Internal - Diseases of the Gallbladder and Bile Ducts

Question 1

Which one is the most important factor in gall clearence?

A) gastrin
B) nitrogen monoxide
C) secretin
D) cholecystokinin
E) VIP

Answer 1

D) cholecystokinin

The hormonal regulation by cholecystokinin (CCK) is the most important factor in postprandial gallbladder contractions, cholinerg mechanism is less important. CCK, which is secreted in as a consequence of a meal relaxes the Oddi sphincter, which facilitates the transposition of the bile to the duodenum. In addition to CCK, secretin is another important agent relaxing the Oddi sphincter. Moreover, noradrenergic and cholinergic neurons secreting VIP and nitrogen monoxide are also involved in relaxing the Oddi sphincter (see also BGY-8.6.)

Question 2

Which one is the most frequent gallstone?

A) Cholesterol stone
B) Bilirubin stone
C) Mixed stone
D) Oxalate stone

Answer 2

A) Cholesterol stone

There are two main types of gallstones. Cholesterol stones are the most frequent in the Western world (75-80%), while bilirubin stones are more frequent in Asia. Cholesterol stones are generated in the gallbladder, while bilirubin stones can also be generated in the bile ducts. Note that oxalate stones are generally kidney stones.

Question 3

Which symptom is not characteristic to disorders of biliary excretion?

A) abdominal distension
B) ”fullness” feeling
C) severe steatorrhoea
D) abdominal discomfort
E) pain under the right ribs

Answer 3

C) severe steatorrhoea

Abdominal distension and discomfort, ”fullness” feeling and pain under the right ribs are all characteristic to disorders of biliary excretion. However, severe steatorrhoea is characteristic to malabsorption and pancreatic insufficiency. In physiological cases, with a daily 75 g fat intake the daily excreted faeces consists no more than 7 g of fat. However, in cases of malabsorption 20-40% and in cases of pancreatic insufficiences 60% of the daily fat intake can be excreted with the faeces resulting in severe steatorrhoea.

Question 4

How often is the outlet of the ductus choledochus and the ductus pancreaticus joint (Ampulla of Vater)?

A) 10%
B) 30%
C) 50%
D) 70%
E) 90%

Answer 4

E) 90%

In 90% of the cases there is a joint duct and outlet of the ductus pancreaticus and the ductus choledochus resulting in the so-called Ampulla of Vater. Frequently, and accessorial pancreatic duct also exists (duct of Santorini) ending in the ductus pancreaticus in the majority of the cases, however sometimes an independent outlet may also be present. In 5-10% of the cases, when pancreas divisum exists ductus pancreaticus does not communicate with the ductus choledochus (see also BGY-8.27.).

Question 5

Which of the following agents facilitate biliary excretion?

1) CCK
2) secretin
3) bile salts
4) adrenalin

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 5

A) 1st, 2nd and 3rd answers are correct

Bile salts, secretin and cholecytokinin (CCK) also facilitate biliary excretion. The enterohepatic circulation stimulated by bile salts allocate bile to the liver resulting in biliary secretion. Biliary excretion is also facilitated by the bile secretion-stimulating effects of secretin. The hormonal regulation by cholecystokinin (CCK) is the most important factor in postprandial gallbladder contractions. CCK, which is secreted in as a consequence of a meal relaxes the Oddi sphincter, which facilitates the transposition of the bile to the duodenum. Stimulation of the nervus vagus also results in gallbladder contractions and relaxation of the Oddi sphincter, while sympatic stimulation (adrenalin) results in contrary consequences (see also BGY-8.1.).

Question 6

What is the procedure to choose in case of incidentally discovered gallstones not causing any symptomes?

1) surgical removal of the gallbladder
2) lithotripsy performed with ultrasound
3) starting a lasting gallstone solubilizer medication
4) informing the patient of the gallstones and personalized therapeutic consideration

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 6

D) only 4th answer is correct

Gallstones do not cause symptoms in a large portion of the cases, these ”silent” stones generally do not require therapy, however the patients should be informed. Profylactic cholecystectomy in patinets without any symptoms is generally not justifiable. Symptoms occur in 20% of the patients. In these latter cases it is an indication for operation.

Question 7

Which of the following does decrease the spasm of the Oddi sphincter?

1) nitrates
2) chocolate
3) cholecystokinin
4) morphine

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 7

A) 1st, 2nd and 3rd answers are correct

Nitrates, chocolate and cholecystokinin decreases, while morphin increases the spasm of the Oddi sphincter. Cholecystokinin has a pivotal role in the postprandial relaxation of the Oddi sphincter. Chocolate also decreases the spasm of the Oddi sphincter. Additionally, nitrates may be therapeutically applied in cases of biliary colic. Contrary, giving major analgeticum (morphin) in cases of biliary colic is not recommended, because it may result in sphincter spasm enhancing the pain, and it may also mask the clinical manifestation of an acute abdominal catastrophe (perforation of the gallbladder).

Question 8

What are the indications of endoscopic sphincterotomy?

1) choledocholithiasis
2) Oddi-sphincter-dyskinesis
3) acute recidive gallbladder attack resulting in acute pancreatitis
4) carcinoma of the pancreatic head

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 8

A) 1st, 2nd and 3rd answers are correct

Indications for endoscopic sphincterotomy during ERCP include choledocholithiasis, Oddi-sphincter-dyskinesis and acute recidive gallbladder attack resulting in acute pancreatitis. Main aim of the intervention is to assure optimal bile excretion and flow and prevent the emergence of a secondary inflammation. Sphincterotomy is indispensable for the proper removal of a stone, however in cases of carcinoma of the pancreatic head only an operation can be curable. In palliative cases sphincterotomy is also inssufficient, since implantation of a stent is also needed.

Question 9

Which of the following procedures are useful for functional examination of the gallbladder?

1) liver scintigraphy
2) MRCP (magnetic resonance cholangiopancreatography)
3) intravenous urography
4) cholescintigraphy

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 9

C) 2nd and 4th answers are correct

Functional examination of the gallbladder and the bile ducts can be carried out using cholescintigraphy, cholangio-CT and cholangio-MR. During cholescintigraphy, isotope-labeled agents which are metabolised by the hepatocytes and secreted into the bile are administered and detected using gamma camera. In the case of obstruction of the bile ducts when ultrasound examination cannot detect the cause of the obstruction or when ERCP is not recommended, cholangio-CT and cholangio-MR might help the diagnosis. Nowadays classical oral or intravenous cholangiocholecystography is only rarely performed. Intravenous urography is a false answer.

Question 10

Which enzyme of the bile contributes to fat digestion?

1) lipase
2) cholic acid
3) colipase
4) neither of the aforementioned

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 10

D) only 4th answer is correct

Lipase and colipase are not bile components, while cholic acid is not enzyme, therefore the correct answer is that neither of them is an enzyme of the bile contributing to fat digestion. Fat digestion is performed in two, consecutive processes. Firstly, pancreatic lipase performs hydrolysis, which is followed by the dispersion of the fatty acids and the monoglycerides. During the enterohepatic circulation, bile acids are secreted into the bile, which is followed by their absorption from the bowel (see also BGY-8.16.).

Question 11

What is the Courvoisier-sign?

1) pain under the right ribs + jaundice + fever
2) jaundice + melaena + epigastric pain
3) fever + jaundice + tactile resistance in the upper abdomen
4) tactile, not painful enlarged gallbladder

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 11

D) only 4th answer is correct

In cases of carcinoma of the major duodenal papilla or of the pancreatic head, additionally to intensifying mechanical icterus, the enlargement of the gallbladder, which is not painful is also a major characteristic (Courvoisier-sign). It is separable from the obstruction from the ductus cysticus after biliary colic, which results in an enlarged, tactile gallbladder hydrops which is a painful, tense mass under the right ribs.

Question 12

Which of the following diseases can cause direct hyperbilirubinaemia?

1) Gilbert’s syndrome
2) Rotor syndrome
3) haemolysis
4) choledocholithiasis

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 12

C) 2nd and 4th answers are correct

Rotor syndrome and choledocholithiasis can cause direct hyperbilirubinaemia. Rotor syndrome is a rare, autosomal recessive disorder, when damage in the active transport results in the inhibited secretion of the conjugated bilirubin into the bile. The elevated levels of conjugated bilirubin in the blood results in direct hyperbilirubinaemia. Dubin-Johnson syndrome is similar to Rotor syndrome, however in Dubin-Johnson syndrome melanin accumulation in the hepatocytes results in macroscopically black liver. The majority of posthepatic icterus is due to choledocholithiasis, which results also in direct hyperbilirubinaemia.

Question 13

What is the most important differentiating laboratory parameter in cases of obstructive jaundice?

1) elevated direct bilirubin
2) elevated total bilirubin
3) elevated urinary UBG
4) no UBG in the urine

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 13

D) only 4th answer is correct

In cases of obstructive jaundice, urinary UBG levels decrease in accordance with the extent of the obstruction and, after total obstruction, urinary UBG is no longer detectable. The colour of the faeces is becoming lighter as well resulting in acholic faeces. In cases of prehepatic or hepatic jaundice, urinary UBG levels are elevated. In obstructive jaundice, total bilirubin and direct bilirubin levels are elevated, jaundice occurs in cases of partial obstruction as well.

Question 14

Which statements are true regarding biliary functions and blood cholesterol levels?

1) Elevated biliary functions elevate blood cholesterol levels.
2) Elevated biliary functions decrease blood cholesterol levels.
3) Elevated biliary functions elevate LDL levels.
4) Bile is the only elimination route for cholesterol from the body.

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 14

C) 2nd and 4th answers are correct

Cholesterol is insoluble in water, however it is soluble in the bile. Bile is the only elimination route for cholesterol from the body. Elevated biliary functions decrease blood cholesterol levels. If the amount of cholesterol increases beyond a level or the amount of bile acids decreases, cholesterol precipitates resulting in stone formation. Damaged biliary function (intrahepatic or extrahepatic jaundice) results in elevated levels of blood cholesterol (see also BGY-8.2. and BGY-8.18. - Card 2 & 15).

Question 15

Which of the following may be the complication of gallstones?

1) obstructive jaundice
2) acute pancreatitis
3) cholecystitis
4) chronic pancreatitis

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 15

E) all of the answers are correct

The most common complication of gallstones is obstructive jaundice, acute panreatitis and cholecystitis. In 15-20% of gallbladder stone cases, choledocholithiasis is present as well, which is the main cause of the obstructive jaundice. Gallstones jammed into the major duodenal papilla causes acute biliary pancreatitis. In some cases, the resence of gallstone or sludge is not present during the diagnosis, because it has already passed over the major duoenal papilla. In 90% of the acute cholecystitis cases, gallstone jammed into the ductus cysticus is the cause. Local irritation and refractory acute inflammations may cause chronic cholecystitis as well. In 4% of the chronic pancreatitis cases gallstones are the main cause of the disease (see also. BGY-8.17. - Card 14).

Question 16

Solubizing the gallstone which is smaller than 2 cm and has been formed during pregancy is advised later, because pregnancy is only a temporary state predisposing to gallstone formation.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 16

A) both the statement and the explanation are true and a causal relationship exists between them.

Pregnancy associates with elevated cholesterol secretion and decreased motility of the gallbladder and therefore is a temporary predisposition factor for gallstone formation. Orally administered bile acids may alter the components of the bile and therefore smaller gallstones may be solubilized. This can be true for gallstones formed during pregnancy as well. Therefore both statements are true and there is a causal link between them (see also BGY-8.7.).

Question 17

All gallstones should be surgically removed, because gallstone is formed only in permanently functionally damaged gallbladders.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 17

E) both the statement and the explanation are false

Gallbladders do not cause symptoms in the majority of the cases, these are the so-called ”silent” stones. In these cases, therapy is not advised, nor is surgical involvement needed. Clinical symptoms only arise in 20% of the patients, when surgical removal is the definitive therapy. Functionally damaged gallbladder is only one predisposing factor for gallstone formation (see also BGY-8.8. and BGY-8.31.).

Question 18

Sudden dieting does not predispose to gallstone formation, because environment in non-functioning gallbladders favors gallstone formation.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 18

D) the statement is false, but the explanation itself is true

Sudden dieting results in decreased bile acid synthesis, elevated cholesterol secretion to the bile and decreased motility of the gallbladder, all predisposing to gallstone formation. Environment in non-functioning gallbladders favors gallstone formation. First statement is false, second statement is true (see also BGY-8.7.).

Question 19

Laparoscopic cholecystectomy is a lower load for the patient compared to open cholecystectomy, because the abdomen is not opened in a large surface.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 19

A) both the statement and the explanation are true and a causal relationship exists between them.

Nowadays, laparoscopic cholecystectomy is more routinely used compared to open cholecystectomy. Since the abdomen is not opened on a large surface, laparoscopic cholecystectomy results in a lower load for patients, resulting in shorter hospitalization. Therefore both statements are true and there is a causal link between them.

Question 20

Abdominal ultrasound examination can detect gallbladder carcinoma with great security, therefore gallbladdder carcinoma is usually detected at early stage.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 20

E) both the statement and the explanation are false

Symptoms of gallbladder carcinoma are not characteristic and at early stage are the same as of cholelithiasis. One third of the patients do not have symptoms until the first general tumor symptoms arise. Laboratory findings are not characteristic. Abdominal ultrasound examination and other imaging techniques can only detect gallbladder cancer at later stages, when curative operations cannot be performed. Therefore the prognosis of gallbladder carcinoma is very poor: 80% of the cases are inoperable, five-year-survival is 1-3%, mean survival is 6 months. Both statements are false.

Question 21

Gallstones are generated in the gallbladder, because in the gallbladder the concentration of the bile is at least five fold.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 21

A) both the statement and the explanation are true and a causal relationship exists between them.

The role of the gallbladder in stone formation is complex. Bile concentration is a very important factor in this process. In case of motility disorder of the gallbladder and consequent bile stasis, the periodic dilution of concentrated bile is lacking, mucin gel accumulates, deconjugated bilirubin forms an insoluble complex with calcium, thus these processes contribute greatly to the lithogenicity of bile and stone formation. Therefore the statement and justification are both correct, with causality.

Question 22

Treatment of chronic abdominal complaints occurring after cholecystectomy is easy, because in these cases with the introduction of antacid treatment most symptoms can be ceased.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 22

E) both the statement and the explanation are false

The presence of abdominal complaints with biliary nature, occurring after cholecystectomy, with relation to the date of operation is called postcholecystectomy syndrome in the literature. The term of the syndrome indicates a temporal relationship with the operation, rather than a causal one. The etiological classification of the syndrome distinguishes biliary causes (e.g. residual stone, stenosis of the ampulla of Vater, postoperative stricture), extrabiliary causes (e.g. ulcer, gastroesophageal reflux disease), and functional diseases (e.g. irritable bowel syndrome, nonulcer dyspepsia). The treatment is often a professional challenge due to the diverse etiology. Antacid treatment ceases the symptoms only in a fraction of cases. Because of these, both the statement and the explanation are incorrect.

Question 23

Klatskin tumour can be easily removed surgically, because the tumour is located in the porta hepatis.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 23

D) the statement is false, but the explanation itself is true

Klatskin tumor, located in the porta hepatis, is usually unresectable at the time of the diagnosis. In case of resectable tumor the local resection has to be combined with liver resection, therefore is considered a hardly feasible operation. As palliative therapy the preparation of biliodigestive anastomosis, surgical or endoscopic stent implantation, chemoembolization, or irradiation come into question. Thus the statement is incorrect, the explanation itself is correct.

Question 24

The common bile duct (ductus choledochus) usually leads to the duodenum through the minor papilla, because the duct of Wirsung leads to the duodenum through the ampulla of Vater.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 24

D) the statement is false, but the explanation itself is true

The common bile duct and pancreatic duct (duct of Wirsung) have a short common section and common outlet (ampulla of Vater) in 90 percent of cases. An accessory pancreatic duct (duct of Santorini) is often present, leading to the pancreatic duct (duct of Wirsung), but may also end in an accessory pancreas papilla. In 5-10 percent of cases, in case of pancreas divisum, pancreatic duct (Wirsung) is not connected to the common bile duct and ends in the accessory minor papilla. Therefore the statement is incorrect, but the explanation itself is correct (see also BGY-8.5.).

Question 25

Ultrasound scan detects bile duct stones with great certainty, because ultrasound is absolute reliable in the detection of gallbladder stones as well.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 25

D) the statement is false, but the explanation itself is true

Although abdominal ultrasound is very efficient in detecting gallbladder stones, in the diagnosis of bile duct stones, despite of good specificity (80 percent) the sensitivity is low (60 percent), therefore ultrasound is unreliable in detecting bile duct stones. In case of suspicion of bile duct stones, exact diagnosis can be expected from invasive methods (ERCP, rarely percutaneous transhepatic cholangiography, PTC). Modern imaging methods (CT, CT-cholangiography, MR) have differential diagnostic role. Therefore the statement is incorrect, the explanation itself is correct.

Question 26

The surgical solution of bile duct stenoses is advised, when the intervention with ERCP is unsuccessful, because surgical intervention is cheaper than stent exchanges.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 26

C) the statement is true, but the explanation is false.

In case of benign bile duct stones, various balloon catheters can be applied, and endoprostheses, stents can be implanted through ERCP. If ERCP is unsuccessful, surgical solution is considered, however, the results of surgical methods for the solution of benign bile duct strictures are unsatisfactory. Surgery means a greater burden to patients, and it is neither cheaper, nor simpler technically, than stent exchange. Therefore, although the statement is true, the explanation is incorrect.

Question 27

Prophylactic antibiotic therapy in obstructive jaundice decreases the complication rate of ERCP, because the assurance of free bile flow is of secondary importance.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 27

C) the statement is true, but the explanation is false.

In case of obstructive jaundice the main goal of treatment is the cessation of bile flow obstruction (usually stone) and the prevention of secondary inflammation. The assurance of free bile flow is of primary importance. Prophylactic antibiotic therapy may reduce the rate of inflammatory complications of ERCP. In case of appropriate equipment and practiced endoscopy specialist the complication rate does not exceed 10 percent, and mortality is less than 1 percent. In case of cholangitis occurring as a consequence of bile duct stones, besides early ERCP, wide-spectrum antibiotic treatment is necessary, considering the severe complication. Thus the statement is correct, the explanation is not.

Question 28

In case of gallstones the first choice of treatment is always medical stone dissolution, because it is cheap and only 10% of gallstones recur within two years.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 28

E) both the statement and the explanation are false

Bile acid treatment dissolves or reduces gallstones in 1-3 years in 50-60 percent of patients. Great disadvantage of stone solution is its expense, and that after the cessation of treatment the stones recur shortly in 30-50 percent of cases. The definitive treatment of cholelithiasis is cholecystectomy. Thus both the statement and the explanation are incorrect (see also BGY-8.20.).

Question 29

Gallstone production is common in small bowel diseases, because in these cases the reabsorption of bile acids that keep the bile in solution is damaged.

A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 29

A) both the statement and the explanation are true and a causal relationship exists between them.

Diseases of the small intestine, especially the terminal ileum cause disturbed bile acid reabsorption, thereby the bile acid pool is reduced with a consequent bile acid hyposecretion. For these reasons diseases of the small intestine are important risk factors of gallstone production. Therefore the statement and explanation are correct, with causality.

Question 30

What is the first choice of examination?

A 45-year-old woman with known bile stones complains of a cramping, severe abdominal pain under the right ribs irradiating in the scapulae, beginning about 30 minutes after eating and associated by nausea. During physical examination she indicates a strong pain on pressure under the right ribs, and fluctuating resistance can be felt here.

A) abdominal CT
B) stomach X-ray
C) gastroscopy
D) abdominal US
E) chest X-ray

Answer 30

D) abdominal US

The first choice of examination is abdominal ultrasound, that confirms gallbladder stones in almost all of the cases, gives exact information about the size of the gallbladder, wall thickness, wideness of bile ducts, and surrounding organs.

Question 31

What labor test helps setting the correct diagnosis?

A 45-year-old woman with known bile stones complains of a cramping, severe abdominal pain under the right ribs irradiating in the scapulae, beginning about 30 minutes after eating and associated by nausea. During physical examination she indicates a strong pain on pressure under the right ribs, and fluctuating resistance can be felt here.

1) white blood cell count
2) serum-amylase
3) total urine
4) direct bilirubin

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 31

E) all of the answers are correct

All four examinations may help setting the diagnosis. Increased white blood cell count may refer to cholecystitis; elevated serum-amylase may confirm biliary pancreatitis; complete urinalysis, through the changes of bilirubinuria and urobilinogenuria may help differentiate between hepatocellular and mechanical icterus; direct bilirubin level my refer to the severity of jaundice and the extent of mechanical obstruction.

Question 32

What is the most probable diagnosis?

A 45-year-old woman with known bile stones complains of a cramping, severe abdominal pain under the right ribs irradiating in the scapulae, beginning about 30 minutes after eating and associated by nausea. During physical examination she indicates a strong pain on pressure under the right ribs, and fluctuating resistance can be felt here.

A) acute pancreatitis
B) gallstone ileus
C) gastric perforation
D) hydrops vesicae felleae
E) choledocholithiasis

Answer 32

D) hydrops vesicae felleae

The symptoms are typical for biliary colic. The painful, fluctuating resistance palpated during physical examination after the colic is gallbladder hydrops, that develops as a consequence of a gallstone stuck in the cystic duct. In old patients the hydrops has to be differentiated from the nontender gallbladder accompanied with escalating jaundice without colic (Courvoisier’s sign), which is typical for carcinoma of the ampulla of Vater and head of pancreas (see also BGY-8.13.).

Question 33

What therapuetic interventions are considered?

A 45-year-old woman with known bile stones complains of a cramping, severe abdominal pain under the right ribs irradiating in the scapulae, beginning about 30 minutes after eating and associated by nausea. During physical examination she indicates a strong pain on pressure under the right ribs, and fluctuating resistance can be felt here.

1) inserting a central venous catheter and administering nitrates
2) laparoscopic cholecystectomy
3) endoscopic sphincterotomy and stone extraction
4) complete fasting, conservative medical treatment

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 33

C) 2nd and 4th answers are correct

Medical treatment consists of complete fasting, fluid and electrolyte replacement, symptomatic treatment (parenteral analgesics and spasmolytics), and in case of inflammatory signs, also parenteral antibiotics. The definitive solution is cholecystectomy. According to the modern surgical approach, the preferred method is the so called early laparoscopic cholecystectomy, i.e. the operation has to be carried out within 24-72 hours after the presentation of symptoms. With early cholecystectomy severe, often life threatening complications (acute cholecystitis, gallbladder perforation, cholangitis, acute pancreatitis) can be prevented, hospitalization is shorter, treatment is less expensive.

Question 34

What is the next examination of choice?

A 78-year-old man is admitted to the hospital because of significant weight loss and jaundice. Abdominal US confirms a gallbladder without stone and dilated intrahepatic bile ducts, the extrahepatic bile ducts are not wider.

A) iv. cholescintigraphy
B) abdominal CT
C) ERCP
D) percutaneous transhepatic drainage

Answer 34

C) ERCP

Certain diagnosis is provided by ERCP, that accurately localizes the bile duct obstruction and gives information about the degree of obstruction. If ERCP cannot be carried out due to technical reasons or the general state of the patient, a non-invasive MR-cholangiography may help in the diagnosis. If endoscopy is insolvable (e.g. after Billroth’s II resection of the stomach, significant duodenum stenosis etc.), percutaneous transhepatic drainage may lead to diagnosis and serve as palliative treatment.

Question 35

Which laboratory results help in setting the diagnosis?

A 78-year-old man is admitted to the hospital because of significant weight loss and jaundice. Abdominal US confirms a gallbladder without stone and dilated intrahepatic bile ducts, the extrahepatic bile ducts are not wider.

1) normal CRP level
2) elevated erythrocyte sedimentation rate
3) high LDH level
4) elevated CEA level

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 35

C) 2nd and 4th answers are correct

Elevated erythrocyte sedimentation rate (ESR) and elevated CEA level may help setting the diagnosis. However, it has to be emphasized, that normal ESR does not exclude the possibility of malignancy; the sensitivity and specificity of CEA in bile duct (Klatskin) tumour is low (high level is found in only 20 percent of cases). CRP and LDH are less helpful in the diagnosis because of low specificity and sensitivity.

Question 36

What is the most probable diagnosis?

A 78-year-old man is admitted to the hospital because of significant weight loss and jaundice. Abdominal US confirms a gallbladder without stone and dilated intrahepatic bile ducts, the extrahepatic bile ducts are not wider.

A) acute cholecystitis
B) acute hepatitis
C) primary biliary cirrhosis
D) bile duct tumour (Klatskin)
E) pancreas head carcinoma

Answer 36

D) bile duct tumour (Klatskin)

Besides the anamnesis (old patient, weight loss, jaundice) the dilated intrahepatic bile ducts without extrahepatic dilation refer to proximal hilar bile duct (Klatskin) tumour. Weight loss and the lack of gallstones are against cholecystitis; elderly age, weight loss, dilated intrahepatic bile ducts are against acute hepatitis and primary biliary cirrhosis. In pancreas head carcinoma primarily the extrahepatic bile ducts are dilated.

Question 37

What is the treatment of choice?

A 78-year-old man is admitted to the hospital because of significant weight loss and jaundice. Abdominal US confirms a gallbladder without stone and dilated intrahepatic bile ducts, the extrahepatic bile ducts are not wider.

A) bypass surgery
B) ERCP, stent implantation
C) duodenal tube
D) treatment with ursodeoxycholic acid
E) bedrest, supportive treatment

Answer 37

B) ERCP, stent implantation

In case of resectable tumour the treatment of choice is naturally surgical resection. Klatskin tumour located in the hepatic hilum is often unresectable at the time of diagnosis. Therefore the solution of jaundice and possible palliative treatment may be stent implantation during ERCP. The resectability of the tumour is determined during surgical exploration after the cessation of jaundice.

Question 38

Typical symptoms of Caroli syndrome:

1) recurring cholangitis
2) haematuria
3) shaking chills, fever
4) peptic duodenal ulcer

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 38

B) 1st and 3rd answers are correct

Recurring cholangitis may appear in Caroli syndrome, with symptoms like shaking chills and fever and the development of septic state. Recurring cholangitis is caused by stasis and bacterial infection in the dilated bile ducts.

Question 39

Criterion of early cholecystectomy in case of gallstones:

1) jaundice
2) previous abdominal operation
3) cholangitis not responding to antibiotics
4) within 24-72 hours after the formation of symptoms

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 39

D) only 4th answer is correct

Early cholecystectomy can be carried out within 24-72 hours after the presentation of symptoms, because after this time the prevalence of complications raises.

Question 39

Morphological characteristics of Caroli syndrome:

1) fusiform dilation of intrahepatic bile ducts
2) crooked cystic duct
3) bile duct stenosis
4) shortened common bile duct

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 39

B) 1st and 3rd answers are correct

In Caroli syndrome both the dilation of intrahepatic bile ducts and bile duct stenosis may be present, thus B is the correct answer.

Question 40

Criterion of the solution of gallstones with bile acids:

1) permeable cystic duct
2) calcareous gallbladder
3) well contracting gallbladder
4) age above 50 years

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 40

B) 1st and 3rd answers are correct

The correct answer is B, because the criterion of gallstone solution with bile acid is that bile acids can reach the gallbladder, which is operable (able to contract).

Question 41

Characteristics of gallbladder polyps:

1) 95 percent are benign
2) can be detected with ultrasound
3) adenomas larger than 10 mm are precancerous
4) inflamed polyps are common

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 41

A) 1st, 2nd and 3rd answers are correct

The correct answer is A, because 95 percent of gallbladder polyps are benign, most of them can be detected with ultrasound, and in adenomas larger than 10 mm the possibility of malignant transformation emerges. Inflamed polyps do not occur.

Question 42

Characteristics of Mirizzi’s syndrome:

1) obstructive icterus
2) normal bilirubin level
3) dilated hepatic duct
4) diarrhoea

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 42

B) 1st and 3rd answers are correct

Mirizzi’s syndrome is characterized by obstructive icterus and dilated hepatic duct, because the stone in the gallbladder fundus presses the common bile duct, with the mentioned symptoms as consequences.

Question 43

Possible cause of gallbladder hypokinesia:

1) diabetes
2) extended starvation
3) pregnancy
4) steroid treatment

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 43

A) 1st, 2nd and 3rd answers are correct

Gallbladder hypokinesia may be caused by motility disorder associated with diabetes and pregnancy, and the lack of gallbladder contraction due to extended starvation.

Question 44

It can be typical symptom of tumour of the ampulla of Vater:

1) jaundice
2) fever
3) pruritus
4) diarrhoea

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 44

B) 1st and 3rd answers are correct

The ampulla of Vater obstructs bile flow, which causes jaundice, and jaundice leads to pruritus.

Question 45

Possible cause of postcholecystectomy syndrome:

1) cystic duct remnant syndrome
2) bile duct stenosis
3) remaining bile duct stone
4) gallstone ileus

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 45

A) 1st, 2nd and 3rd answers are correct

After cholecystectomy the long cystic duct remnant may compress bile ducts, stenoses may evolve during the operation, if bile ducts are injured. The surgeon may miss a stone in the bile ducts and leave it there. These are considered symptoms of the state after cholecystectomy.

Question 46

Characteristics of cholelithiasis:

1) can be detected in 10 percent of the population
2) more common in women than in men
3) its incidence increases with age
4) its prevalence does not change with age

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 46

A) 1st, 2nd and 3rd answers are correct

The first three answers are correct, the fourth is not, because the prevalence of cholelithiasis increases with age. The first three answers are based on epidemiological data.

Question 47

Characteristics of juxtapapillary diverticulum:

1) can be cause of chronic liver disease
2) endoscopic papillotomy is contraindicated
3) is often associated with bile duct malformations
4) raises the risk of bile duct stones

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 47

D) only 4th answer is correct

D is the correct answer, because juxtapapillary diverticulum raises the risk of bile duct stone by a supposed bile flow obstruction. It does not cause chronic liver disease, endoscopic papillotomy is not contraindicated anymore, and it is not often associated with bile duct malformations.

Question 48

The most common location of obstruction in gallstone ileus:

1) hepatic flexure
2) colonic diverticulum
3) duodenal diverticulum
4) ileocecal valve

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 48

D) only 4th answer is correct

D is the correct answer, because the gallstone that got in the bowel is usually stuck at the ileocecal valve, because bowel lumen is narrower here.

Question 49

Predisposing factors of acute acalculous cholecystitis, except:

1) prolonged starvation
2) immobility
3) hemodynamic instability associated with severe abdominal diseases
4) nonalcoholic steatohepatitis

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 49

D) only 4th answer is correct

D is the correct answer, because nonalcoholic steatohepatitis does not cause acalculous cholecystitis. The conditions listed as 1., 2., 3. cause gallbladder dysfunction, and therefore may lead to cholecystitis.

Question 50

It may be the complication of choledocholithiasis:

1) chronic cholangitis
2) biliary pancreatitis
3) secondary biliary cirrhosis
4) liver cyst

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 50

A) 1st, 2nd and 3rd answers are correct

Choledocholithiasis does not cause liver cyst, therefore A is the correct answer. Obstruction of bile flow may lead to chronic cholangitis, if a stone gets stuck at the ampulla of Vater, biliary pancreatitis, and if bile flow obstruction is persisting (for years), secondary biliary cirrhosis may also develop.