LE3 SubSpec

Question 1

1. The following statements are FALSE regarding pediatric surgery patients:

A. Children are little adults, not little people
B. Children do not suffer pain after surgery
C. Sick children shout before they whisper
D. Never listen to the mother and the father

Answer 1

A. Children are little adults, not little people

Rationale: The statement “Children are little adults, not little people” is incorrect. Pediatric patients are not simply smaller versions of adults. They have unique physiological and psychological needs, requiring specialized care and attention, as highlighted in the surgical principles. The correct statement is that “Children are not little adults, they are little people,” emphasizing their distinct needs.

Question 2

2. The most common cause of a neck mass in a child is:

A. Lymphadenopathy
B. Thyroglossal duct cyst
C. Cystic hygroma
D. Branchial cleft anomalies

Answer 2

A. Lymphadenopathy

Rationale: The most common cause of a neck mass in children is lymphadenopathy, typically due to reactive or infectious causes. Enlarged lymph nodes in the neck are often seen with infections like upper respiratory tract infections or localized conditions.

Question 3

3. The most common variant of a congenital diaphragmatic hernia is:

A. Anterolateral
B. Anteromedial
C. Posterolateral
D. Posteromedial

Answer 3

C. Posterolateral

Rationale: The most common variant of congenital diaphragmatic hernia is the posterolateral defect, also known as a Bochdalek hernia. It results from the failure of the pleuroperitoneal membrane to close completely during development, leading to abdominal contents herniating into the thoracic cavity.

Question 4

4. Which type of esophageal atresia with tracheoesophageal fistula (EA-TEF) describes an H-type fistula?

A. Type A
B. Type B
C. Type C
D. Type D
E. Type E

Answer 4

E. Type E

Rationale: H-type esophageal atresia with tracheoesophageal fistula (TEF) is classified as Type E. In this type, there is no esophageal atresia, but a fistulous connection exists between the trachea and esophagus, resembling an “H” shape.

Question 5

5. Which type of intestinal atresia is characterized by the bowel receiving its blood supply in a retrograde fashion from the ileocolic or right colic artery?

A. Type 1
B. Type 2
C. Type 3
D. Type 4

Answer 5

C. Type 3

Rationale: Type IIIb intestinal atresia involves an extensive mesenteric defect, where the distal ileum receives its blood supply in a retrograde fashion via the ileocolic or right colic artery. This characteristic differentiates it from other types of intestinal atresias.

Question 6

6. A remnant of a portion of the embryonic vitelline duct is called:

A. Urachus
B. Meckel’s Diverticulum
C. Mesenteric Cyst
D. Intestinal Duplication

Answer 6

B. Meckel’s Diverticulum

Rationale: Meckel’s diverticulum is a remnant of the vitelline duct (also known as the omphalomesenteric duct) that normally obliterates during fetal development. When this duct fails to regress, it forms Meckel’s diverticulum, which can cause complications such as bleeding, obstruction, or inflammation.

Question 7

7. Which of the following is TRUE regarding the Todani classification of multiple dilatations of the extrahepatic ducts?

A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V

Answer 7

D. Type IV

Rationale: According to Todani’s classification, Type IV refers to multiple dilations of the intrahepatic and extrahepatic bile ducts. Subtype IVa involves both intrahepatic and extrahepatic ducts, while Subtype IVb involves only extrahepatic bile ducts. This classification helps in understanding the nature and distribution of biliary dilations.

Question 8

8. Which of the following is a characteristic of Eagle-Barrett syndrome?

A. Abdominal defect in the umbilicus
B. Ambiguous Genitalia
C. Lax lower abdominal musculature
D. Moisture or urine flow from the umbilicus

Answer 8

A. Lax lower abdominal musculature

Rationale: Eagle-Barrett syndrome, also known as Prune-Belly Syndrome, is characterized by a triad of features: extreme laxity of the lower abdominal musculature, dilated urinary tract (including the bladder), and bilateral undescended testes. The condition results in a characteristic wrinkled appearance of the abdomen.

Question 9

9. The most common cardiac anomaly associated with omphalocele is:

A. Ventricular septal defect (VSD)
B. Tetralogy of Fallot
C. Tricuspid atresia
D. Atrial septal defect (ASD)

Answer 9

A. Ventricular septal defect (VSD)

Explanation:
The most common cardiac anomaly associated with omphalocele is ventricular septal defect (VSD).

Omphalocele is a congenital abdominal wall defect that is often associated with other anomalies, particularly cardiac defects, which occur in up to 50% of cases.
Among these cardiac anomalies, VSD is the most frequently observed, followed by other structural heart defects like atrial septal defect (ASD) and tetralogy of Fallot.

Question 10

9. Most common site of rhabdomyosarcoma origin
   a. Trunk
   b. Genitourinary tract
   c. Extremities
   d. Head and neck

Answer 10

D. Head and neck

Rationale: The most common site of rhabdomyosarcoma origin is the head and neck region (36%). Rhabdomyosarcoma is a soft tissue tumor that arises from mesenchymal tissue and is often seen in children.

Question 11

10. The leading cause of intestinal obstruction in children is:

A. Intussusception
B. Crohn’s disease
C. Volvulus
D. Hirschsprung’s disease

Answer 11

C. Intussusception

Rationale: Intussusception is the leading cause of intestinal obstruction in young children. It occurs when a segment of the intestine telescopes into another, leading to obstruction and reduced blood supply. It often presents with intermittent abdominal pain, vomiting, and a “currant jelly” stool.

Question 12

11. A lateral neck mass associated with rotation of the head towards the opposite side of the mass is indicative of:

A. Thyroglossal duct cyst
B. Cystic Hygroma
C. Branchial cleft cyst
D. Torticollis

Answer 12

D. Torticollis

Rationale: Torticollis is characterized by the rotation of the head toward the opposite side of the affected neck muscle. It is caused by the shortening or tightening of the sternocleidomastoid muscle, which often results in a palpable mass in the lateral neck.

Question 13

12. Which of the following conditions requires immediate surgical intervention?

A. Midgut volvulus
B. Esophageal atresia
C. Intussusception
D. Duodenal atresia

Answer 13

A. Midgut volvulus

Rationale: Midgut volvulus is a surgical emergency due to the risk of bowel ischemia and necrosis caused by twisting of the midgut around the superior mesenteric artery. Immediate surgical intervention is required to untwist the bowel and prevent life-threatening complications. Other conditions listed, while important, generally allow for some time before intervention.

Question 14

13. The most frequent and lethal gastrointestinal disorder affecting the intestine of the stressed, preterm neonate is:

A. Malrotation
B. Short Bowel Syndrome
C. Mesenteric Ischemia
D. Necrotizing Enterocolitis

Answer 14

B. Necrotizing enterocolitis
Rationale: Necrotizing enterocolitis (NEC) is the most frequent and lethal gastrointestinal disorder in preterm neonates, characterized by inflammation and necrosis of the intestinal lining. It is associated with high morbidity and mortality, ranging from 10% to 50%, especially in stressed or premature infants.

Question 15

14. The cardinal symptom of intestinal obstruction in the newborn is:

A. Distended Abdomen
B. Vomiting bile
C. Paucity of gas in radiographs
D. No passage of meconium

Answer 15

A. Vomiting bile
Rationale: Bilious vomiting is the cardinal symptom of intestinal obstruction in newborns. It is a key indicator of a surgical emergency, often associated with conditions such as malrotation, atresias, or volvulus. Other signs include abdominal distension and failure to pass meconium.

Question 16

15. Which condition is characterized by persistent obstructive jaundice with normal biliary tracts?

A. Physiologic Jaundice
B. Biliary Atresia
C. Inspissated bile
D. Choledochal cyst

Answer 16

C. Inspissated bile
Rationale: Inspissated bile is characterized by persistent obstructive jaundice with normal biliary tract anatomy. It is caused by increased viscosity of bile leading to obstruction of bile canaliculi, often seen in conditions like hemolysis or cystic fibrosis.

Question 17

16. A 10-year-old female presents with an anterior neck mass noted by the mother. The mother noticed the mass since the child was 2, but it recently became enlarged and tender after a cough. On examination, there is a tender and swollen mass approximately 1.5 cm in the upper midline of the neck. The mass does not move upon swallowing but moves with tongue protrusion. What is the most likely diagnosis?

A. Infected branchial cleft cyst
B. Thyroglossal duct cyst
C. Infected cystic hygroma
D. Lymphadenopathy

Answer 17

B. Thyroglossal duct cyst
Rationale: A thyroglossal duct cyst presents as a midline neck mass that does not move with swallowing but moves with tongue protrusion. This cyst arises from the remnant of the thyroglossal duct during embryonic development and is commonly found in children aged 2-4 years. It becomes symptomatic when infected or inflamed.

Question 18

17. A 10-year-old female presents with an anterior neck mass noted by the mother. The mother noticed the mass since the child was 2, but it recently became enlarged and tender after a cough. On examination, there is a tender and swollen mass approximately 1.5 cm in the upper midline of the neck. The mass does not move upon swallowing but moves with tongue protrusion. What is the most likely diagnosis?

What is the appropriate management for the patient in the previous question?

A. antibiotic, neck ultrasound, surgery
B. sclerotherapy
C. antibiotic and I&D
D. Complete excision of the cyst and sinus tract

Answer 18

D. Complete excision of the cyst and sinus tract

Question 19

18. A newborn, term, small for gestational age, with no prenatal consult, develops respiratory distress shortly after delivery. On physical examination, the patient has a scaphoid abdomen. Chest x-ray shows an indistinct diaphragm on the left, opacification and air bubbles in part of the left hemithorax, and a deviated endotracheal and nasogastric tube. What is the most likely diagnosis?

A. Diaphragmatic hernia
B. Congenital lobar emphysema
C. Bronchopulmonary foregut malformation
D. Bronchiectasis

Answer 19

A. Diaphragmatic hernia

Question 20

19. Respiratory distress in diaphragmatic hernia is primarily due to:

A. Hypoplastic lung on the affected side
B. Compression of the mobile mediastinum, which shifts to the opposite side of the chest, compromising air exchange in the contralateral lung
C. Pulmonary hypertension
D. All of the above

Answer 20

D. All of the above

Rationale: Respiratory distress in diaphragmatic hernia occurs due to multiple factors:
-Hypoplastic lung on the affected side: The lung on the hernia side is underdeveloped, leading to inadequate gas exchange.
-Compression of the mobile mediastinum: Abdominal contents herniate into the chest cavity, pushing the mediastinum to the opposite side and impairing air exchange in the contralateral lung.
-Pulmonary hypertension: Persistent fetal circulation and reduced pulmonary perfusion due to structural abnormalities exacerbate respiratory distress.

Question 21

21. A newborn with excessive drooling, vomiting after feeding, a distended abdomen, and an x-ray showing coiling of the orogastric tube in the upper esophagus and a dilated stomach most likely has which type of esophageal atresia with tracheoesophageal fistula (EA-TEF)?

a. Type A
b. Type C
c. Type H
d. Type B
e. Type D

Answer 21

b. Type C
Rationale: The most common type of esophageal atresia with tracheoesophageal fistula (TEF) is Type C, where there is a blind upper esophageal pouch and a fistulous connection between the trachea and the distal esophagus. This is confirmed by symptoms such as excessive drooling and vomiting after feeding, with radiographic findings of coiling in the upper esophagus and dilated stomach.

Question 22

22. The initial management of esophageal atresia with tracheoesophageal fistula (EA-TEF) involves:

a. Respiratory stabilization, decompression, timing of surgery
b. Decompression, nutrition, timing of energy
c. Antibiotic, hydration, timing of surgery
d. Nutrition, determination of anomalies, timing of surgery

Answer 22

a. Respiratory stabilization, decompression, timing of surgery
Rationale: Initial management of EA-TEF focuses on respiratory stabilization, minimizing positive pressure, decompressing the proximal pouch to prevent aspiration, and planning timely surgical repair to restore continuity of the esophagus.

Question 23

23. On day 2 post-op, a patient with EA-TEF develops respiratory distress. A chest x-ray shows pleural effusions. Which of the following is the most appropriate management?

A. Early leakage
B. Immediate exploration
C. Can be managed conservatively
D. Possible due to excessive tension

Answer 23

B. Immediate exploration
Rationale: Postoperative respiratory distress with pleural effusion in a patient with repaired EA-TEF is typically managed conservatively unless there are signs of significant complications like leakage or tension pneumothorax. Immediate exploration is rarely required.

Question 24

24. A 1-year-old male presents to the ER after ingesting muriatic acid. Which of the following statements is FALSE?

A. Caustic substance will cling to the esophagus
B. Strictures occur at the anatomic narrowed areas of the esophagus
C. A child may be symptom-free but usually will be drooling and unable to swallow saliva
D. There are multiple effective immediate antidotes for ingestion of corrosive substances

Answer 24

D. There are multiple effective immediate antidotes for ingestion of corrosive substance
Rationale: There are no specific antidotes for corrosive ingestion. Management focuses on supportive care, including pain relief and airway management. Immediate measures like diluting the substance with water or milk may help but are not definitive antidotes. Drooling and inability to swallow saliva are typical symptoms, and strictures can occur at narrowed areas of the esophagus due to scarring.

Question 25

25. A 2-year-old female presents to the ER after ingesting a coin. A chest x-ray (AP/lateral) shows a radiopaque, round object on the AP view and a linear shape in the lateral view just above the thoracic inlet. Where is the coin located? A. Coin is in the esophagus B. Coin is in the trachea C. 2 coins were swallowed, one in the esophagus, one in the trachea D. Radiologic markers showing the previous position of the coin

Answer 25

A. Coin in the esophagus Rationale: On an AP view of the X-ray, a coin lodged in the esophagus appears as a circular object ("en face"), while on the lateral view, it appears as a line ("on edge"). This differentiates esophageal location from tracheal placement, where the coin's appearance is reversed.

Question 26

26. If the coin in the previous question is proximally located in the esophagus, what is the most appropriate management? A. Removal using Magill forceps during direct laryngoscopy B. Esophagoscopy, removal of foreign body C. Esophagotomy D. Repeat x-ray after 24 hours and see if the coin has proceeded to the abdomen

Answer 26

A. Removal using Magill forceps during direct laryngoscopy Rationale: If a coin is lodged in the upper esophagus for less than 24 hours, it can often be safely removed using Magill forceps during direct laryngoscopy. If this fails or if the coin has been present for longer, esophagoscopy may be required.

Question 27

27. An infant presents with bilious vomiting. The infant appears well, and the abdomen is not distended. However, the upper abdomen appears globular but soft and non-tender. A chest x-ray shows two air-filled bubbles in the upper abdomen with an absence of distal gas. What is your primary diagnosis? A. Duodenal atresia B. Midgut volvulus C. Intestinal atresia D. Duodenal duplication cyst

Answer 27

A. Duodenal Atresia Rationale: The presence of bilious vomiting and the characteristic "double bubble" sign on the chest X-ray, with no distal gas, strongly suggests duodenal atresia. This congenital condition is due to incomplete recanalization of the duodenum during embryonic development. It is commonly associated with Down syndrome.

Question 28

28. Which chromosomal abnormality is most commonly associated with duodenal atresia? A. Trisomy 21 B. Trisomy 18 C. Trisomy 13 D. Turner Syndrome

Answer 28

D. Trisomy 21 Rationale: Duodenal atresia is commonly associated with Down syndrome (Trisomy 21). Approximately one-third of cases of duodenal atresia are seen in neonates with this chromosomal anomaly, along with potential cardiac defects.

Question 29

29. A 10-day-old infant presents with bilious vomiting, irritability, and abdominal tenderness. An abdominal x-ray shows dilated proximal bowel and a paucity of distal bowel gas with a few scattered air-fluid levels, suggesting a complete duodenal obstruction. What is the most probable diagnosis? a. Duodenal atresia b. Midgut volvulus c. Intestinal atresia d. Duodenal duplication cyst

Answer 29

b. Midgut volvulus Rationale: Recurrent bilious vomiting, abdominal distension, and scattered air-fluid levels on X-ray suggest midgut volvulus, which is a surgical emergency. It results from abnormal rotation of the midgut, leading to ischemia and obstruction.

Question 30

30. What is the appropriate management for a patient with midgut volvulus? a. decompress, hydrate, and serial x-rays, surgery if conservative management failed b. usually resolves with conservative management c. decompress, hydrate, antibiotics d. decompress, hydrate, prompt surgery

Answer 30

d. decompress, hydrate, prompt surgery Rationale: Management of midgut volvulus requires immediate fluid resuscitation, nasogastric decompression, and urgent surgical intervention. A Ladd’s procedure is performed to untwist the volvulus and prevent recurrence.

Question 31

31. Which of the following statements about duplication cysts is FALSE? A. They contain mucosa. B. They are in continuity with the gastrointestinal tract. C. They are most commonly found in the ileum. D. They may be cystic or tubular.

Answer 31

B. They are in continuity with the gastrointestinal tract.

Question 32

32. Which of the following is NOT included in the Ladd procedure for malrotation? A. Widening of the base of the mesentery. B. Division of Ladd's bands. C. Appendectomy. D. Fixation of the cecum and duodenum in place.

Answer 32

D. Fixation of cecum and duodenum in place Rationale: The Ladd procedure is the standard surgical treatment for intestinal malrotation. It involves lysis of Ladd’s bands, broadening of the mesentery, appendectomy to prevent future confusion with appendicitis, and placement of the cecum and duodenum in a non-rotated position rather than fixation, allowing free movement and reducing volvulus risk.

Question 33

33. A 14-day-old preterm infant presents with bloody stool, a history of neonatal sepsis, recent vomiting, abdominal distention, a palpable abdominal mass, diffuse tenderness, bilious OGT drainage, oliguria, leukocytosis, and thrombocytopenia. An abdominal x-ray shows air within the walls of the bowels. What is your initial diagnosis? A. Necrotizing enterocolitis B. Intussusception C. Intestinal atresia D. Meconium ileus

Answer 33

A. Necrotizing enterocolitis Rationale: Necrotizing enterocolitis (NEC) is characterized by abdominal distension, tenderness, bilious drainage, and systemic signs like sepsis. Radiologic findings, such as pneumatosis intestinalis (gas within the bowel walls), are pathognomonic for NEC. The patient's presentation, including leukocytosis and thrombocytopenia, further supports this diagnosis.

Question 34

34. Based on the clinical presentation and x-ray findings in the previous question, what is the Bell stage of this infant's necrotizing enterocolitis (NEC)? A. Stage I B. Stage II C. Stage III D. Stage IV

Answer 34

C. Stage III Rationale: According to Bell's staging for NEC, Stage III includes systemic signs like sepsis, metabolic acidosis, and disseminated intravascular coagulation (DIC). The patient has diffuse abdominal tenderness, a palpable mass, and systemic signs, indicating advanced disease.

Question 35

35. What is the appropriate management for a patient with Stage II necrotizing enterocolitis (NEC)? A. Since diagnosis is not yet established, NO (nasogastric tube), decompress, hydration, antibiotics, and additional diagnostics such as ultrasound or upper GI series. B. Conservative management with serial examinations looking for indications for surgery. C. NO, decompress, hydrate, antibiotics, then exploratory laparotomy once stabilized. D. Can be managed by NPO, OGT, hydration, antibiotics, and TPN.

Answer 35

D. Can be managed by NPO, OGT, hydration, antibiotics, and TPN. Rationale: Management of NEC at Bell Stage IIIA involves non-operative measures such as bowel rest (NPO), nasogastric decompression (OGT), intravenous fluids, antibiotics, and total parenteral nutrition (TPN). Surgical intervention is reserved for cases with perforation or non-resolving NEC, classified as Stage IIIB.

Question 36

36. An 18-month-old male was brought to the clinic due to abdominal pain. The mother reported that the pain began a week ago and was accompanied by episodes of watery stools that provided some relief. These episodes lasted for about 5 days without other associated symptoms or signs of dehydration. The child appeared well afterward, but episodes of abdominal pain returned the day before the consult. This time, there were no episodes of diarrhea but intermittent vomiting. The mother observed that the child appeared well between attacks, although the pain intensified with each episode, prompting the consult. On physical examination, the abdomen was soft, but a palpable mass was noted in the right upper quadrant (RUQ) with an absence of bowel sounds in the right lower quadrant (RLQ). On digital rectal examination (DRE), no mass was palpated, but bloody mucus streaks were noted upon finger retraction. What is the most probable diagnosis? a. Malrotation and midgut volvulus b. Intussusception c. Short bowel syndrome d. Appendicitis

Answer 36

B. Intussusception Rationale: Intussusception is the telescoping of one segment of the intestine into another, often causing episodic abdominal pain, vomiting, and the passage of "currant jelly" stools (mucus and blood). The presence of a palpable mass in the right upper quadrant (RUQ), "sausage-shaped," with an empty RLQ (Dance’s sign), is characteristic. The history of intermittent pain and bloody mucus further supports this diagnosis.

Question 37

37. An 18-month-old male presents with a history of abdominal pain, watery stools, and now intermittent vomiting. On examination, the abdomen is soft with a palpable mass in the RUQ and an absence of bowel in the RLQ. DRE reveals bloody mucus. What is the next best step in management? A. Observation and analgesics. B. Abdominal ultrasound. C. Resuscitation, antibiotics, laparotomy. D. Barium enema.

Answer 37

C. Resuscitation, antibiotics, laparotomy. Rationale: The first step in managing intussusception is resuscitation and administration of IV antibiotics to prevent or treat infection. Air enema is the preferred diagnostic and therapeutic method for reducing intussusception in stable patients without signs of perforation or severe peritonitis.

Question 38

38. Which of the following statements is TRUE regarding the management of intussusception? A. Resection and anastomosis should be done. B. Air enema is always successful. C. Observation is appropriate in most cases. D. Antibiotics are the primary treatment.

Answer 38

A. Resection and anastomosis should be done.

Question 39

39. Which of the following statements is FALSE regarding appendicitis in pediatric patients? A. All are true. B. If a fecalith is seen outside the appendix on imaging, every effort should be made to retrieve it and remove it along with the appendix. C. When there is evidence of peritonitis, intestinal obstruction, or perforation, the child should undergo appendectomy. D. If symptoms are present for more than 4-5 days, a CT scan of the abdomen is reasonable.

Answer 39

D. All are true Rationale: All statements regarding appendicitis in pediatric patients are correct: Symptoms lasting more than 4-5 days warrant a CT scan. Appendectomy is indicated in cases of peritonitis, obstruction, or sepsis. Retrieval of a fecalith found on imaging outside the appendix is crucial during surgery.

Question 40

40. Which of the following patients would most likely benefit from an interval appendectomy? A. 10-year-old with 5 days of abdominal pain, no signs of peritonitis. B. 10-year-old with 5 days of abdominal pain, with signs of peritonitis. C. 2-year-old with 5 days of abdominal pain, no signs of peritonitis. D. 2-year-old with 5 days of abdominal pain, with signs of peritonitis.

Answer 40

A. 10-year-old with 5 days of abdominal pain, no signs of peritonitis Rationale: Interval appendectomy is considered for cases where the patient has prolonged symptoms without peritonitis, allowing inflammation to subside before surgical intervention. This approach avoids complications associated with emergency surgery. Children younger than 5 years or those with peritonitis require early surgical intervention.

Question 41

41. A 3-day-old infant presents with abdominal distention, no passage of meconium, bilious vomiting, and mild dehydration. On digital rectal examination (DRE), there is a forceful expulsion of gas and meconium. Which of the following statements is FALSE? A. Approximately 20% of all cases are diagnosed beyond the newborn period. B. Rehydration, systemic antibiotics, decompression, and rectal irrigation are used for non-operative management. C. Requires surgery in all cases. D. All are true.

Answer 41

C. Requires surgery in all cases Rationale: Hirschsprung's disease, caused by the absence of ganglion cells in the distal colon, requires surgery in most cases but not all. Management initially involves non-operative measures like decompression and antibiotics during the diagnostic phase. Surgical intervention is performed later to resect the aganglionic segment and restore bowel function.

Question 42

42. A 2-day-old female newborn presents with abdominal distention. On examination, the abdomen is distended, and DRE is not possible due to an imperforate anus with a dimpling. Which of the following statements is FALSE? A. The most frequent defect is a rectourethral fistula. B. The most common associated malformation is a urinary tract defect. C. Surgical management is determined by the anatomic defect. D. All are true.

Answer 42

A. Most frequent defect is rectourethral fistula Rationale: In anorectal malformations, rectourethral fistula is the most common defect in males, while in females, the most common defect is rectovestibular fistula. This condition often involves associated urinary tract defects, and management depends on the type and severity of the malformation.

Question 43

43. A 5-year-old female was referred for evaluation due to abdominal distention. On physical examination, the patient was noted to have jaundice and a palpable mass in the right upper quadrant (RUQ). A whole abdominal ultrasound revealed a cystic structure arising from the biliary tree. Which of the following statements regarding this case is true EXCEPT: A. Drainage by cystenterostomy is beneficial B. May lead to the development of malignancy C. Prognosis after complete excision is excellent D. All are true

Answer 43

A. Drainage by cystenterostomy is beneficial Rationale: Drainage by cystenterostomy is not recommended for choledochal cysts because it leaves the cyst wall intact, leading to recurrent cholangitis and potential malignancy. The definitive treatment is complete surgical excision of the cyst with biliary reconstruction. Prognosis after complete excision is excellent, reducing the risk of malignancy.

Question 44

44. A newborn presents with an abdominal wall deformity where intestinal contents freely protrude. Which of the following findings would NOT be expected? A. All characteristics would be expected. B. No overlying sac. C. The defect is in the umbilical cord. D. The size of the defect is usually <4cm.

Answer 44

D. All characteristics would be expected Rationale: Gastroschisis is characterized by freely protruding intestinal contents without an overlying sac, almost always to the right of the umbilicus. The defect size is typically <4 cm, but "all characteristics would be expected" is incorrect as some anomalies (like associated conditions) might vary. The defect does not involve the umbilical cord. 45. Answer: C. Intestinal atresia

Question 45

45. Which of the following anomalies is most commonly associated with gastroschisis? A. Intestinal atresia B. Trisomy 21 C. Cardiac anomalies D. Ureteral dilatation

Answer 45

C. Intestinal atresia Rationale: The most common associated anomaly with gastroschisis is intestinal atresia, occurring in about 10% of cases. Other anomalies are uncommon with gastroschisis, distinguishing it from omphalocele, which is associated with syndromic conditions and chromosomal abnormalities.

Question 46

46. Which of the following statements about Prune Belly Syndrome is FALSE? A. Fertility is unlikely even with orchidopexy. B. Incidence is significantly higher in males. C. The most significant comorbidity is pulmonary hypoplasia. D. Ureteric obstruction is commonly present.

Answer 46

D. Ureteric obstruction is commonly present. Rationale: Prune-Belly Syndrome, also known as Eagle-Barrett Syndrome, is associated with ureteral dilation, but obstruction is rare due to decreased smooth muscle and increased collagen. The syndrome is more common in males, and pulmonary hypoplasia is the most significant comorbidity. Fertility is often unlikely even with orchidopexy.

Question 47

47. A 10-month-old male presents with a history of a right inguinal bulge that resolves spontaneously. On examination, the mass reappears when he cries and extends to the scrotum but reduces with gentle compression. What is the best management? A. Repair of right inguinal hernia as an elective procedure. B. Ultrasound of the abdomen and scrotum. C. Emergent operative repair. D. Orchiopexy of the right testicle.

Answer 47

B. Repair of inguinal hernia as an elective procedure Rationale: Inguinal hernia in a stable patient with reducible swelling can be repaired electively. Emergency surgery is reserved for cases with signs of incarceration or strangulation. The absence of distress or other complications in this case makes elective repair the best choice.

Question 48

48. A 6-year-old female presents with an umbilical swelling present since birth. The protrusion is reducible with a 1.5 cm fascial defect. What is the best management recommendation? A. Operative repair electively. B. Continued observation. C. Emergency admission and operation. D. Ultrasound to rule out an intra-abdominal mass.

Answer 48

B. Operative repair electively Rationale: An umbilical hernia with a defect size of 1.5 cm in a 6-year-old is unlikely to close spontaneously, as most umbilical hernias close by age 4-5. Elective surgical repair is recommended to prevent complications like incarceration or strangulation.

Question 49

49. A 4-month-old male presents with right testicular swelling. Both testicles are descended. Transillumination of the right scrotum is positive. Ultrasound reports a communicating hydrocele. What is the appropriate management? A. Hydrocelectomy. B. Herniotomy and drainage of hydrocele fluid. C. Aspiration. D. Continued observation.

Answer 49

D. Continued observation Rationale: Communicating hydroceles in infants are often self-resolving within the first year of life as the processus vaginalis closes. Observation is appropriate unless the hydrocele persists beyond 1-2 years of age or becomes symptomatic (e.g., associated with a hernia or causing significant discomfort).

Question 50

50. Which of the following statements regarding a patent urachus is FALSE? A. A partially obliterated urachus presents as a cyst. B. Recurrent urinary tract infection. C. The first sign is moisture or urine flow from the umbilicus. D. All are true.

Answer 50

D. All are true Rationale: A: A partially obliterated urachus can present as a urachal cyst. B: Urachal anomalies, including a patent urachus, may lead to recurrent urinary tract infections. C: The first sign of a patent urachus is often moisture or urine discharge from the umbilicus. D: Since all the options are correct, the answer is that all are true.

Question 51

51. The structure separating the left lateral and left medial segments along the umbilical fissure and anchoring the liver to the anterior abdominal wall is the: A. Round ligament B. Arantius' ligament C. Glisson's ligament D. Falciform ligament

Answer 51

C. Falciform ligament Rationale: The falciform ligament separates the left lateral and left medial segments of the liver along the umbilical fissure and anchors the liver to the anterior abdominal wall. It is an important anatomical landmark.

Question 52

52. The gallbladder sits adherent to which hepatic segments? A. IVA and IVB B. III and IVA C. V and VI D. IVB and V

Answer 52

D. IVB and V Rationale: The gallbladder is anatomically adherent to hepatic segments IVB (left lobe) and V (right lobe), as described in liver segmental anatomy.

Question 53

53. Which of the following is NOT a component of bile? A. All are components of bile B. Cholesterol C. Water D. Lecithin

Answer 53

D. All are components of bile Rationale: Bile consists of water, lecithin (phospholipids), cholesterol, bile salts, and other components like bilirubin. Therefore, all the listed options are correct components of bile.

Question 54

54. The most significant clinical finding associated with portal hypertension is: A. Leukopenia B. Gastroesophageal varices C. Splenomegaly D. Ascites

Answer 54

B. Gastroesophageal varices Rationale: Gastroesophageal varices are the most significant clinical manifestation of portal hypertension, leading to variceal bleeding, which is a major cause of morbidity and mortality. Other findings like splenomegaly, ascites, and leukopenia are also associated but are less critical.

Question 55

55. The most common solid tumor in the liver is: A. Hepatocellular carcinoma B. Hepatoblastoma C. Hemangiomas D. Adenoma

Answer 55

A. Hemangioma Rationale: Hemangiomas are the most common benign solid lesions of the liver, consisting of congenital vascular malformations with fibrous tissue and blood vessels. They can vary in size, from small lesions to large cavernous hemangiomas.

Question 56

56. Congenital multiple cysts of the intrahepatic ducts are characteristic of: A. Choledochal cysts B. Caroli's disease C. Polycystic liver disease D. Biliary atresia

Answer 56

D. Caroli's Disease Explanation: Caroli's Disease is a rare congenital disorder characterized by segmental, multifocal cystic dilatations of the intrahepatic bile ducts. It is typically associated with bile duct ectasia and may be accompanied by complications such as recurrent cholangitis, stone formation, and an increased risk of cholangiocarcinoma.

Question 57

57. The most accurate method of determining portal hypertension is: A. Abdominal ultrasonography B. Abdominal CT C. Hepatic venography D. MRI

Answer 57

C. Hepatic venography Rationale: Hepatic venography is the most accurate method for assessing portal hypertension by measuring hepatic venous pressure gradient (HVPG), providing a direct measure of pressure within the liver's venous system.

Question 58

58. Albumin level production per day A. 10mg B. 1000mg C. 100mg D. 10000mg

Answer 58

D. 10,000 mg Rationale: The liver produces approximately 10 grams (10,000 mg) of albumin per day, which is vital for maintaining oncotic pressure and transporting various substances in the blood.

Question 59

59. At what bilirubin level does jaundice typically become detectable? A. 1 mg/dL B. 3 mg/dL C. 5 mg/dL D. 10 mg/dL

Answer 59

A. 3 mg/dL Rationale: Jaundice becomes clinically detectable when bilirubin levels exceed 2.5 to 3 mg/dL. Levels above this threshold cause yellow discoloration of the skin and sclera.

Question 60

60. The most common hepatic arterial variant is: A. Replaced right hepatic artery from the SMA B. Replaced left hepatic artery from the left gastric artery C. Accessory right hepatic artery from the SMA D. Common hepatic artery originating from the aorta

Answer 60

D. Replaced right hepatic artery from SMA Rationale: The most common hepatic arterial variant is a replaced or accessory right hepatic artery arising from the superior mesenteric artery (SMA). This occurs in 10–15% of cases and is critical to recognize during hepatobiliary surgery.

Question 61

61. True about cirrhosis except: A. Cirrhosis can result from viral, autoimmune, drug-induced, alcohol-induced, non-alcoholic fatty liver disease, and metabolic diseases B. Cirrhotic patients should undergo imaging and measurement of ALP every 6 months C. Cirrhotic patients have normocytic, normochromic anemia, leukopenia, and thrombocytopenia D. All are true

Answer 61

B. Cirrhotic patients should undergo imaging and measurement of ALP every 6 months Rationale: This is incorrect because cirrhotic patients should undergo imaging and measurement of AFP (alpha-fetoprotein), not ALP, every 6 months to screen for hepatocellular carcinoma.

Question 62

62. The following would score 1 point in CTP scoring except: A. Bilirubin <2 mg/dl B. Albumin <3.5 g/dl C. INR <1.7 D. All are correct

Answer 62

B. Albumin <3.5 g/dl

Question 63

61. Without medical intervention, bleeding from esophageal varices will only cease if: A. Blood volume depletion B. Spontaneous thrombosis C. Spontaneous regression of varices D. Liver transplantation

Answer 63

A. Blood volume depletion Bleeding from esophageal varices is due to elevated portal venous pressure causing rupture of varices. Without medical intervention, the bleeding can only stop temporarily if there is significant blood volume depletion, leading to decreased venous pressure and subsequently reduced bleeding. However, this is a life-threatening situation as it can lead to hypovolemic shock and death if untreated.

Question 64

62. A patient with portal hypertension whose esophageal varices were eradicated by rubber band ligation develops anemia. The most likely cause is: A. Occult blood loss from portal gastropathy B. Iron deficiency anemia C. Folic acid deficiency anemia D. Vitamin B12 deficiency anemia

Answer 64

A. Occult blood loss from portal gastropathy Portal hypertensive gastropathy is a condition where increased portal pressure causes mucosal and submucosal changes in the stomach, leading to fragile blood vessels and chronic blood loss. This manifests as occult blood loss (hidden blood in the stool), leading to iron deficiency anemia. Following rubber band ligation, while varices are treated, portal hypertensive gastropathy can persist and contribute to ongoing anemia due to subtle, chronic blood loss. The rubber band ligation itself may cause mild post-procedure complications, but anemia in this context is more likely attributed to the portal gastropathy than direct effects of the procedure.

Question 65

63. The following are included in the Milan criteria for liver transplantation EXCEPT: A. Single tumor < 2 cm B. Multiple tumors, each < 3 cm C. No extrahepatic spread D. Child-Pugh score of A or B E. All of the above are part of the Milan criteria

Answer 65

D. Child-Pugh score of A or B The Milan criteria for liver transplantation focus on tumor characteristics to ensure transplant eligibility for hepatocellular carcinoma (HCC). These include: A single tumor ≤ 5 cm, or Up to 3 tumors, each ≤ 3 cm, No extrahepatic spread or vascular invasion.

Question 66

64. Sinusoidal etiology of portal hypertension EXCEPT: A. Schistosomiasis B. Cirrhosis C. Alcohol abuse D. Autoimmune hepatitis

Answer 66

A. Schistosomiasis Portal hypertension is categorized by etiology: Sinusoidal causes include cirrhosis, alcohol abuse, and autoimmune hepatitis, which damage the liver parenchyma and sinusoids. Schistosomiasis is a presinusoidal cause of portal hypertension, as it primarily affects the portal vein system before reaching the hepatic sinusoids.

Question 67

65. The most common hepatic abscess in the Philippines is: A. Ascariasis B. Amebic C. Pyogenic D. Hydatid

Answer 67

B. Amebic abscess Rationale: Amebic liver abscess, caused by Entamoeba histolytica, is the most common extraintestinal manifestation of amoebiasis and the leading cause of hepatic abscesses in the Philippines.

Question 68

66. The following are true regarding ultrasound for liver evaluation EXCEPT: A. Can assess the degree of fibrosis of the liver B. Incomplete visualization of lesion boundaries C. Incomplete imaging of the liver, usually at the dome or beneath the ribs D. Usual imaging tests because it is inexpensive, widely available, no radiation, and well tolerated by patients

Answer 68

B. Incomplete visualization of lesion boundaries

Question 69

67. The remnant of the obliterated umbilical vein is: A. Glisson's ligament B. Falciform ligament C. Round ligament D. Arantius' ligament

Answer 69

C. Round ligament The round ligament of the liver (ligamentum teres) is the fibrous remnant of the obliterated umbilical vein, which carried oxygenated blood from the placenta to the fetus. It is found within the falciform ligament of the liver.

Question 70

68. The human liver can produce approximately how many liters of bile daily? A. 500 mL B. 2 L C. 1 L D. 1.5 L

Answer 70

C. 1 L The human liver produces approximately 1 liter of bile per day. This bile plays an essential role in the digestion and absorption of fats in the small intestine.

Question 71

69. The portal vein is formed by the confluence of which vessels? A. Splenic vein and inferior mesenteric vein B. Splenic vein and superior mesenteric vein C. Inferior mesenteric vein and superior mesenteric vein D. All can be variants

Answer 71

B. Splenic vein and superior mesenteric vein Rationale: The portal vein is formed by the confluence of the splenic vein and superior mesenteric vein. This is crucial for the blood supply to the liver and its metabolic and filtration functions.

Question 72

70. The tests to measure hepatic cell damage are: A. AST (aspartate aminotransferase) B. ALT (alanine aminotransferase) C. Protime (international normalized ratio) D. Both AST and ALT

Answer 72

D. A and B (AST and ALT) Rationale: AST (aspartate aminotransferase) and ALT (alanine aminotransferase) are sensitive markers of hepatic cell damage. Their elevation reflects liver cell injury, commonly due to conditions like hepatitis, fatty liver, or drug toxicity. Prothrombin time measures coagulation, not cellular damage.

Question 73

71. A 50-year-old female with breast cancer undergoing chemotherapy presents with right upper quadrant pain and fever. She is slightly jaundiced and has direct tenderness in the right upper quadrant. Imaging reveals a round or oval hypoechoic lesion with well-defined borders and internal echoes. On CT, the lesion is hypodense with peripheral enhancement and contains air-fluid levels. What is the most probable diagnosis? A. Metastatic lesion B. Amebic abscess C. Pyogenic abscess D. Hydatid cyst

Answer 73

C. Pyogenic abscess Explanation: • A pyogenic liver abscess is the most likely diagnosis in this case, given the patient’s presentation with right upper quadrant pain, fever, and jaundice, as well as the imaging findings.

Question 74

71. A 50-year-old female with breast cancer undergoing chemotherapy presents with right upper quadrant pain and fever. She is slightly jaundiced and has direct tenderness in the right upper quadrant. Imaging reveals a round or oval hypoechoic lesion with well-defined borders and internal echoes. On CT, the lesion is hypodense with peripheral enhancement and contains air-fluid levels. What is the most probable diagnosis? A. Metastatic lesion B. Amebic abscess C. Pyogenic abscess D. Hydatid cyst

Answer 74

C. Pyogenic abscess A pyogenic abscess is characterized by: Fever, right upper quadrant pain, and tenderness. Imaging findings: hypoechoic lesion with internal echoes on ultrasound, hypodense lesion with peripheral enhancement and air-fluid levels on CT. The presence of air-fluid levels strongly suggests a bacterial (pyogenic) abscess.

Question 75

72. The following are true regarding the condition in question 71 EXCEPT: A. May be multiple lesions B. May be a single lesion C. All are true D. Frequently found in the right lobe of the liver

Answer 75

C. All are true Explanation: Pyogenic abscesses are commonly found in the right lobe of the liver and may present as single or multiple lesions. However, the statement "All are true" is not correct, as it includes a catch-all assumption.

Question 76

73. Which of the following is NOT a typical management option for the patient in question 71? A. Empiric/culture-guided antibiotics with or without drainage B. Metronidazole with or without drainage C. Chemotherapy with or without metastasectomy D. Albendazole, cystectomy

Answer 76

C. Chemotherapy with or without metastasectomy Explanation: Pyogenic abscess management involves antibiotics and drainage. Chemotherapy and metastasectomy are management options for metastatic lesions, not abscesses. Albendazole is for hydatid cysts, not pyogenic abscesses.

Question 77

74. A 23-year-old male presents with right upper quadrant pain, fever, and a history of recent travel. He is not jaundiced but has direct tenderness in the right upper quadrant. Imaging reveals a round hypoechoic lesion with low-level internal echoes. On CT, the lesion shows an enhancing wall and a peripheral zone of edema. What is the probable diagnosis? A. Pyogenic abscess B. Amebic abscess C. Hydatid cyst D. Schistosomal cyst

Answer 77

B. Amebic abscess Explanation: The patient's history of recent travel, fever, and right upper quadrant pain is suggestive of an amebic abscess (caused by Entamoeba histolytica). Imaging: Hypoechoic lesion with low-level internal echoes and peripheral edema is typical of an amebic abscess.

Question 78

75. The following are true regarding the condition in question 74 EXCEPT: (Amebic abscess) A. May be multiple lesions B. May be a single lesion C. All are true D. Frequently found in the right lobe of the liver

Answer 78

C. All are true Explanation: Amebic abscesses are usually single but may be multiple and are commonly found in the right lobe of the liver. The statement "All are true" is incorrect because it is unnecessarily inclusive.

Question 79

76. Which of the following is the most appropriate management for the patient in question 74? (Amebic abscess) A. Empiric/culture-guided antibiotics with or without drainage B. Metronidazole with or without drainage C. Chemotherapy with or without metastasectomy D. Albendazole, cystectomy

Answer 79

B. Metronidazole with or without drainage Explanation: Metronidazole is the treatment of choice for amebic liver abscess. Aspiration or drainage is only needed in cases with large abscesses, risk of rupture, or failure to respond to medical therapy.

Question 80

77. A 28-year-old female presents with right upper quadrant pain, slight jaundice, and fever. Ultrasound shows linear filling defects within the bile ducts. What is the probable diagnosis? A. Hepatitis B. Biliary Ascariasis C. Schistosomiasis D. Choledocholithiasis

Answer 80

B. Biliary Ascariasis Explanation: The presence of linear filling defects within the bile ducts is highly suggestive of biliary ascariasis, caused by Ascaris lumbricoides.

Question 81

78. Which of the following statements regarding hepatitis is FALSE? A. Hepatitis A, B, and C can all lead to chronic liver disease, cirrhosis, and hepatocellular carcinoma. B. Current antiviral therapy includes tenofovir and entecavir. C. The most common physical finding for hepatitis A is jaundice and hepatomegaly. D. The ultimate goal of treatment for chronic hepatitis B is viral suppression.

Answer 81

A. Hepatitis A, B, and C can all lead to chronic liver disease, cirrhosis, and hepatocellular carcinoma. Explanation: Hepatitis A does NOT cause chronic liver disease, cirrhosis, or hepatocellular carcinoma, unlike Hepatitis B and C.

Question 82

79. What is the treatment of choice for an amebic liver abscess? A. Metronidazole 750 mg three times a day for 7-10 days B. Percutaneous aspiration C. Surgical drainage D. Observation

Answer 82

A. Metronidazole 750 mg three times a day for 7-10 days Explanation: Metronidazole is the drug of choice. Aspiration is rarely needed unless the abscess is large, at risk of rupture, or not responding to medication.

Question 83

80. A 50-year-old male is diagnosed with an 8 cm amebic abscess in the left lobe of the liver. What is the appropriate management? A. Aspiration + Drainage, Metronidazole 750 mg three times a day for 7-10 days B. Metronidazole alone C. Surgical resection D. Observation

Answer 83

A. Aspiration + Drainage, Metronidazole 750 mg three times a day for 7-10 days Explanation: Large abscesses (>5 cm) or abscesses in the left lobe (risk of rupture) often require aspiration or drainage in addition to metronidazole therapy.

Question 84

81. A 21-year-old male with an incidental ultrasound finding of a single thin-walled, homogenous, fluid-filled lesion with no septations is asymptomatic and has no family history of hereditary diseases. What is the most probable diagnosis? A. Congenital cyst B. Biliary cystadenoma C. Caroli's disease D. Polycystic liver disease

Answer 84

A. Congenital cyst A single, thin-walled, homogenous, fluid-filled lesion with no septations is most likely a simple congenital cyst. These are benign, asymptomatic, and typically found incidentally on imaging. There is no association with hereditary diseases in this case.

Question 85

82. What is the appropriate management for the patient in question 81? (Congenital cyst) A. Percutaneous cyst aspiration B. Sclerotherapy C. May be managed conservatively and observed D. Hepatic resection

Answer 85

C. May be managed conservatively and observed Asymptomatic simple congenital cysts typically require no intervention. Observation is appropriate unless complications arise (e.g., infection or significant growth).

Question 86

83. The most famous robotic system used in surgery today is the: A. Leonardo robot B. Da Vinci Robot C. Goleta Robot D. None of the above E. Aesop Robot

Answer 86

B. Da Vinci Robot The Da Vinci Robot is widely used for minimally invasive surgeries due to its precision, flexibility, and enhanced visualization.

Question 87

84. MIS stands for: A. Minimally Invasive Surgery B. Maximally Invasive Surgery C. Minimally Incisional Surgery D. Medically Indicated Surgery

Answer 87

A. Minimally Invasive Surgery Minimally Invasive Surgery (MIS) refers to surgical techniques performed through small incisions, reducing recovery time and postoperative pain.

Question 88

83. The following are true regarding polycystic liver disease EXCEPT A. Autosomal recessive disease B. The prevalence and number of hepatic cysts are higher in females and increase with advancing age C. Disease progression often results in renal failure D. None are true

Answer 88

A. Autosomal recessive disease

Question 89

84. A 40 year old female with occasional RUQ pain radiating to the back sought consult. Ultrasound was done revealing a slightly distended gallbladder approximately 7x4 cms with intraluminal stones. Also, a solid mass in the liver was noted. Biphasic CT scan confirmed gallbladder stones and described the hepatic mass as an asymmetrical nodular peripheral enhancement that is isodende and has a centripetal fill-in. What is the probable diagnosis of the liver mass? A. Adenoma B. FNH C. Hamartoma D. Hemangioma

Answer 89

D. Hemangioma Rationale: Hepatic hemangiomas are the most common benign liver tumors and typically present with nodular peripheral enhancement and centripetal fill-in on biphasic CT or MRI. This radiological finding is characteristic of hemangiomas, differentiating them from other hepatic masses.

Question 90

85. The following statements are true regarding hepatic hemangiomas EXCEPT: A. High risk for spontaneous rupture B. Enucleation or resection for symptomatic lesions C. Predominantly seen in women D. All are true

Answer 90

D. All are true Rationale: A: Hemangiomas are more common in women with a female-to-male ratio of 4.5:1 to 5:1. B: They carry a risk of spontaneous rupture, which can be life-threatening. C: Enucleation or resection is indicated for symptomatic hemangiomas or large lesions at risk of complications.

Question 91

86. A 30-year-old female presents with a CT scan finding of a well-circumscribed lesion with central scarring. What is the most probable diagnosis? A. Hemangioma B. Focal nodular hyperplasia C. High risk for spontaneous rupture D. Hamartoma

Answer 91

B. Focal Nodular Hyperplasia (FNH) Rationale: FNH is a benign liver lesion that is well-circumscribed and often exhibits a central fibrous scar visible on imaging. It is not encapsulated and has typical findings on CT or MRI, including hyperenhancement in the arterial phase and isoattenuation in the venous phase.

Question 92

87. Which statement is TRUE regarding the diagnosis in question 86 (focal nodular hyperplasia)? A. High risk for malignant transformation B. May be linked to oral contraception or estrogen use C. High risk for spontaneous rupture D. All are true

Answer 92

A. May be linked to oral contraceptive or estrogen use Rationale: FNH is sometimes associated with oral contraceptive or estrogen use, although the exact link is debated. Unlike adenomas, FNH does not have a high risk for rupture or malignant transformation and is often managed conservatively with observation.

Question 93

88. Which of the following statements regarding bile duct hamartomas is FALSE? A. Typically small lesions B. They can be distinguished from metastatic lesions on gross inspection C. Usually visualized on the surface of the liver at laparotomy D. All are true

Answer 93

C. They can be distinguished from metastatic lesions on gross inspection Rationale: Bile duct hamartomas are small lesions (2–4 mm) that are smooth and whitish-yellow. They are difficult to distinguish from metastatic lesions on gross inspection, often requiring excisional biopsy for accurate diagnosis.

Question 94

89. What is the recommended management for a 5 cm hepatic adenoma? A. Resection when symptomatic B. Resection C. Embolization D. Monitoring every 6 months

Answer 94

B. Resection Hepatic adenomas >5 cm are at increased risk for rupture and malignant transformation. Surgical resection is recommended to prevent these complications.

Question 95

90. The most common malignant lesion of the liver is: A. Metastatic breast cancer B. Cholangiocarcinoma C. Metastatic colorectal cancer D. Hepatocellular carcinoma

Answer 95

C. Metastatic colorectal cancer Metastatic colorectal cancer is the most common malignant lesion in the liver, as the liver is a frequent site of metastasis due to its dual blood supply. Primary liver cancers, like hepatocellular carcinoma, are less common.

Question 96

91. Which of the following is NOT a risk factor for hepatocellular carcinoma? A. Hepatitis B or C B. Alcoholic cirrhosis C. Hemochromatosis D. Non-alcoholic steatohepatitis (NASH) E. All of the above are risk factors

Answer 96

E. All of the above are risk factors All the listed conditions (Hepatitis B or C, alcoholic cirrhosis, hemochromatosis, and NASH) are established risk factors for hepatocellular carcinoma (HCC).

Question 97

92. The preferred management for hilar cholangiocarcinoma with primary sclerosing cholangitis is: A. Surgical resection B. Radiation therapy C. Chemotherapy D. Liver transplantation

Answer 97

A. Surgical resection Rationale: The management of hilar cholangiocarcinoma with primary sclerosing cholangitis involves resection whenever possible, combined with biliary drainage to prepare for surgery. Adjuvant therapies like radiation or photodynamic therapy may also be considered.

Question 98

93. A 60-year-old male with a history of alcohol abuse presents with minimal free fluid around the liver, a nodular liver contour, and a 6 cm mass in the right lobe. Laboratory results show bilirubin = 2 mg/dL, albumin = 3 g/dL, and INR = 1.7. What is the most probable diagnosis? A. Focal nodular hyperplasia B. Hepatocellular carcinoma C. Adenoma D. Hepatic abscess

Answer 98

D. Hepatocellular carcinoma Rationale: The patient's cirrhotic features (nodular hepatic contour), laboratory findings (elevated bilirubin, low albumin, prolonged INR), and liver mass suggest HCC. It is a common complication of cirrhosis and alcoholic liver disease.

Question 99

94. How would the diagnosis in question 93 (hepatocellular carcinoma) typically appear on a CT scan? A. Sharply defined borders, hypodense in the venous phase, and subtle hypervascular enhancement in the arterial phase B. Hypodense with peripheral enhancement C. Well-circumscribed mass with a central scar D. Enhanced on the arterial phase, hypodense in the delayed phase

Answer 99

D. Enhanced on the arterial phase, hypodense in the delayed phase Rationale: HCC typically shows arterial phase hyperenhancement due to its hypervascularity and becomes hypointense in the delayed phase on contrast imaging, a characteristic finding on CT or MRI. This pattern helps differentiate it from benign lesions.

Question 100

95. Based on the clinical and laboratory findings in question 93, what is the patient's Child-Turcotte-Pugh (CTP) score? A. 9 B. 11 C. 7 D. 5

Answer 100

C. 9 Rationale: Using the Child-Turcotte-Pugh (CTP) scoring system: Bilirubin: 2 mg/dL (2 points) Albumin: 3 g/dL (2 points) INR: 1.7 (2 points) Encephalopathy: None (1 point) Ascites: Controlled (2 points) Total: 9 points

Question 101

96. Based on the CTP score calculated in question 95, what is the patient's Child-Pugh classification? A. D B. C C. A D. B

Answer 101

B. Class B Rationale: A CTP score of 7–9 falls under Class B. This classification indicates moderately decompensated liver disease.

Question 102

97. What is the interpretation of the Child-Pugh classification determined in question 96? A. Overall surgical mortality rate of 10% B. Overall surgical mortality rate of 30% C. Overall surgical mortality rate of 50% D. Overall surgical mortality rate of 80%

Answer 102

B. Overall surgical mortality rate of 30% Rationale: According to studies, patients with CTP Class B cirrhosis have a surgical mortality rate of 30%. This highlights the significant risk associated with surgery in these patients.

Question 103

98. (This is the same case as in question 93) What is the best management for this patient with hepatocellular carcinoma and Child-Pugh class C cirrhosis? A. Resection B. Liver transplantation C. Transarterial chemoembolization (TACE) D. Palliative care

Answer 103

C. Transarterial chemoembolization (TACE) Rationale: TACE is the standard treatment for intermediate-stage hepatocellular carcinoma (HCC) in patients with CTP Class B cirrhosis. It helps control tumor growth while preserving liver function.

Question 104

99. Which of the following statements is FALSE? A. Ultrasonography is the mainstay for the radiologic evaluation of the liver. B. Common benign lesions of the liver can often be reliably diagnosed by their characteristic imaging features. C. Acute variceal bleeding should be managed with aggressive resuscitation and prompt endoscopic diagnosis with hemorrhage control. D. All are true.

Answer 104

C. Acute variceal bleeding should be managed with aggressive resuscitation and prompt endoscopic diagnosis with hemorrhage control Rationale: While resuscitation and endoscopic management are essential, overzealous replacement of blood products can lead to rebleeding and increased mortality. Blood transfusion should be carefully managed to maintain hemoglobin at approximately 8 g/dL.

Question 105

100. Which of the following statements regarding the resectability of metastatic colorectal cancer to the liver is FALSE? A. Resectability is determined by the volume of the future liver remnant. B. Resectability is determined by the health of the background liver. C. Resectability is determined by the actual tumor number. D. All are true.

Answer 105

D. All are true Rationale: Resectability of metastatic colorectal cancer to the liver depends primarily on: The volume of the future liver remnant. The health of the background liver. The number of tumors is no longer a limiting factor, provided the future liver remnant is adequate for function. Thus, all statements are correct.