics alone
C. Immediate surgical intervention and antibiotics
D. Endoscopic drainage of the gallbladder

Answer 13

Correct Answer: C. Immediate surgical intervention and antibiotics
Rationale: Emphysematous cholecystitis has high morbidity and mortality. Prompt surgical intervention (cholecystectomy) along with appropriate antibiotics is mandatory to control infection and prevent complications.

Question 14

Which of the following is the most appropriate choice for intravenous antibiotic therapy in a patient with severe acute cholecystitis?

A) Azithromycin
B) Piperacillin plus tazobactam
C) Amoxicillin
D) Vancomycin

Answer 14

Correct Answer: B) Piperacillin plus tazobactam

Rationale:
Intravenous antibiotic therapy in severe acute cholecystitis targets common organisms like E. coli, Klebsiella, Enterococcus, Enterobacter, and Streptococcus. Piperacillin plus tazobactam is an effective combination that covers these organisms and is widely used in this scenario.

Effective antibiotics include piperacillin plus tazobactam, imipenem, meropenem, ceftriaxone plus metronidazole, and levofloxacin plus metronidazole

Question 15

Which of the following is the preferred timing for surgical intervention in patients with uncomplicated acute cholecystitis?

A) Within 24 hours of diagnosis
B) Within 48–72 hours of diagnosis
C) More than 6 weeks after diagnosis
D) Immediately following diagnosis, regardless of the patient’s condition

Answer 15

Correct Answer: B) Within 48–72 hours of diagnosis

Rationale:
For patients with uncomplicated acute cholecystitis, the optimal timing for surgery is early elective laparoscopic cholecystectomy, ideally performed within 48–72 hours after diagnosis. Early surgery within this timeframe is associated with a lower complication rate and shorter hospital stays compared to delayed surgery, which is typically reserved for high-risk patients or those with uncertain diagnoses.

Question 16

Which of the following patients is MOST likely to undergo percutaneous drainage (cholecystostomy tube) instead of immediate surgery for acute cholecystitis?

A) A stable patient with uncomplicated acute cholecystitis
B) An elderly patient with multiple comorbidities and a high surgical risk
C) A patient with mild cholecystitis without complications
D) A patient with acute cholecystitis who is diagnosed early within 48 hours

Answer 16

Correct Answer: B) An elderly patient with multiple comorbidities and a high surgical risk

Rationale:
Percutaneous drainage (cholecystostomy tube) is often used in seriously ill or debilitated patients, particularly those who are not surgical candidates due to high risks, such as the elderly with multiple comorbidities. This approach can help stabilize the patient, and elective surgery may be performed at a later date.

Question 17

Which of the following complications would make urgent cholecystectomy or percutaneous cholecystostomy the most appropriate intervention in a patient with acute cholecystitis?

A) Mild nausea and vomiting
B) Empyema, emphysematous cholecystitis, or perforation
C) Abdominal distension without fever
D) Jaundice without abdominal pain

Answer 17

Correct Answer: B) Empyema, emphysematous cholecystitis, or perforation

Rationale:
Urgent (emergency) cholecystectomy or percutaneous cholecystostomy is most appropriate in patients with acute cholecystitis complicated by conditions such as empyema, emphysematous cholecystitis, or perforation. These conditions require prompt intervention due to their potential for serious morbidity and mortality. Mild symptoms like nausea and abdominal distension do not typically warrant such urgent interventions.

Question 18

What is the classic triad of symptoms associated with acute cholangitis?

A) Biliary pain, fever, and nausea
B) Biliary pain, jaundice, and spiking fevers with chills
C) Abdominal distension, vomiting, and fever
D) Jaundice, hypotension, and confusion

Answer 18

Correct Answer: B) Biliary pain, jaundice, and spiking fevers with chills

Rationale:
The characteristic presentation of acute cholangitis, known as Charcot’s triad, includes biliary pain, jaundice, and spiking fevers with chills. These symptoms are indicative of biliary obstruction and infection. Nausea, vomiting, and confusion may be present in severe cases, but they are not part of the classic triad.

Question 19

What is the most common cause of acute cholangitis?

A) Viral hepatitis
B) Gallstones causing bile duct obstruction
C) Pancreatitis
D) Hepatic cirrhosis

Answer 19

Correct Answer: B) Gallstones causing bile duct obstruction

Rationale:
The most common cause of acute cholangitis is biliary obstruction, often caused by gallstones, which can block the bile duct and lead to infection. Other causes may include tumors or strictures, but gallstones are the most frequent. Viral hepatitis and pancreatitis can cause biliary symptoms but are not the primary causes of cholangitis.

Question 20

Which of the following is a distinguishing feature of suppurative acute cholangitis compared to nonsuppurative acute cholangitis?

A) Jaundice
B) Mental confusion, bacteremia, and septic shock
C) Biliary pain
D) Blood culture positivity

Answer 20

Correct Answer: B) Mental confusion, bacteremia, and septic shock

Rationale:
Suppurative acute cholangitis is a severe form characterized by the presence of pus under pressure in a completely obstructed ductal system. This leads to severe systemic toxicity, including mental confusion, bacteremia, and septic shock. Nonsuppurative cholangitis is less severe and typically responds to antibiotics and supportive care without such complications.

Question 21

Which of the following is the most appropriate initial intervention for a patient with acute suppurative cholangitis?

A) Broad-spectrum antibiotics alone
B) Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
C) Intravenous hydration and pain management
D) Percutaneous cholecystostomy without drainage

Answer 21

Correct Answer: B) Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy

Rationale:
In acute suppurative cholangitis, prompt decompression of the obstructed bile duct is critical to prevent further progression of sepsis and organ failure. ERCP with endoscopic sphincterotomy is the preferred initial intervention as it allows for both diagnosis and therapeutic relief of the obstruction. Antibiotics alone are generally insufficient in severe cases

Question 22

Which of the following is the most appropriate management for a patient with nonsuppurative acute cholangitis?

A) Endoscopic drainage immediately
B) Antibiotics and supportive care
C) Open surgical drainage of the bile duct
D) Observation without antibiotics

Answer 22

Correct Answer: B) Antibiotics and supportive care

Rationale:
In nonsuppurative acute cholangitis, patients typically respond to antibiotics and supportive care. These patients generally do not require immediate endoscopic or surgical intervention unless there are signs of worsening infection or biliary obstruction. In contrast, suppurative cholangitis requires urgent drainage and may not respond to antibiotics alone.