Biliary Tract

Question 1

Prolonged hospitalization with FASTING, TRAUMA, POST-OP, PPN/TPN can all cause this type of BILIARY DISEASE?

Answer 1

ACALCULOUS CHOLECYSTITIS

Question 2

What occurred in a patient with CHOLECYSTITIS where AIR is noted in the biliary tree and they have not yet had an ERCP?

Answer 2

FISTULA

Question 3

A patient with CHOLELITHIASIS feels better initially, but develops N/V and abdominal pain with inability to tolerate PO?

Answer 3

GALLSTONE ILEUS (stone stuck in small bowel, at IC valve or duodenum causing GOO)

Question 4

For which patients with BILIARY DYSKINESIA would CHOLECYSTECTOMY be beneficial?

Answer 4

Those with SYMPTOMS

Question 5

What is the recommended SURVEILLANCE for GALLBLADDER POLYPS <10 mm?

Answer 5

Imaging every 6 MONTHS for 1-2 YEARS to ensure no rapid growth then STOP

Question 6

WHEN should CHOLECYSTECTOMY be performed for GALLBLADDER POLYPS?

Answer 6

When the POLYP >10 mm or ANY SIZE in PSC

Question 7

This condition is associated with GALLSTONES, FEMALES, ANOMALOUS pancreaticobiliary ducts, PSC, chronic SAMLMONELLA typhi, IBD and galbladder POLYPS?

Answer 7

GALLBLADDER CANCER (very poor prognosis)

Question 8

JAUNDICE, RUQ PAIN, FEVER?

Answer 8

CHOLANGITIS

Question 9

This BILIARY CONDITION is more COMMON in patients post LIVER TRANSPLANT, AIDS and HYPERlipidemia?

Answer 9

Sphincter of Oddi Dysfunction (SOD)

Question 10

Which SOD type is associated with AST/ALT elevation of >1.1 AND CBD >10 mm, AND BILIARY COLIC?

Answer 10

SOD Type I (treat with ERCP/sphincterotomy)

Question 11

Which SOD type is associated with AST/ALT elevation OR CBD >10 mm, AND BILIARY COLIC?

Answer 11

SOD Type II (treat with ERCP/sphincterotomy)

Question 12

Which SOD type is associated with BILIARY COLIC but WITHOUT AST/ALT elevation OR CBD DILATION?

Answer 12

SOD Type III (no longer considered) - NO ERCP (no different than placebo)

Question 13

Does diagnosis of SOD and treatment depend on Sphincter of Oddi Manometry (SOM)?

Answer 13

NO (empiric sphincterotomy)

Question 14

Choledochal Cyst associated with congenital HEPATIC FIBROSIS and RENAL disease with RECURRENT CHOLANGITIS and INTRA-HEPATIC CALCULI?

Answer 14

CAROLI’s DISEASE

Question 15

What is the TREATMENT for CHOLEDOCHAL CYSTS?

Answer 15

SURGERY (to prevent cancer - cholangiocarcinoma)

Question 16

In which POPULATION are CHOLEDOCHAL CYSTS most COMMON?

Answer 16

JAPANESE

Question 17

Which condition is associated with BLACK gallstones?

Answer 17

CHRONIC HEMOLYSIS such as seen in PROSTHATIC AORTIC VALVE REPLACEMENT, LVAD, Cirrhosis, PSC

Question 18

Rapid Weight Loss, Parity, Obesity, and Estrogen Replacement Therapy are all associated with what type of GALLSTONES?

Answer 18

CHOLESTEROL stones

Question 19

How do you treat a patient who presents with BILIARY COLIC and is only found to have BILIARY SLUDGE?

Answer 19

CHOLECYSTECTOMY (same as stones)

Question 20

What BILIARY DISEASE is PSC associated with?

Answer 20

CHOLANGIOCARCINOMA

Question 21

What type of GALLBLADDER POLYPS are associated with CHOLANGIOCARCINOMA?

Answer 21

POLYPS >10 mm (cholesterol and adenomyomatosis)

Question 22

Which CHOLEDOCHAL CYST TYPE does NOT need SURGERY and can be treated with ERCP ans SPHINCTEROTOMY alone?

Answer 22

Type III

Question 23

What type of SURGERY is required for CHOLEDOCHAL CYSTS?

Answer 23

ROUX-en-Y HEPATICOJEJUNOSTOMY

Question 24

In a patient WITHOUT CLEAR GB SYMPTOMS, even if they have MILD elevation of LIPASE or anti-gliuadin Ab positivity or reduced GB EF, what is their most LIKELY diagnosis?

Answer 24

FUNCTIONAL DYSPEPSIA (treat with anti-spasmotic or TCA)

Question 25

In a patient with **SOD** symptoms (such as Type II) if elevated **LFTs**, these have to be elevated without **NAFLD** due to obesity, etc. and the most likely diagnosis of persistent **GB** symptoms, **EVEN AFTER** **CHOLECYSTECTOMY** is likely what?

Answer 25

**FUNCTIONAL DYSPEPSIA** (further imaging with CT, EUS or MRI) prior to ERCP/sphincterotomy

Question 26

What are the **COMMON** 2 **CONTRAINDICATIONS** to **LAPAROSCOPIC** **CHOLECYSTECTOMY**?

Answer 26

**ADHESIONS** from prior surgeries, **COAGULOPATHIES**

Question 27

Can **GALLBLADDER DYSKINESIA** cause symptoms?

Answer 27

More than likely **NO** (it's usually **functional dyspepsia**)

Question 28

Pt with **CONVICING GB SYMPTOM**S and **NEGATIVE GB US**, what do you do next B**EFORE CHOLECYSTECTOMY**?

Answer 28

**CCK-HIDA** scan (low EF)

Question 29

Pt presents with **RUQ** abdominal pain, **T.Bili \>4**, **CBD \>6 mm** or **\>8 mm post-cholecystectomy**, **ASCENDING CHOLANGITIS** or **CBD** **STONE** on **US** what's the **NEXT STEP**?

Answer 29

**ERCP**

Question 30

How **LONG** should you **WAIT** to perform an **ERCP** in a patient with **BILIARY PANCREATITIS** if they have **NO CHOLANGITIS** or continued **PD** obstruction?

Answer 30

**48 HOURS** (let pancreatitis subside as ERCP can cause pancreatitis)

Question 31

What **COLOR** are **CBD** stones that formed **POST-CHOLECYSTECTOMY** (usually **\>2 years** after)?

Answer 31

**BROWN** pigment

Question 32

Which post-op bile duct leaks require **IR drainage**?

Answer 32

Those **\>3 cm**

Question 33

A patient presents **~2-10 DAYS** post **CHOLECYSTECTOMY** with **FEVER**, **ABDOMINAL PAIN** and possible **ASCITES** usually have what?

Answer 33

Post-OP BILE DUCT **LEAK**

Question 34

What is the **TREATMENT** for a post-OP **COMMON HEPATIC DUCT** (**CHD**) **LEAK**?

Answer 34

**SURGICAL HEPATICOJEJUNOSTOMY**

Question 35

What is the **TREATMENT** of a post-OP Bile Duct **Leak**?

Answer 35

ERCP with **10 F stent** (sphincterotomy is NOT needed) - **remove** after **4 WEEKS**

Question 36

Occlusive **INJURY** to this **DUCT** can occur during **CHOLECYSTECTOMY** resulting in **SEGMENTAL** cholestasis due to infection and **INTRA-HEPATIC STONE** disease, **ATROPHY** of the liver **LOBE** and **CHOLANGITIS**?

Answer 36

**RIGHT HEPATIC DUCT** (RHD)

Question 37

**2 YEARS** post **CHOLECYSTECTOMY**, patient presents with elevated **LFTs**, biliary **PAIN**, **JAUNDICE** and **DILATED INTRAHEPATIC DUCTS** on imaging?

Answer 37

Post-OP **OCCLUSIVE** **INJURY** to **CHD** or **CBD**

Question 38

Up to what **LENTGH** are **BILIARY STRICTURES** likely to respond to **ERCP** with stent placement?

Answer 38

**1 CM**

Question 39

What is the **TREATMENT** for **REFRACTORY** **BILIARY STRICTURES**?

Answer 39

Biliary **BYPASS** surgery (alternative to hepaticojejunostomy)

Question 40

What are **SOD** patients at **RISK** for if undergoing **ERCP** and how should they be treated?

Answer 40

**PANCREATITIS** - prophylactic **PD** **stent** placement, rectal **INDOMETHACIN** and **IVFs**

Question 41

Metastatic **COLON**, **GASTRIC**, **PANCREATIC**, **BREAST** and **MELANOMA** can all cause **BILIARY** obstruction **HOW**?

Answer 41

**HILAR LYMPHADENOPATHY**

Question 42

What **TYPE** of biliary **STENT** should be placed for a patient with **INOPERABLE PANCREATIC CANCER**?

Answer 42

**BARE METAL STENT** (fully covered stents can migrate, partially covered stents still occlude)

Question 43

What should be done to determine **TREATMENT** of a **HILAR MALIGNNCY** prior to **ERCP**?

Answer 43

**MRCP** to determine which side (L or R) would benefit more from **STENTING**

Question 44

What is **BEST** used to diagnosed **IDIOPATHIC ACUTE PANCREATITIS** (sludge, strictures, divisum, ampullary neoplasm, IPMN)?

Answer 44

**EUS** (or secrectin-MRCP)

Question 45

What is the **MODALITY** of choice for diagnosis of **CHRONIC PANCREATITIS**?

Answer 45

**EUS** (Rosemont Criteria 9)

Question 46

What should be **EXCLUDED** **PRIOR** to attempting EUS-guided **Cystgastrostomy** of a pancreatic **PSEUDOCYST**?

Answer 46

The presence of an **ANEURYSM** or **PSEUDOANEURYSM**

Question 47

What is the **RISK** of **POST-ERCP PANCREATITIS**?

Answer 47

**3-10%** (up to 25% in high-risk patients)

Question 49

Prior **POST-ERCP** pancreatitis, SOD, **FEMALE**, normal **BILIRUBIN**, previous **ACUTE** **RECURRENT** **PANCREATITIS** and **NO CHRONIC PANCREATITIS** are all **RISK** factors for what?

Answer 49

**POST-ERCP PANCREATITIS**

Question 50

What should be **MODIFIED** when performing an **ERCP** for choledocholithiasis in a patient with **CIRRHOSIS**?

Answer 50

**Balloon dilation** of papilla rather than sphincterotomy to minimize risk of post-OP bleed

Question 51

How are **INTRAPERITONEAL** perforations during **ERCP** or endoscopy treated (severe **PAIN**, **GUARDING**, **FEVER**, **LEUKOCYTOSIS**)?

Answer 51

**SURGERY**

Question 52

How are **RETROPERITONEAL** perforations during **ERCP** treated?

Answer 52

**NGT SUCTION**, **ANTIBIOTICS**, **OBSERVATIONS** (only 10-20% require surgery)

Question 53

**WHEN** are **PHROPHYLACTIC** antibiotics **RECOMMENDED** in the **PERI-ERCP** time?

Answer 53

Whenever there is a **SUSPICION** of **OBSTRUCTION** of a **POORLY-DRAINING** space (contiue for **5-7 days** post ERCP if drainage is still poor such as in PSC, malignancy)

Question 54

What is a **SUPERIOR** modlaity for staging **ESOPHAGEAL** **MALIGNANCIES** and lesions?

Answer 54

**EUS**

Question 55

When should a **GIST** be removed surgically?

Answer 55

When it is **\>2 cm**, **IRREGULAR** contour, is **ULCERATED** or **BLEEDING**

Question 56

When performing an **EUS**, when is **PROPHYLACTIC ANTIBIOTIC** use recommended and why?

Answer 56

When performing **FNA** of CYSTS, to prevent **ABSCESS** formation (for peri-rectal spaces, continue for 48 hours post)

Question 57

**WHEN** are **B/L PTC DRAINS** required with eventual **HEPATICOJEJUNOSTOMY** to fix a **BILE** **LEAK**?

Answer 57

When there has been a **COMPLETE DISRUPTION** of the Common Hepatic Duct (**CHD**)

Question 58

Abdominal **PAIN** same as **PRIOR** to cholecystectomy, **ELEVATED LFTs**, **DILATED CBD**?

Answer 58

**SOD-I** (treat with **ERCP/SPHINCTEROTOMY**)

Question 59

If on **MANOMETRY**, a patient is **PROVEN** to have **ELEVATED** ampullary pressure and thus **SOD**, especially in a patient with **ACUTE RECURRENT IDIOPATHIC PANCREATITIS**, what is the **PERCENTAGE** of clinical improvement post **ERCP/SPHINCTEROTOMY**?

Answer 59

**50%**

Question 60

Which patients have the **HIGHEST** **post-ERCP** risk of **BLEEDING**?

Answer 60

Those that **MUST** resume **ANTICOAGULATION** within **3 days** post-ERCP (valve replacements)

Question 61

What can be **ADDED** to **ERCP BRUSH CYTOLOGY** to improve diagnostic yield by **20%** when "**ATYPICAL**" cells are noted but no diagnosis of malignancy exists?

Answer 61

**FISH** analysis (**F**luorescence **I**n-**S**itu **H**ybridization)