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

DISCUSSION: Segments are the major subdivision of the right and left lobes of the liver. In either the classic lobar (American) or the segmental (French) system, the most variable aspect is the biliary system. Therefore the hepatic venous or portal system defines most segments. The French system depicts eight segments, with the caudate lobe as segment I and the other seven segments defined primarily by the hepatic venous system. Segments are not well-depicted by topography.

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

DISCUSSION: All of these features are important. The angle of takeoff of the left hepatic duct may make operative visualization difficult with the patient in the supine position. Because there may be more than two major hepatic ducts, visualization of two large ducts does not ensure that the system is normal. Ducts from any of the right-side segments can join below the confluence. Dissecting one superior edge of the gallbladder before it joins the cystic duct is particularly important in preventing injury.

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

DISCUSSION: The portal vein provides two thirds to three quarters of the total hepatic blood flow. The portal vein is incapable of direct autoregulation. The hepatic artery after transplantation classically infarcts portions of the biliary system, whereas hepatic metastases often arrive there via the portal vein. Most of their blood supply comes from the hepatic artery.

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

DISCUSSION: Bile formation is an active process at both the canalicular and ductular sites. The paracellular pathway probably plays a minor physiologic role. Secretin and glucagon are likely physiologic regulators of biliary secretion. Bile salts are extremely important and are probably the most important agent in the changes that occur when enterohepatic circulation is interrupted.

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

DISCUSSION: While other functions undoubtedly may be important postoperatively, the most common abnormalities occurring after a major hepatic resection are related to loss of protein synthesis and consequences of glucose metabolism. Therefore, it is usually advisable to administer supplemental amounts of protein and sugar postoperatively.

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

DISCUSSION: Involvement of the right lobe with abscess formation approximates 70% of pyogenic abscesses. This is thought to be due to the streaming effect of superior mesenteric venous inflow to the right lobe. In addition, the greater volume of the right lobe predisposes more tissue to seeding by bacterial organisms. While appendicitis comprised 25% to 40% of cases in early series, early recognition and operative therapy for appendicitis have reduced its importance significantly. In current series, malignant or benign biliary obstruction is the underlying cause of 35% to 50% of cases. Recent studies have shown that the underlying disease or an immunocompromised host is more important prognostically than solitary versus multiple abscesses.

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

DISCUSSION: The development of ultrasonography and computed tomography (CT) in the past two decades has enabled earlier diagnosis and advances in treatment of hepatic abscess. Formerly, open surgical drainage was considered necessary in essentially all cases of pyogenic abscess. Numerous recent series, however, have reported high success rates and low mortality from the percutaneous catheter drainage of abscesses under CT or ultrasonographic guidance. Optimal management of pyogenic abscess, however, involves not only treatment of the abscess, whether by percutaneous or surgical methods, but correction of the underlying source as well. All modes of therapy are more successful in treating solitary lesions than multiple ones.

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

DISCUSSION: Mortality for uncomplicated amebic abscess should be less than 5%, in contrast to the 15% to 20% rate for pyogenic abscess. After the demonstration by radiologic examination of an abscess, appropriate serologic tests and resolution of symptoms after a course of treatment with an antiamebic agent such as metronidazole constitute presumptive diagnosis of amebic abscess. Aspiration of abscess contents rarely yields amebic organisms. In contrast to pyogenic abscess, amebic abscess rarely requires surgical or percutaneous drainage, except in the case of an extremely large abscess or bacterial superinfection. Amebic abscess affects males in a 9:1 to 10:1 ratio and generally affects a younger population than pyogenic abscess. Additionally, in the United States the populations most affected are immigrants from endemic areas such as Mexico or Latin America and American tourists to those regions.

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

DISCUSSION: Adenomas typically enlarge and cause symptoms, may rupture, and have a definite malignant potential. Therefore they should generally be resected when found. FNH is not a true neoplasm and generally has an uneventful course. Both are related to BCPs, although the relationship of adenoma is more firmly established. While small bile duct hamartomas are much more common, hemangiomas are the most common lesion to come to the attention of surgeons. They should not generally be biopsied because of possible hemorrhage. By definition, nodular regenerative hyperplasia occurs in the absence of cirrhosis.

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

DISCUSSION: Although exact comparisons are impossible, hepatoma seems to be the most common cause of cancer death worldwide, despite its relative infrequency in the United States. Colorectal metastasis is a more common indication for surgical treatment in the United States. The fibrolamellar variant and possibly the very well-differentiated tumor probably have a better prognosis than hepatomas in general. Previous studies from Africa in which there was a high incidence of rupture account for the poor prognosis that was generally attributed to hepatoma. Recent studies from Europe and the United States have shown that survival after presentation is usually measured in years.

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

DISCUSSION: Most bile duct cancers are discovered after they are incurable, and only a tiny subset of resected proximal lesions are cured. The more distal the lesion, the more likely is resection to achieve cure (e.g., approximately 30% 5-year survival for periampullary lesions as compared with 0% to 10% for hilar lesions). The use of adjuvant or primary radiation remains controversial because of the heterogeneity of the patient populations on which this modality has been used. Because of the localized nature of this disease it would seem that transplantation would produce favorable results; however, this has not been the case.

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

DISCUSSION: The parasitic infection is fairly common in certain parts of Europe but very rare in the United States. Resection without peritoneal soilage is the treatment of choice. The E. multilocularis form, which is endemic to parts of the United States, is more likely to be fatal because it is rarely resectable. This form is more likely to resemble a malignancy than E. granulosus, although the natural course of the disease usually spans many years.

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

DISCUSSION: By far the most common cause of hemobilia is trauma. Tumors also may cause the syndrome but are relatively uncommon causes. For severe hemobilia the best therapy is arteriographic embolization. Usually the site of bleeding or a false aneurysm can be identified. Operation should be reserved as a last resort or when the condition is recognized intraoperatively. Percutaneous cholangiography–associated intrabiliary hemorrhage is usually, but not always, minor and self-limiting. Ultrasonography is a very nonspecific diagnostic technique for hemobilia. Arteriography remains the best diagnostic method.

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

DISCUSSION: Ligation of the right or left hepatic artery frequently causes enzyme elevation but is usually tolerated by the patient, particularly when this is a life-saving maneuver. Ligation of the hepatic artery distal to the gastroduodenal branch is more risky but is also usually tolerated. Ligation of the hepatic artery proximal to the gastroduodenal one does not normally cause enzyme abnormalities because of abundant collateral flow through that branch.

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

DISCUSSION: Metabolic alkalosis and hypokalemia are common in patients with cirrhosis because they often have associated secondary hyperaldosteronism (especially those with ascites), diarrhea, and frequent emesis. Hyperaldosteronism enhances H+ and K+ exchange for Na+ in the distal tubule of the kidney. The cause of diarrhea in patients with cirrhosis is unknown, but malabsorption secondary to splanchnic venous hypertension may be a contributing factor. Emesis is common in alcoholic cirrhotics and patients with tense ascites. Deleterious effects of metabolic alkalosis include impaired tissue oxygen delivery secondary to shift of the oxyhemoglobin dissociation curve to the left and conversion of ammonium chloride to ammonia, which may contribute to encephalopathy.

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

DISCUSSION: Pressure measured by wedging a catheter into a hepatic vein (hepatic venous wedge pressure) closely correlates with directly measured portal venous pressure in patients with portal hypertension when the site of elevated resistance is at the sinusoidal or postsinusoidal level. Such is the case in alcoholic cirrhosis and alcoholic hepatitis. When the site of increased resistance is at the presinusoidal level, either within (schistosomiasis) or outside (portal vein thrombosis) the liver, the hepatic venous wedge pressure is normal despite markedly elevated portal vein pressure. Although schistosomiasis is one of the more frequent causes of portal hypertension worldwide, in North America presinusoidal portal hypertension is considerably less common than alcoholic liver disease. A normal hepatic venous wedge pressure in a patient who has bled from varices should lead one to suspect a presinusoidal cause. A specific diagnosis can often be made by visceral angiography or liver biopsy.

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

DISCUSSION: Shunt operations are the most effective means of preventing recurrent variceal hemorrhage. Rebleeding rates after endoscopic sclerotherapy range from 40% to 60%. Although extensive esophagogastric devascularization has effectively prevented recurrent bleeding in Japanese series, these operations have been followed by rebleeding rates in excess of 25% in most Western series. Although one controlled trial has shown more frequent recurrent hemorrhage following the distal splenorenal shunt than after the portacaval shunt, most series have reported rebleeding rates of less than 10% for both of these operations. Both the liver and the splanchnic viscera are important sites of ascites formation. Since the distal splenorenal shunt maintains sinusoidal and mesenteric venous hypertension and requires interruption of important retroperitoneal lymphatics, it tends to aggravate rather than relieve ascites. Hepatic sinusoidal pressure may be unchanged or even increased after an end-to-side portacaval shunt. Only side-to-side portal-systemic shunts, such as the side-to-side portacaval shunt, reliably decompress both the liver and splanchnic viscera, thus preventing ascites formation.

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

DISCUSSION: The conventional splenorenal shunt and side-to-side portacaval shunts completely divert portal flow away from the liver (nonselective shunts). The distal splenorenal shunt is a selective shunt that preserves hepatic portal perfusion in the majority of patients; however, the magnitude of portal flow is decreased because the gastrosplenic component is diverted into the renal vein. Additionally, many patients (especially alcoholic cirrhotics) develop collaterals between the mesenteric venous circulation and the shunt, resulting in gradual attrition of the remaining portal flow. Although there have been anecdotal reports of portal vein thrombosis after endoscopic sclerotherapy, two controlled trials have demonstrated better preservation of hepatic portal perfusion in sclerotherapy patients than in persons who receive the distal splenorenal shunt.

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

DISCUSSION: The Sugiura procedure consists of devascularization of the esophagus to the inferior pulmonary vein and the proximal two thirds of the stomach, splenectomy, and distal esophageal transection. The devascularization component should be done as close to the esophagus and stomach as possible. The coronary vein and paraesophageal collaterals are preserved to maintain an effective portal-systemic collateral pathway and thereby discourage reformation of varices.

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

DISCUSSION: While many patients with portal hypertension develop hypersplenism, it is rarely clinically significant. A splenectomy should not be performed unless platelet counts are persistently less than 20,000 per cu. mm. or white blood cell counts are less than 1200 per cu. mm. Unfortunately, splenectomy is sometimes done for clinically insignificant hypersplenism, thus obviating a distal splenorenal shunt if the patient should subsequently bleed from varices. The initial treatment for most patients with bleeding esophageal varices should be endoscopic sclerotherapy; however, operation is required for the approximately one third of patients who fail sclerotherapy and for noncompliant persons, those living in remote geographic locations, and patients bleeding from gastric varices. Ascites can be controlled by a medical regimen of dietary salt restriction and diuretic therapy in more than 95% of patients. When ascites is intractable to medical management, either intermittent large-volume paracenteses or a surgical peritoneovenous shunt should be done. With rare exceptions, encephalopathy should be treated medically. Most important is elimination of any precipitating factors that led to the neuropsychological disturbance. Lactulose, neomycin, and dietary protein restriction may also be components of the medical treatment regimen.

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

DISCUSSION: Vasopressin acts through vasoconstriction of splanchnic arterioles. Both portal venous inflow and portal venous pressure are reduced, resulting in control of acute variceal bleeding in approximately 50% of patients. However, the adverse side effects of systemic hypertension, bradycardia, decreased cardiac output, and coronary vasoconstriction are quite common during vasopressin infusion. Simultaneous administration of nitroglycerin or nitroprusside eliminates these side effects—and in one controlled trial enhanced therapeutic effectiveness. Although the mechanism of action of this combined infusion is not clear, vasodilation of portal-systemic collaterals, resulting in a further reduction in portal pressure, may be responsible.

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

DISCUSSION: The PVS is a palliative procedure that does not prolong life. In comparing the early risks of the procedure with those of repeated paracentesis, the shunt cannot be justified as a temporizing procedure to facilitate ascites control in the patient awaiting liver transplantation. Oliguria is common in the first 24 hours after shunt insertion. A correctly placed PVS (patency confirmed using an intraoperative “shuntogram”) expands the intravascular volume with a continuous reinfusion of ascites. Inspection should identify elevation of the jugular venous pressure, and a diuretic (usually furosemide) is needed. The mechanisms of action of the two shunts are very different. TIPSS reduces portal pressure and controls ascites by reducing the rate of ascites formation. PVS reinfuses the ascites fluid, thereby reducing the prerenal stimulus to sodium retention and making the patient more responsive to diuretic therapy.

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

DISCUSSION: Because of the high complication rate and the long-term failure rate, the PVS is used only when other, more lasting options for therapy either are not available or are contraindicated. The chronic alcoholic patient may benefit from a peritoneovenous shunt because his ascites is the dominant problem related to his chronic liver disease, and persistent alcoholism is a contraindication to liver replacement in most centers. PVS may be quite effective for the temporary management of acute intractable postoperative ascites, such as in patient A; however, it is absolutely contraindicated in the presence of infection. Patient B has ascites as her dominant problem as well; however, with PBC as the underlying liver disease, she is an excellent candidate for transplantation. Patient D also has ascites as the major problem; however, the side-to-side portosystemic shunt is a far better long-term treatment option than PVS.

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

DISCUSSION: The ability to specifically identify persons infected with HCV has only recently become available. Therefore, data about epidemiology are less than complete. It is very likely not true that more blood donors carry HCV because of the large preponderance of HBV in the United States. It is true, however, that successful elimination of most of the HBV carriers occurs through routine testing. Although serologic tests are available for HCV, they are tests, not of antigen, but of antibody. Therefore, this test alone may not screen out persons who are infected but have not yet developed or may never develop antibody. Risk groups for the relatively newly defined HCV may well not be comprehensively established, and therefore this explanation may be a contributor. There are no differences in virulence between these classes of hepatitis virus.

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

DISCUSSION: Although some types of hepatitis are more often asymptomatic than symptomatic, that is not the case for hepatitis B. Further, even if the HBV infection is asymptomatic, serious long-term side effects may occur. A prior infection with hepatitis B confers lifelong immunity even if the antibody titer wanes below the protective level of 10 mIU. HBIg is useful in reducing the incidence of postexposure HBV infection from around 30% with no intervention, to 15% with standard immune globulin, to about 5% to 7% with HBIg. HBV infection is required for infection with HDV and is therefore an essential step toward, rather than preventive of, HBV infection.

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

DISCUSSION: Most common duct stones originate in the gallbladder and migrate to the common duct, where they may become larger. These stones tend to consist predominantly of cholesterol (about 80% of gallbladder stones are predominantly cholesterol). Stones found in the bile ducts after cholecystectomy may have been overlooked, but de novo stone formation does occur. Arbitrarily, stones found 2 years after cholecystectomy are assumed to have formed within the duct system. Calcium bilirubinate stones are thought to result from precipitation of insoluble bilirubin monoglucuronide formed by deconjugation of bilirubin diglucuronide, a reaction promoted by the enzyme beta-glucuronidase, which is produced by bacteria in the biliary tract. Calcium bilirubinate stones are found almost exclusively in patients who have some form of biliary tract lesion that causes partial obstruction, and these patients tend to have bactibilia. Stones smaller than approximately 5 mm. often can be extracted through a dilated cystic duct or pushed into the duodenum. Larger stones are best left for postoperative endoscopic sphincterotomy and extraction. Patients with more than five stones or stones larger than 1.5 cm. should be treated by open choledocholithotomy or, when indicated, a biliary-enteric anastomosis. Not all patients with symptomatic common duct stones have elevated serum bilirubin, but when jaundice is present the bilirubin is only rarely greater than 15 mg. per dl.

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

DISCUSSION: Even a minor obstructing lesion in the extrahepatic duct system can produce cirrhosis over time, and the development of portal hypertension, ascites, and esophageal varices. Therefore, all biliary strictures should be treated unless this is not possible or there is no chance for success. The presence or absence of jaundice is of no significance. Often, the only biochemical abnormality is mild elevation of alkaline phosphatase. The long-term results of percutaneous balloon dilatation are not yet known, but short-term results are good. Although some argue that balloon dilatation should be the initial treatment, its role is ill-defined, and it should not be viewed as standard therapy at this time. Biliary-enteric anastomoses are predisposed to stricture, for reasons that are ill-understood. A mucosa-to-mucosa anastomosis, large size of the anastomosis, a normal duct at the point of anastomosis, and stenting appear to be elements that work against stricture. About 70% of anastomoses are not complicated by strictures. Common duct strictures caused by chronic pancreatitis are located in the distal portion of the duct and are easily treated by side-to-side choledochoduodenostomy. A wide anastomosis is usually possible, and because of this stenting often is not necessary. Although a Roux-en-Y biliary-enteric reconstruction is acceptable treatment, no advantage over choledochoduodenostomy has been demonstrated.

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

DISCUSSION: Cholangiography is essential for both diagnosis and evaluation of resectability. Brushings of the lesion for diagnosis and temporary stenting, done percutaneously or endoscopically, are often done at the time of cholangiography. Angiography and CT are helpful, but in the absence of hepatic artery or portal vein occlusion these tests are not accurate predictors of resectability. The primary obstacles to complete resection are invasion of the portal vein or the hepatic artery and proximal extension of the tumor into the liver. The long-range prognosis for patients who undergo treatment for extrahepatic bile duct cancer is poor, even when the lesion is surgically resectable and adjuvant therapy is given. Only about 10% of patients are alive without disease at 10 years. Nevertheless, bile duct cancer tends not to metastasize to distant sites, so resection and radiation therapy are useful in prolonging symptom-free life. Tumors in the proximal third of the extrahepatic bile duct system are treated by a Roux-en-Y biliary-enteric anastomosis. To ensure excision of the entire tumor this anastomosis usually must be made to the individual hepatic ducts, which must be stented individually. Tumors of the middle third usually require anastomosis to the proximal hepatic duct. In contrast, lesions of the distal third require Whipple's procedure with appropriate reconstruction. Thus, the treatment of extrahepatic bile duct cancer depends on the location of the tumor. Pain is not a prominent feature of bile duct cancer. Most cases become manifest by the insidious development of jaundice.

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

DISCUSSION: In the past, choledochal cyst was treated by Roux-en-Y cystojejunostomy, but long-term results were poor. Excision of the cyst is essential to prevent recurrent pancreatitis. In addition, the development of carcinoma in about 25% of patients mandates cyst excision. Accordingly, excision of the cyst with biliary reconstruction by Roux-en-Y hepaticojejunostomy and diversion of the flow of pancreatic juice through the ampulla of Vater is currently the standard treatment. Sclerosing cholangitis causes fibrosis of bile ducts both within and outside the liver. This process, which is poorly understood, causes strictures in the duct system, characteristically with normal or dilated segments between strictures. Unfortunately, this anatomic arrangement does not lend itself to biliary reconstructive procedures. Each case must be analyzed, however, because in some patients the anatomic situation may lend itself to balloon dilatation or reconstruction. When the gallbladder appears to be absent, a search should be made for an ectopically located organ in the retroduodenal area, within the falciform ligament, and within the substance of the right lobe of the liver. With true gallbladder agenesis the common duct may be dilated, and choledocholithiasis is present in about one fourth of those who undergo operation. Therefore, operative needle cholangiography should always be done. Dissection of a long, fused cystic duct is fraught with hazard because the cystic and common ducts may share a common wall and serious duct damage may occur. The cystic duct should be ligated and divided immediately proximal to the area of fusion.

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

DISCUSSION: The presence of pain is the sine qua non of acute calculous cholecystitis. Chronic cholecystitis associated with cholelithiasis may develop in the absence of pain, and in critically ill patients pain may not be a prominent feature of acute acalculous cholecystitis. Only about 10% of patients with acute cholecystitis are jaundiced. Although an occasional patient may have concomitant bile duct obstruction, the jaundice associated with acute cholecystitis is probably due to absorption of bile pigments from the diseased gallbladder. The presence of jaundice in a patient with right-side upper quadrant pain should also suggest the possibility of acute cholangitis secondary to bile duct obstruction. Ultrasonography is very accurate in the detection of gallstones, but stones may be present in the absence of acute cholecystitis. Thickening of the gallbladder wall and a collection of fluid around the gallbladder are ultrasonographic findings in some patients with acute cholecystitis, but they are not always present and are not specific. Ultrasonography may be useful when the diagnosis is obscure because other conditions in the liver, pancreas, and kidney can be detected; however, it is not the definitive test for acute cholecystitis. Cholescintigraphy is specific for the diagnosis of acute calculous cholecystitis (accuracy over 95% in experienced hands). The rapidity, simplicity, and accuracy make cholescintigraphy the definitive diagnostic test in acute calculous cholecystitis; however, it must be interpreted cautiously in the context of another critical illness or recent surgery or trauma, because false-positives are not unusual in these situations.

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

DISCUSSION: About half of the cases of acute acalculous cholecystitis are associated with other conditions, including sepsis, sarcoidosis, polyarteritis nodosa, and systemic lupus erythematosus. A majority of cases occur after trauma, burns, or major surgical procedures performed for other conditions. The precise pathogenesis has not been determined. The diagnosis of acute acalculous cholecystitis is often difficult because symptoms may be masked by another illness, injury, or the postoperative state. Unlike acute calculous cholecystitis, in which pain is always present, pain occurs in only about 70% of cases. In addition, cholescintigraphy is sometimes inaccurate. These factors make the diagnosis difficult, and a high index of suspicion is necessary, especially in patients who have had operations or trauma. Unexplained abdominal pain, sepsis, and ileus should prompt a thorough investigation. The mortality rate for acute acalculous cholecystitis is higher than that of the calculous type. The incidence of gangrene and perforation of the gallbladder is higher. The accompanying illnesses and conditions and the frequent delays in diagnosis undoubtedly contribute to the higher death rate. Percutaneous cholecystostomy has been used as a diagnostic and therapeutic maneuver in patients who are thought to have acute acalculous cholecystitis. Aspiration and culture of bile assist in confirming the diagnosis, and continuous drainage successfully treats the acute condition. Surprisingly, persistent gangrene and subsequent complications have been infrequent. Immediate cholecystectomy should be done if significant improvement does not take place within 12 hours of percutaneous cholecystostomy. Long-term management of the tube and the need for elective cholecystectomy must be individualized. The experience with percutaneous cholecystostomy is too small to determine whether this technique reduces the mortality rate.

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

DISCUSSION: Cholecystectomy should be done in an otherwise healthy patient as soon as the diagnosis is made and the patient is properly prepared for surgery. However, patients who have one or more significant risk factors such as a recent myocardial infarction, unstable angina, clinically significant coronary artery disease, or cirrhosis should not have immediate cholecystectomy unless they do not improve within 24 to 36 hours in response to antibiotic administration and supportive care. Antibiotic administration should commence as soon as the diagnosis is made and should be continued for 24 hours postoperatively—or for 7 days if significant peritonitis is present. This use of antibiotics has significantly reduced septic complications after cholecystectomy for acute cholecystitis. In most cases the gallbladder is tensely distended, making visualization and dissection of the cystic duct area difficult and perhaps dangerous. Decompression of the gallbladder by insertion of a needle facilitates retraction and dissection of the gallbladder. Although some advise that operative cholangiography be done only on a selective basis, its routine use helps to delineate anatomy and facilitates detection of an occasionally unsuspected bile duct stone. Accordingly, it is used routinely in elective cases. In acute cholecystitis, however, the biliary duct system may be very friable, and operative cholangiography should be done only when it is safe to do so.

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

DISCUSSION: Cholecystectomy (and concomitant operative cholangiography) are indicated for symptomatic patients to relieve pain and to prevent the development of acute cholecystitis and its complications. Morbidity and expense are not as great for elective cholecystectomy as they are for cholecystectomy for acute cholelithiasis. The risk of the development of symptoms in patients who have asymptomatic stones is approximately 2% per year, a rate associated with mortality and morbidity that do not exceed those of elective cholecystectomy. Therefore, cholecystectomy is not indicated for asymptomatic patients. Patients who have angina pectoris should not have cholecystectomy until their coronary artery disease has been treated adequately, even if this requires a coronary artery bypass procedure. Heart disease is the most frequent cause of death after cholecystectomy. Prophylactic cholecystectomy, formerly recommended for insulin-dependent diabetics, is not indicated because several studies have shown that the mortality rate from acute cholecystitis is no higher for diabetics than for nondiabetics.

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

DISCUSSION: Studies have clearly documented that postoperative pain following laparoscopic cholecystectomy is less than that experienced after open cholecystectomy and that patients can resume normal activity sooner. This appears to be related to the reduced trauma to the abdominal wall by virtue of the very small incisions used in laparoscopic procedures. The best evidence is that the bile duct injury rate (0.4%) is approximately double that for open cholecystectomy. The incidence of this serious complication will probably decrease with improved techniques, better training, and more advanced instrumentation. Only symptomatic patients should have cholecystectomy. Prophylactic removal of the gallbladder is not cost effective. All elective operations are contraindicated in the first trimester, so as to prevent fetal anomalies and spontaneous abortion. The laparoscopic technique is not contraindicated thereafter except in patients in whom peritoneal access cannot safely be established. This is rarely a problem. Premature labor is a risk in the third trimester. Thus, unless cholecystectomy can be avoided altogether during pregnancy, the second trimester is the most propitious time.

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

DISCUSSION: Although Charcot's triad (pain, chills and fever, jaundice) is diagnostic of cholangitis, the complete triad occurs only in 50% to 70% of patients. Fever is the most common symptom; therefore, cholangitis should be considered in all patients who have unexplained fever. Episodes of pain, chills, and fever are often so brief as not to concern the patient. Cholangitis does not occur in the absence of partial or complete bile duct obstruction. All patients diagnosed as having cholangitis should have appropriate diagnostic studies to determine the cause. This usually involves cholangiography. The presence of bacteria in bile does not produce symptoms in the absence of partial or complete obstruction of the bile duct system. When obstruction is present, pressure within the system increases, giving rise to reflux of bacteria or their toxic products into the hepatic venous circulation. This cholangiovenous reflux produces chills, fever, and the hemodynamic changes of sepsis. Death may ensue if treatment is not instituted promptly. Choledocholithiasis, the most commonly associated problem, may produce partial or complete obstruction. When bacteria are not present in the bile duct system, choledocholithiasis may go undetected unless the degree of obstruction is sufficient to cause jaundice. Other causes of cholangitis are benign and malignant strictures, biliary-enteric anastomoses, invasive procedures, foreign bodies, and parasitic infestation of the bile ducts.

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

DISCUSSION: Cholangitis does not occur in the presence of a normal bile duct system, and all patients with cholangitis have an abnormality. Thus, recurrent episodes of cholangitis signal the need for diagnostic studies. Cholangiography usually will be necessary. The presence of any foreign body in the biliary tract is frequently associated with bactibilia and recurrent episodes of cholangitis. Even a silk suture exposed to the lumen of a bile duct has been known to cause cholangitis. Pigment stone and sludge formation may result from the bacterial deconjugation of bilirubin diglucuronide to bilirubin monoglucuronide, which precipitates as calcium bilirubinate. This material can occlude indwelling tubes and predispose to more frequent episodes of cholangitis. Long-term administration of an oral antibiotic may reduce the frequency and severity of attacks of cholangitis; however, this method of management should not be routine. Correction of the underlying problem is essential. Chronic obstruction and recurrent infection eventually lead to secondary biliary cirrhosis and its complications of portal hypertension, ascites, and bleeding esophageal varices. Once this stage of the disease is reached, correction of the underlying biliary tract problem does not reverse the changes in the liver. Once again, every effort should be made to eliminate the cause of the cholangitis early in the course of disease. The only effective treatment for end-stage liver disease is hepatic transplantation.

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

DISCUSSION: Uncontrolled sepsis and the consequent multisystem organ failure are the life-threatening sequelae of acute toxic cholangitis. Thus, the initial goal of treatment is to decompress the biliary duct system to prevent reflux of bacteria and their toxic products into the circulation. This can be done by intubating the duct system through the percutaneous, transhepatic, or the endoscopic route or by insertion of a T tube in the common duct at operation. Removal of the stone causing the obstruction is not necessary to stabilize the patient. Only after the duct is decompressed should the cause of the obstruction be addressed. When transhepatic biliary drainage has been used, endoscopic or surgical removal of the stone can be carried out after the patient has recovered completely. When initial therapy is sphincterotomy, the stone should be removed as part of the procedure. Often the stone falls out without manipulation. If surgical placement of a T tube is the initial treatment, the stone should be removed only if it is convenient to do so. The long-range goal of treatment of patients with bile duct obstruction is to prevent cirrhosis, ascites, portal hypertension, and hemorrhage from esophageal varices; however, death from sepsis is the immediate threat in acute toxic cholangitis. Gallstone pancreatitis may occur in patients who have an impacted stone in the distal duct, independent of the presence or absence of acute toxic cholangitis; however, gallstone pancreatitis is more often associated with the passage of a stone into the duodenum.

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

DISCUSSION: An antecedent biliary-enteric fistula is necessary to allow stone migration into the intestinal tract, and this results in air entering the biliary tree (pneumobilia). It also allows contamination of the bile ducts with intestinal bacteria, which in fact occurs in only a minority of such cases. The stone obstructs the narrower distal bowel, producing small bowel obstruction. Such a stone, if opaque, can be seen on plain radiography and, if not, can be appreciated by sonography. Stools are not acholic, since the cholecystoenteric fistula allows bile access to the intestinal lumen.

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

DISCUSSION: It is true that gallstone ileus occurs mostly in elderly women and should always be suspect when small bowel obstruction presents in this age group. The great majority of cases of gallstone ileus are preceded by a spontaneous fistula occurring between the gallbladder and duodenum, allowing gallstones to enter the intestinal tract, which can potentially block the terminal ileum. Finding air within the biliary tree should always arouse suspicion of the possibility of this diagnosis when it is associated with a radiographic pattern of small bowel obstruction. The initial part of the operative approach to this disease is to relieve the bowel obstruction by performing an enterotomy just proximal to the point of obstruction to remove the stone. Where possible, definitive repair of the fistula should be undertaken to avoid recurrent obstruction and to obviate the possible recurring complications of cholangitis. Percutaneous drainage of bile collections combined with endoscopic papillotomy may be sufficient treatment for external and internal biliary fistulas but is never an allowable approach in the presence of gallstone ileus with small bowel obstruction. Relief of the obstruction is mandated in this setting.

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

DISCUSSION: The prevalence of carcinoma of the gallbladder in patients who have or have had a cholecystoenteric fistula is believed to be 15%. The prevalence of carcinoma in a calcified, or “porcelain,” gallbladder is reported to range from 12.5% to 61%. It is generally accepted that adenoma of the gallbladder is a precancerous lesion that presents as a polypoid lesion. Xanthogranulomatous cholecystitis is a rare form of chronic cholecystitis believed to be associated with a higher incidence of cancer. This form of cholecystitis is also important because, grossly, it may mimic cancer of the gallbladder.

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

DISCUSSION: Radical resection, radiation therapy, and chemotherapy have been effective only anecdotally. Most believe that the dismal prognosis of carcinoma of the gallbladder does not justify anything more than palliative treatment. About 88% of patients are dead within a year of diagnosis, and only about 4% are alive after 5 years, regardless of the type of treatment. Those whose surgeon was unaware of the presence of the tumor at the time of cholecystectomy (approximately 12% of cases) are most likely to survive long term. There are insufficient data to support conclusively the proposition that the patient with unexpected carcinoma found on histologic examination should undergo reoperation with intent for radical excision. There also are indirect suggestions that the prognosis of gallbladder carcinoma may be improving, but it is not clear if this is spontaneous or due to either earlier diagnosis or surgical management.

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

DISCUSSION: The clinically recognized embryonic malformations of the pancreas include heterotopic pancreas, pancreas divisum, and annular pancreas. Heterotopic pancreatic tissue most often takes the form of a firm nodule of variable size in the stomach, duodenum, small bowel, or Meckel's diverticulum. The typical complications of heterotopic pancreas include intestinal obstruction, ulceration, or hemorrhage. Pancreas divisum is an anatomic variant that results from failure of fusion of the two primordial pancreatic duct systems. In pancreas divisum the major portion of the pancreas is drained via the duct of Santorini through the minor duodenal papilla. Relative stenosis of the minor duodenal papilla can cause pancreatitis. Pancreas divisum is not associated with gastrointestinal bleeding. Annular pancreas results when histologically normal pancreatic tissue completely or partially encircles the second portion of the duodenum. Varying degrees of duodenal obstructive symptoms may be observed in both children and adults with this condition.

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

DISCUSSION: The pancreas occupies a retroperitoneal position in the upper abdomen, extending obliquely from the duodenal C loop to a more cephalad position where the pancreatic tail abuts the hilum of the spleen. The portion of the pancreas anterior to the confluence of the superior mesenteric vein, splenic vein, and portal vein is designated the neck of the gland. The uncinate process extends posterior to the superior mesenteric vein and approaches the superior mesenteric artery. The head of the pancreas is intimately associated with the second portion of the duodenum, and these two structures are jointly supplied by two arterial arcades known as the anterior and posterior pancreaticoduodenal arteries, which originate as branches of the celiac axis and superior mesenteric artery.

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

DISCUSSION: The endocrine portion of the pancreas is served by the islets of Langerhans, which number 1 million islets per gland. The islets of Langerhans drain their endocrine secretions into the bloodstream. Insulin-producing beta cells comprise the majority of the islet population. Alpha cells produce glucagon and constitute approximately 20% to 25% of the total islet cell number. Delta cells of the islets produce somatostatin. The acini and ductal systems constitute the exocrine portion of the pancreas. The acinar cells contain zymogen granules in their narrow, centrally located apical portion. The pancreatic duct system includes intercalated duct cells along the ductal pathway, terminating in the main excretory duct of the pancreas.

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

DISCUSSION: CCK is the most potent endogenous stimulant of pancreatic enzyme secretion. The pancreatic acinar cells respond to CCK with release of their zymogen granules into the ductal system. Peptidases are released in inactive form, later to be activated by contact with duodenal enterokinase and activated trypsin. Secretin is the most potent endogenous stimulant of pancreatic water and electrolyte secretion. The concentrations of the anions bicarbonate and chloride vary and are largely dependent on the secretory flow rate stimulated by secretin.

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

DISCUSSION: Several prognostic systems have been demonstrated to predict the severity of pancreatitis accurately. Two Ranson prognostic criteria have been developed: one each, for pancreatitis that is not due to gallstones and pancreatitis that is. The systems have minor differences. In both of the Ranson systems elevated blood glucose, leukocytosis, and elevations of serum LDH have proved to have prognostic importance. The degree of amylase elevation is not one of the parameters, nor is the degree of ALT elevation.

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

DISCUSSION: Standard therapy for all patients with mild acute pancreatitis should include intravenous fluid resuscitation, electrolyte replacement, and analgesics. Nasogastric decompression is typically reserved for patients with significant ileus who are at risk for emesis and aspiration. Subcutaneous therapy with octreotide, the octapeptide analog of somatostatin, has not been proven to influence the outcome in patients with mild pancreatitis. Prophylactic antibiotics are not used for mild pancreatitis. Antibiotics are reserved for patients with severe pancreatitis (defined as greater than three Ranson prognostic signs with associated CT evidence of pancreatic or peripancreatic necrosis).

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

DISCUSSION: Chronic pancreatitis is a clinical entity that includes recurrent or persistent abdominal pain with evidence of exocrine and endocrine pancreatic insufficiency. While chronic pancreatitis may result from repeated episodes of acute pancreatitis, not all patients with recurring acute pancreatitis progress to chronic pancreatitis. The most common causes of chronic pancreatitis include alcohol abuse, hyperparathyroidism, congenital anomalies of the pancreatic duct, pancreatic trauma, and cystic fibrosis. The most useful radiographic tests in patients with suspected chronic pancreatitis are CT and endoscopic retrograde cholangiopancreatography (ERCP). Mesenteric angiography has no role in the evaluation of most patients with chronic pancreatitis. Patients with disabling chronic pancreatitis who require operative intervention are candidates for a longitudinal pancreaticojejunostomy (Peustow procedure) if pancreatography demonstrates a dilated pancreatic duct. Total pancreatectomy is rarely performed because of the significant problems associated with labile insulin sensitivity, steatorrhea, and weight loss.

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

DISCUSSION: Pancreatic ascites typically occurs because of a pancreatic duct disruption, most commonly involving alcohol abuse and resultant acute pancreatitis. In pancreatic ascites, pancreatic exocrine secretions exit a pancreatic duct disruption and drain anteriorly into the peritoneal cavity. Patients typically present with painless massive ascites, as the pancreatic enzymes that extravasate into the peritoneal cavity are typically nonactivated. The diagnosis of pancreatic ascites is best made by paracentesis, in which the analysis of the ascites fluid reveals it to be high in amylase (more than 1000 U. per dl.) and high in albumin (more than 3 gm. per dl.). Nonoperative treatment is initially indicated in most patients with pancreatic ascites. Should nonoperative therapy fail, surgical therapy is directed to closure of the pancreatic duct disruption. Preoperative pancreatography is useful in directing surgical therapy. Distal pancreatic duct disruption may be treated with distal pancreatectomy or with Roux-en-Y pancreaticojejunostomy. Pancreatic leaks in the more proximal aspects of the gland are treated with Roux-en-Y pancreaticojejunostomy. Suture ligation of the pancreatic duct with omental patching is not considered appropriate therapy for pancreatic duct disruptions.

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

DISCUSSION: Adenocarcinoma of the pancreas is newly diagnosed in approximately 28,000 patients in the United States every year. It is the fifth most common cause of cancer death in the United States, exceeded only by lung, colorectal, breast, and prostate cancer. The majority of cases of adenocarcinoma of the pancreas occur in the head of the gland, and if resectable, are treated via pancreaticoduodenectomy. Recent studies have shown that factors favoring long-term survival after pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas include negative nodal status, negative margin status, small tumor diameter, and diploid DNA content. No accurate screening tests for adenocarcinoma of the pancreas are currently available. The best serologic test appears to be the CA 19–9, which is elevated in the majority of patients with adenocarcinoma of the head of the pancreas. Unfortunately, the test is not sufficiently sensitive or specific, and further screening tests are needed.

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

DISCUSSION: Insulinoma is the most common endocrine tumor of the pancreas. Insulinoma is associated with Whipple's triad, which consists of (1) symptoms of hypoglycemia at fasting; (2) documentation of blood glucose levels of less than 50 mg. per dl.; and (3) relief of symptoms following administration of glucose. The most reliable method for diagnosing insulinomas is a monitored fast. Neither an oral or an intravenous glucose tolerance test is indicated in the majority of patients being evaluated for insulinoma. Support for the diagnosis of insulinoma can come from documenting elevated C peptide and proinsulin levels. Screening for anti-insulin antibodies is indicated to rule out the possibility of surreptitious insulin administration. Tumor localization is typically performed with CT, endoscopic ultrasonography, or angiography. ERCP is not indicated for evaluation of most pancreatic endocrine tumors, as the tumors only rarely communicate with the main pancreatic duct system. As many as 90% of patients with insulinoma have benign solitary pancreatic adenomas amenable to surgical cure.

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

DISCUSSION: Gastrinoma patients typically present with peptic ulceration of the upper gastrointestinal tract and abdominal pain. As many as 50% of patients may have diarrhea, which may be a prominent feature in some cases. Approximately 25% of gastrinoma patients have the disease associated with the MEN-1 syndrome, whereas 75% have a sporadic variety of the disease. Recent evidence indicates that extrapancreatic gastrinomas are common. Careful attention must be paid to the duodenum and peripancreatic lymph nodes at the time of abdominal exploration. Before elective operation it is imperative that the gastric acid hypersecretion be controlled. The control of gastric hypersecretion is best performed by the administration of one of the substituted benzimidazoles, such as omeprazole or lansoprazole.

Answer: a, c, d

Enzyme secretion is regulated primarily through hormonal and neural factors. The enteric hormone cholecystokinin, released from endocrine cells in the duodenal mucosa, is the predominant regulator and stimulates acinar cells through specific membrane-bound receptors. Acetylcholine strongly stimulates acinar cells when released from postganglionic fibers of the pancreatic plexus and acts in synergy with CCK to potentiate enzyme secretion. Secretin weakly stimulates acinar cell secretion and potentiates the effect of cholecystokinin on the acinar cells.

Bicarbonate is formed from carbonic acid by the enzyme carbonic anhydrase. Secretin, the major stimulant for bicarbonate secretion, is released from the duodenal mucosa in response to a duodenal luminal pH of less than 3.0. Cholecystokinin only weakly stimulates bicarbonate secretion, whereas it potentiates secretin-stimulated bicarbonate secretion. Gastrin and acetylcholine are weak stimulants of bicarbonate secretion.

Answer: b, c

The venous drainage of the pancreas and duodenum follows the arterial supply. The anterior and posterior venous arcades drain the head; the body and tail drain into the splenic vein. All venous effluent from the pancreas ultimately drains into the portal vein which is formed by the confluence of the superior mesenteric vein and the splenic vein at the superior border of the pancreas. The anterior and posterior venous arcades in the head of the pancreas drain directly into the suprapancreatic portal vein. The anteroinferior pancreaticoduodenal arcades drain with the right gastroepiploic vein to form a common venous trunk with the right colic vein. This trunk is known as the gastrocolic trunk and enters the superior mesenteric vein at the inferior border of the neck of the pancreas. The posteroinferior venous arcade empties directly into the superior mesenteric vein. The veins of the head drain laterally into the superior mesenteric and portal veins. There are no venous tributaries entering the superior mesenteric vein anteriorly. For this reason, it is safe to dissect the neck of the pancreas directly anterior to the superior mesenteric and portal veins when performing a pancreaticoduodenectomy.

Answer: c

In 90% of individuals, the main pancreatic duct, or duct of Wirsung, runs the entire length of the pancreas and joins the common bile duct to empty into the duodenum at the ampulla of Vater. The pancreatic duct is 2 to 3.5 mm in diameter and contains 20 secondary branches, which drain the tail, body, and uncinate process. The drainage of the lesser duct, or duct of Santorini, is variable. The lesser duct commonly drains the superior portion of the head of the pancreas. It empties separately into the second portion of the duodenum through the lesser papilla located 2 cm proximal to the ampulla of Vater. Pancreas divisum results from an incomplete fusion of the ventral pancreatic duct with the dorsal duct during fetal development and is present in 5% of patients. In this anomaly, the lesser duct drains the entire pancreas via an accessory ampulla located proximal to the ampulla of Vater. Inadequacy of this pattern of drainage can result in chronic pain.

Answer: b, c

The pancreas receives its blood supply from a variety of major arterial sources. In the head of the pancreas, there are arcades in the anterior and posterior surfaces, which generally collateralize. These arcades arise from branches of the gastroduodenal and the superior mesenteric arteries. Just distal to the first portion of the duodenum, the gastroduodenal artery becomes the superior pancreaticoduodenal artery, which divides into anterior and posterior branches. The inferior pancreaticoduodenal artery is the first branch of the superior mesenteric artery and divides into anterior and posterior branches.

The body and tail of the pancreas are supplied by the splenic artery. The splenic artery arises from the celiac trunk and courses along the superior surface of the pancreas to the spleen. Approximately ten branches of the splenic artery supply the body and tail of the pancreas.

Answer: a

Orally administered glucose stimulates a greater insulin response than an equivalent amount of intravenous glucose through the release of enteric hormones that potentiate insulin secretion. This effect is known as the enteroinsular axis. Gastric inhibitory polypeptide (GIP) appears to be an important regulator of this effect, although other gut peptides, such as glucagon-like peptide I (GLP-1), may contribute to this effect as well. Nutrients that regulate insulin secretion include amino acids, such as arginine, lysine, and leucine, and free fatty acids. Hormones that stimulate insulin secretion include glucagon, GIP, and cholecystokinin, whereas somatostatin, amylin, and pancreastatin are inhibitory. Insulin is also stimulated by sulfonylurea compounds, which act independently of the glucose concentration and form the basis of treatment of type II, or insulin-independent, diabetes.

Answer: c

Within the pancreas are small nests of cells that are responsible for the secretion of hormones that control glucose homeostasis. These nests are called islets of Langerhans and constitute 2% of the pancreatic mass. The islets contain an average of 3000 cells and range in diameter from 40 to 900 mm. The islets are composed of four major cell types—alpha (A), beta (B), delta (D), and PP or F cells, which secrete glucagon, insulin, somatostatin, and pancreatic polypeptide, respectively. The B cells are centrally located within the islet and constitute 70% of the islet mass, whereas the PP, A, and D cells are located at the periphery of the islet. They constitute roughly 15%, 10%, and 5% of the islet cell mass, respectively.

Answer: b

The common causes of pancreatic abscesses are infected pancreatic pseudocysts and necrotizing pancreatitis. The diagnosis is suggested by persistent fever, leukocytosis, and a palpable abdominal mass. Bacteremia and systemic toxicity are late clinical features. Percutaneous aspiration with positive cultures is the definitive preoperative test, facilitated by CT scanning or ultrasound-guidance to suspicious peripancreatic fluid collections. When diagnosed, the treatment of choice is wide surgical débridement with removal of all infected and revitalized tissues. Generous drainage is mandatory. One of the major sources of morbidity and mortality in this situation is the late development of mycotic visceral pseudoaneurysms, particularly involving the splenic circulation. These may be complex management problems, requiring angiographic embolization or other innovative treatment strategies.

Answer: d

Generally, a pancreatic pseudocyst can be observed for a period of weeks or months in an effort to allow for spontaneous resolution. Percutaneous ultrasound-or CT-directed aspiration or drainage catheter placement is an initial treatment option. Simple aspiration is performed if the initial aspirate is sterile; if the aspirate is infected, a catheter or open drainage procedure is appropriate. Determination of pancreatic ductal anatomy is important. Contrast injection into the pseudocyst at the time of aspiration should be considered to assess the possibility of pancreatic ductal communication and obstruction, or multiple cysts. The pseudocyst recurrence rate after simple aspiration is about 20% to 25%.

Answer: e

A variety of pharmacologic agents that directly or indirectly reduce acinar cell enzyme release or ductal secretion have undergone clinical evaluation for the treatment of acute pancreatitis—generally with unimpressive results. Among the first were anticholinergic drugs. Despite extensive experience over many years, no objective data have emerged to support their use. Clinical trials of glucagon and calcitonin based on the same principle have produced a similar lack of supportive data. More recently, a somatostatin analog has been subjected to clinical trials for patients with acute pancreatitis. Somatostatin inhibits pancreatic enzyme and bicarbonate secretion by preventing the normal release of cholecystokinin, secretin, and other gut peptides. Despite the theoretical appeal, it has not been possible to demonstrate that somatostatin alters the natural history or prognosis of simple acute pancreatitis, although it does diminish pancreatic secretion.

Peritoneal lavage as a specific therapy for acute pancreatitis was proposed after experimental studies demonstrated improved survival in animals with fulminant pancreatitis. The concept was appealing in that activated proteases and other vasoactive substances identifiable in peritoneal aspirates from patients with pancreatitis would be removed, rather than systemically absorbed. Unfortunately, clinical trials using this approach have produced disappointing results, and the eventual overall mortality rate appears unchanged.

Answer: a, b, c, d

Many surgical procedures in the upper abdomen are associated with postoperative pancreatitis. The incidence of acute pancreatitis after gastric resection ranges from 0.6% to 1.23%. After biliary tract surgery, particularly after common bile duct exploration itself, acute pancreatitis occurs with an incidence of 0.5% to 3%. Direct manipulation or retraction of the pancreas or pancreatic duct appears to be the most common cause. About 1% of patients develop acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). This is a predictable event, and the risk can be minimized by limiting the pressure used for contrast injection of the pancreatic duct. Acute pancreatitis also occurs in patients after coronary artery bypass surgery and a variety of other procedures remote from the pancreas. Although pancreatitis in this circumstance is thought to result from ischemia, hypotension is not always noted. The systemic consequences of activation of the inflammatory system may contribute to changes in microvascular blood flow.

Answer: a, b, c

Initial management of pancreatic pseudocysts is based on symptoms. If the patient is asymptomatic and the cyst is small (< 5.0 cm) it can be safely observed as many of these will resolve over a period of weeks. Concurrent chronic alcoholic pancreatitis (by history or as indicated by pancreatic calcification), pseudocyst size greater than 5 cm, the presence of a multilocular or debris-filled pseudocyst cavity, and chronicity (longer than 6 weeks) are all factors that are associated with a lower probability of spontaneous resolution.

Answer: b, d, e

Ranson prognostic signs include:

ON ADMISSION

Age above 55 years

White blood cell count above 16,000/µL

Glucose level above 200 mg/dL

Lactase dehydrogenate level above 350 IU/L

SGOT value above 250 IU/L

AFTER 48 HOURS

Hematocrit decrease of 10%

Blood urea nitrogen level increase of 5 mg/dL

Ca2+ level below 8 mg/dL

PaO2 level below 60 mmHg

Base deficit value above 4 mEq/L

Fluid sequestration greater than 6 L

Answer: a

A patient who has simple cholelithiasis and an episode of acute pancreatitis is usually treated nonoperatively until clinical resolution of the pancreatitis occurs. The rate of recurrent biliary pancreatitis is as high as 34% to 56% within 6 weeks; therefore, an aggressive operative approach is appropriate. Cholecystectomy is often performed after the resolution of acute pancreatitis but before hospital discharge. Common bile duct instrumentation in this setting has a substantially increased risk of recurrent acute pancreatitis.

Answer: b

The operative treatment for pseudocysts depends on the underlying cause of the cyst, as well as the size, location, and maturity of the pseudocyst wall. Whenever possible, the status of the pancreatic duct should be assessed preoperatively, preferably by ERCP. Operative drainage can be either external or internal. External drainage is chosen in the presence of infection or an immature capsule. The disadvantages of external drainage include the risk of pancreatic fistula formation and a pseudocyst recurrence. External drainage has been associated with a higher mortality rate, probably because it is used in patients at higher risk, especially those with sepsis, pancreatic abscesses, or ruptured pseudocysts.

The type of internal drainage procedure selected depends on the location of the pseudocyst and whether or not there is associated pancreatic ductal pathology. Cystogastrostomy is the simplest and safest alternative if the pseudocyst is appropriately adjacent to the posterior wall of the stomach. Cystojejunostomy using a Roux-en-Y or loop jejunostomy may also be appropriate, depending on the location and specific anatomy of the pseudocyst. Pancreatic resection is associated with the lowest recurrence rate (3%), but is limited to pseudocysts occurring in the tail of the pancreas.

Answer: a, c

In autopsy series, the evidence for past acute pancreatitis averages 0.31%. Variations among populations are highly dependent on social factors such as ethanol use and on environmental and hereditary determinants such as the incidence of gallstones. Acute pancreatitis may occur at any age but is most common in adults between 30 and 70 years of age. In general, patients with gallstone-induced pancreatitis are older (age 40 to 60 years), whereas those with alcohol-associated pancreatitis are younger (age 30 to 40 years). The sex distribution of acute pancreatitis depends on the clinical cause of the disease, with women representing 68% of patients with gallstone-associated pancreatitis. Conversely, when alcohol is the primary association, men account for most patients.

Clinical associations with acute pancreatitis can be divided into three broad categories-biliary stones, ethanol, and others. Biliary tract stone disease and ethanol-induced pancreatitis account for most cases of acute pancreatitis reported worldwide. The particular distribution of causes reflects the source of the patient population evaluated. In a summary of 18 different reports of acute pancreatitis in the United States with a combined total of 7147 patients, 53% of patients were believed to have ethanol-induced disease, whereas 28% had proven biliary stones. In contrast, of 1539 patients reported on from Great Britain, 52% had gallstones, 7% were ethanol related, and 34% had no identifiable cause.

Answer: a

In the United States, alcohol consumption is the major cause of chronic pancreatitis: with approximately 70% of cases attributable to this factor. Most patients with symptomatic chronic pancreatitis have consumed large volumes of alcohol daily for a prolonged period of time. The average daily intake of alcohol is 150 to 175 g with the mean duration of alcoholism before recognition of pancreatitis being 18 years for men and 11 years for women. The incidence of chronic pancreatitis on autopsy studies of chronic alcoholics is 50 times the rate of non-drinking controls. Only 10% of alcoholics develop chronic pancreatitis—suggesting that factors other than long-term alcohol exposure may also influence susceptibility. In both experimental and clinical studies, the risk of alcohol-induced chronic pancreatitis is increased by a high-protein, high-fat diet.

Answer: d

Routine tests of blood or serum are not helpful in making a diagnosis of chronic pancreatitis. Although serum amylase levels are almost always elevated in acute pancreatitis—amylase levels may be normal, elevated, or subnormal in chronic pancreatitis. Determination of urinary amylase secretion and calculation of urinary amylase clearance does not improve sensitivity or specificity. Indirect tests of pancreatic function which measure absorption of nutrients that first require pancreatic digestion are not helpful in early cases of chronic pancreatitis. Clinically detectable malabsorption is absent until 90% of exocrine function is lost. Because of this, indirect tests of pancreatic function do not detect early disease. In addition, false positive tests may occur in other disease states associated with malabsorption (Crohn’s disease, sprue, postgastrectomy states, or in association with diabetes mellitus, cirrhosis, or renal disease. ERCP has become widely recognized as the most sensitive and reliable method for diagnosing chronic pancreatitis. Sensitivity approaches 90% with equal specificity.

Answer: b

When patients with chronic pancreatitis have pancreatic ductal dilatation (greater than 8 mm. ductal decompression using longitudinal pancreaticojejunostomy may be employed for relief of pain. The finding that pancreatic ductal hypertension exists in patients with painful chronic pancreatitis and that surgical decompression reduces intrapancreatic pressure to normal provides the rationale for this operation. The anterior surface of the pancreas is exposed through the lesser sac. The entire pancreatic duct is opened from the pancreatic tail to a point 1 cm from the duodenum. A side-to-side anastomosis is then performed between the opened pancreatic duct and a loop of jejunum. Splenectomy is not necessary. In-hospital mortality rates of less than 5% have been widely reported. Approximately 80% of patients report complete or substantial improvement of pain following longitudinal pancreaticojejunostomy.

Answer: b

Operative management of patients with stricture of the common bile duct associated with chronic pancreatitis is justified to treat symptoms and to prevent development of biliary cirrhosis. Operative indications include progressive jaundice, cholangitis, liver biopsy evidence of biliary cirrhosis, persistent elevation of alkaline phosphatase at greater than three times normal, and progressive stricture demonstrated by radiologically progressive dilatation of extrahepatic and intrahepatic biliary ducts. Both choledochoduodenostomy and choledochojejunostomy are excellent operative choices.

Answer: c

Biliary complications involving the common bile duct can occur in chronic pancreatitis because of the intimate association of that structure with the head of the pancreas. In two-thirds of individuals, the common bile duct traverses the pancreatic parenchyma and in an additional 25%, the common bile duct lies within a groove along the posterior surface of the pancreas. Fibrosis associated with chronic pancreatitis can encase and compress the common bile duct. Common bile duct stenosis is relatively common in chronic pancreatitis, occurring in approximately 10% of cases observed long-term. Cholangiography typically reveals a long, gradually tapering stricture conforming to the intrapancreatic portion of the common bile duct. In contrast, malignant strictures usually result in abrupt termination of the biliary duct. The proximal suprapancreatic portion of the bile duct is variably dilated.

Answer: d

After alcohol-induced and hereditary disease, idiopathic chronic pancreatitis is the most common cause of calcifying pancreatitis in North American patients. This designation is given to those cases without a recognizable cause. Idiopathic pancreatitis accounts for about 15% of the cases and has two peaks in incidence, suggesting that differing underlying causes may exist. The first peak occurs in young adulthood and the second has an occurrence at approximately 60 years of age.

Answer: a, c

Patients with chronic pancreatitis have decreased long-term survival compared to the general population. An excess of mortality of 30% over 20 years has been estimated. Less than 20% of deaths are directly attributable to pancreatitis or its complications. Excess mortality is related to extrapancreatic complications of alcoholism and smoking, including cancers of the aerodigestive system, complications of diabetes, and complications of cirrhosis.

Answer: d

Pain is a predominant symptom complex in most patients with chronic pancreatitis. Chronic pancreatic pain is usually localized to the epigastrium with radiation to the back in the region of the upper lumbar vertebrae. Discomfort may be exacerbated by eating and is usually alleviated by abstinence from food and by bending forward. Malabsorption and weight loss, clinical manifestations of steatorrhea, are only observed when greater than 90% of exocrine tissue has been destroyed. Clinical signs of malabsorption are a late manifestation of chronic pancreatitis. Although abnormal glucose tests can be demonstrated in 50% to 70% of patients with chronic Pancreatitis: overt diabetes mellitus is present in only 30% to 40%. Endocrine deficits are usually progressive. If individual patients are repetitively tested, progressive deterioration is often observed.

Answer: a

The proper treatment is surgical removal of the tumor; aggressive pancreatic resection is appropriate. It is crucial to avoid mistaking a mucinous cystic tumor for a pancreatic pseudocyst. Internal drainage of a malignant mucinous cystic tumor results in catastrophic tumor dissemination and should never be performed. With appropriate treatment, all patients with histologically benign tumors should be cured; for tumors demonstrating malignant change, 5-year survival after surgery is about 60%.

Answer: b, c

During performance of pancreaticoduodenectomy, the lesser sac is opened widely through the gastrocolic omentum. This maneuver allows inspection of the body and tail of the gland to determine the extent of the tumor involvement and allows examination of lymph nodes along the superior and inferior body of the pancreas and around the celiac axis. Enlarged nodes in these areas should undergo biopsy and be submitted for frozen-section examination, since tumor in these areas is beyond the bounds of standard pancreaticoduodenectomy and constitutes a contraindication to resection. If there is no evidence of lymphadenopathy, a dissection between the anterior surface of the portal vein and the posterior surface of the neck of the pancreas is performed. Ordinarily, only thin areolar tissue lies between the pancreas and the portal vein, and a communication behind the neck of the pancreas can be established. If there is hard tissue intervening and such communication cannot be established, this implies invasion of the anterior surface of the portal vein and signals unresectability by standard methods.

Answer: a

Standard transcutaneous ultrasonography is the appropriate first test in the evaluation of the patient with jaundice, because the presence of a dilated common bile duct or intrahepatic bile ducts is essentially diagnostic of extrahepatic biliary obstruction. This finding directs the physician to a search for the cause of the obstruction. If the bile ducts are not dilated, mechanical obstruction is unlikely and the diagnostic thrust should move toward hepatocellular disease. Ultrasonography is also the best test to determine whether gallstones are present; this is extremely important because choledocholithiasis is one of the conditions most likely to cause jaundice in the elderly population.

Answer: a, c

Sixty to 70% of pancreatic ductal adenocarcinomas occur in the head of the gland. About 15% reside in the body of the gland, another 10% are in the tail, and the remaining 5% to 15% are diffuse. The predilection of pancreatic cancer to develop in the head of the gland is unexplained, but has the practical consequence that tumors in the head are diagnosed earlier because they cause obstructive jaundice whereas tumors in the body and tail tend to be more advanced at the time of symptomatic presentation. Tumors in the body and tail are typically larger at the time of diagnosis (average, 7 to 8 cm) than in the head (average, 4 to 5 cm).

Answer: b

Pancreaticoduodenectomy is a formidable operation, and until recently, average operative mortality was reported to approximate 20%. In the past few years, several centers have reported large series with operative mortalities lower than 5%.

The most dreaded complication of pancreaticoduodenectomy is disruption of the pancreaticojejunostomy, which occurs in about 10% of patients. Anastomotic breakdown may lead to the development of an upper abdominal abscess or may present as a external pancreatic fistula. In its most virulent form, disruption leads to necrotizing retroperitoneal infection which may erode major arteries and veins of the upper abdomen, including the portal vein or its branches or the stump of the gastroduodenal artery. Impending catastrophe is often preceded by a small herald bleed from the drain site. Such an event is an indication to return to the operating room to widely drain the pancreaticojejunostomy and to repair the involve