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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_40_библиотеки_им_акад_М_И_Перельмана
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Fig.4.2 MRCP
CHAPTER 4 | BILIARYDISORDERS
Fig.4.3 Endoscopic ultrasound image
What is the diagnosis?
A. Biliary microlithiasis
B. Cholecystitis
C. Choledochal cyst
D. Cholelithiasis
E. Gallbladder polyp
CHAPTER 4 | QUESTIONS
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8. A 36- year- old man, who had recently moved to the UK from Kashmir,
presented to the emergency department with episodic severe right
upper- quadrant pain.
Investigations:
Ultrasound abdomen The distal CBD contains several hypoechoic
tubular structures with well- dened echogenic
walls seen making curling movements.
Which of the following is the most likely cause?
A. Ascaris lumbricoides
B. Clonorchis sinensis
C. Entamoeba histolytica
D. Fasciola hepatica
E. Opisthorchis viverrini
9. A 28- year- old- man was seen in clinic with a ve- year history of recurrent
episodic right upper- quadrant pain and two previous episodes of
cholangitis requiring ERCP and clearance of CBD calculi. His pain had
persisted despite cholecystectomy two years before.
Investigations:
Serum bilirubin
Serum alanine transferase
(ALT)
Serum alkaline phosphatase
(ALP)
Haemoglobin 125 g/ L
Platelet count 245 × 109/ L
Liver stiness 4.5 kPa
Abdominal ultrasound Multiple foci of intrahepatic microlithiasis in both lobes
Genetic analysis Homozygous mutation (c.139C>T) in ABCB4 gene
What is the best next management strategy?
A. Cholangioscopy and electrohydraulic lithotripsy (EHL)
B. Ezetimibe
C. High dose vitamin C
D. Liver transplantation (LT)
E. Ursodeoxycholic acid
25 µmol/ L
75 U/ L
230 U/ L
of the liver. No CBD calculi or duct dilatation.
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CHAPTER 4 | BILIARYDISORDERS
10. Question focused on knowledge of the procedure rather than
diagnostics/ patient management.
Which of the following statements about cholangioscopy is most correct?
A. Air embolism is a recognized complication of dual- operator cholangioscopy (DOC)
B. Biliary sphincterotomy is usually not required
C. It is associated with a low rate of clearance of extrahepatic bile duct stones unable to be
removed with conventional ERCP
D. It is associated with higher rates of cholangitis compared with conventional ERCP
E. Single- operator cholangioscopy has superior image quality compared with the dual-
operator technique
11. A 35- year- old man with large- duct primary sclerosing cholangitis (PSC)
developed jaundice, worsening liver biochemistry, and fevers.
Investigations:
MRCP (Fig. 4.4)
Fig.4.4 MRCP
Which of the following statements is true with regard to the MRCP
nding?
A. It is associated with specic genetic polymorphisms aecting bile acid transport
B. It occurs in 50% of patients with PSC over the course of their disease
C. Management with biliary stenting is associated with fewer short- term complications than
balloon dilatation at ERCP
D. Prophylactic antibiotics are not required prior to investigation with ERCP
E. Serum carbohydrate antigen CA 9- 9 is a good surveillance strategy for development of
cholangiocarcinoma (CCA)
CHAPTER 4 | QUESTIONS
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12. A 75- year- old man presented with a two- month history of progressive
jaundice and weight loss. An MRCP showed a suspicious stricture in the
mid CBD.
Which of the following is an established risk factor for CCA?
A. Caucasian ethnicity
B. Cirrhosis
C. Fasciola hepatica
D. Hepatitis E
E. Primary biliary cholangitis
13. A 55- year- old man with a history of recurrent pancreatitis presented
with a one- week history of painless jaundice. Ultrasound and MRCP
revealed dilated common hepatic and intrahepatic ducts with suspicion
of a distal CBD stricture. Staging CT revealed no mass lesion, vessel,
or nodal involvement. Cholangiogram at ERCP conrmed a short distal
CBD stricture. Brush cytology was obtained and the stricture was
stented (Fig. 4.5).
Fig.4.5 Brush cytology specimen from biliary stricture. See also Plate 10
What is the next step in management?
A. EUS tissue sampling
B. Refer for chemotherapy
C. Refer for cholangioscopy
D. Refer for surgery
E. Repeat ERCP and brushing
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CHAPTER 4 | BILIARYDISORDERS
14. A 68- year- old woman presented with a one- week history of painless
jaundice, dark urine, and pale stools. There was pruritus and
weight loss. She had no other medical history and World Health
Organisation (WHO) performance status 0.She was referred to the
hepatopancreatobiliary multidisciplinary team (MDT) meeting.
Investigations:
Serum bilirubin
Serum alanine transferase (ALT) 262 U/ L
Serum alkaline phosphatase (ALP) 290 U/ L
Serum gamma- GT 386 U/ L
Serum albumin 34 g/ L
INR 1.0
Haemoglobin 140 g/ L
White cell count 7.7 × 109/ L
Platelet count 319 × 109/ L
Serum CA 19- 9 1,033 U/ ml
Serum CEA 2.8 µg/ ml
Serum CA 125 15 U/ ml
CT abdomen and pelvis with contrast (Fig. 4.6)
222 µmol/ L
Fig.4.6 CT abdomen and pelvis
What is the most likely outcome of the multidisciplinary team meeting
with regard to the next step in her management?
A. Chemotherapy
B. ERCP, brushings, and metal stent
C. ERCP, brushings, and plastic stent
D. PET- CT
E. Surgery
CHAPTER 4 | QUESTIONS
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15. A 66- year- old man presented with ve months’ history of weight loss
and two months’ history of jaundice. He had no other past medical
history.
Investigations:
Serum bilirubin
Serum alkaline phosphatase (ALP) 425 U/ L
Serum alanine transferase (ALT) 77 U/ L
MRCP (Fig. 4.7)
Which of the following is most likely to support a benign diagnosis?
A. Absence of arterial or portal venous invasion
B. Bulky pancreas and hypodense wedge- shaped renal lesions
C. Elevated serum immunoglobulin G subclass 4 (IgG4)
D. Enhancing thickened bile duct wall
E. Hilar mass lesion
91 µmol/ L
Fig.4.7 MRCP
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CHAPTER 4 | BILIARYDISORDERS
16. A 55- year- old man with hepatitis C cirrhosis and HCC had a liver
transplant three months ago. He presented with a history of progressive
jaundice.
Investigations:
Serum bilirubin
Serum alkaline phosphatase (ALP) 104 U/ L
Serum alanine transferase (ALT) 442 U/ L
Serum albumin 34 g/ L
Serum C- reactive protein (CRP) 7 mg/ L
Serum tacrolimus level 8 ng/ mL
Blood cultures Negative
MRCP (Fig. 4.8)
transplant operation note Modied piggyback common hepatic artery
88 µmol/ L
to common hepatic artery at gastroduodenal
artery. Duct- to- duct anastomosis. DCD
(donation after circulatory death) donor. CMV
positive- positive.
Fig.4.8 MRCP
What is the next best investigation?
A. CMV DNA titre
B. CT liver triple phase
C. ERCP
D. Liver biopsy
E. Ultrasound abdomen
CHAPTER 4 | QUESTIONS
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17. A 30- year- old woman was reviewed in clinic after a recent inpatient stay
with cholangitis. During her admission, an ultrasound scan showed a
dilated CBD. Subsequent ERCP did not reveal choledocholithiasis but it
did show a fusiform dilatation of the CBD. An MRCP was arranged as an
outpatient, which conrmed spindle- like dilatation along the length of
the CBD. Adiagnosis of choledochal cyst type Iwas made. The patient
was currently asymptomatic.
What is the most appropriate management?
A. Cholecystoenterostomy
B. Expectant management and ERCP as required for episodes of cholangitis
C. MRCP every two years and surgical excision if progressive duct dilatation occurs
D. Surgical excision
E. Surgical excision only if the patient becomes symptomatic
18. A 25- year- old man was referred with abnormal liver function tests.
Investigations:
Serum bilirubin
Serum alkaline phosphatase (ALP) 340 U/ L
Serum alanine transferase (ALT) 48 U/ L
MRCP Fusiform extrahepatic duct dilatation with
Use of which recreational drug is most likely to be responsible?
A. 3,4- Methyl enedioxy methamphetamine (MDMA)
B. Amphetamine
C. Ketamine
D. Methadone
E. Nitrous oxide
19 µmol/ L
distal tapering.
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CHAPTER 4 | BILIARYDISORDERS
19. A 54- year- old Nigerian man who had recently moved to the United
Kingdom presented to the emergency department with severe
pneumococcal pneumonia.
Investigations:
Haemoglobin 110 g/ dl
White cell count 6 × 109/ L
Platelet count 106 × 109/ l
HIV antibody Positive
CD4+ count 9 cells/ μL
HIV viral load 1.7 × 107/ mL
Serum bilirubin 95 µmol/ L
Serum alanine transferase (ALT) 79 U/ L
Serum alkaline phosphatase (ALP) 390 U/ L
MRCP CBD dilatation with smooth margins and
terminal tapering. Multiple alternating
stenosis and saccular dilatations of the
intrahepatic biliary tree of both liver lobes.
No gallstones visualized.
Which opportunistic infection is most associated with this condition?
A. Cryptosporidium parvum
B. Cytomegalovirus (CMV)
C. Giardia intestinalis
D. Microsporidia
E. Pneumocystis jirovecii
20. What is the 10- year incidence of recurrent PSC after liver
transplantation?
A. 5%
B. 0%
C. 20%
D. 50%
E. 75%
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chapter
BILIARYDISORDERS
4
ANSWERS
1. E. Twenty per cent chance of developing biliary colic
• Asymptomatic gallstones have a 20% chance of becoming symptomatic with biliary colic over
the next 0years
• Asymptomatic gallstones have a low (2%– 3%) risk of being complicated by pancreatitis,
cholecystitis, or biliary obstruction, and therefore cholecystectomy is not routinely
recommended
Asymptomatic gallstones are found in 0%– 20% of the global adult population and generally
do not require therapy. Patients with asymptomatic gallstones have a 20% chance of becoming
symptomatic with biliary colic over the next 0years. The onset of gallstone- associated pain
indicates a higher chance of developing complications (cholecystitis, choledocholithiasis) and
provides a rational for cholecystectomy in symptomatic patients unless surgical risk is prohibitive.
Patients with asymptomatic gallstones only have a 2%– 3% chance of developing pancreatitis,
cholecystitis, and biliary obstruction, and cholecystectomy is therefore not recommended for
patients with asymptomatic stones. Mirizzi’s syndrome is a rare complication of gallstones. It
refers to biliary obstruction with jaundice either as a direct consequence of stone impaction or
from inammation when a large stone resides in Hartmann’s pouch of the gallbladder. This causes
obstructive jaundice via pressure on the CBD and is treated with cholecystectomy.
Lammert F, Gurusamy K, Ko CW etal. Gallstones. Nat Rev Dis Primers. 206 Apr 28;2:6024.
Doi:0.038/ nrdp.206.24.
2. B. Adenomyomatosis
• ADM is a benign cause of gallbladder thickening that is commonly asymptomatic
• Histologically, it is characterized by outpouchings of the mucosa into thickened muscle wall
(Rokitansky– Ascho sinuses)
• Care must be taken to dierentiate ADM from gallbladder carcinoma, which may be aided by
use of MRCP
Gallbladder ADM is a relatively common, asymptomatic, and benign cause of diuse or focal
gallbladder wall thickening, which is commonly identied incidentally during investigation for other
pathologies. Histologically, it is characterized by epithelial proliferation and hypertrophy of the
muscles of the gallbladder wall with outpouchings of the mucosa into thickened muscular layer,
known as ‘Rokitansky– Ascho sinuses’. ADM is identied in %– 9% of cholecystectomy specimens
and is associated with gallstones in >50% of cases. While ADM is a benign condition, it must be
dierentiated from gallbladder carcinoma, which carries a very poor prognosis. Ultrasound is often
the rst- line diagnostic test with MRCP reserved for cases when an experienced radiologist cannot
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0004
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