Pancreas Flashcards
(117 cards)
1
Q
What is the BEST treatment of a PANCREATIC DUCT LEAK (post-op, etc.) even if the ASCITES it created is SIGNIFICANT?
A
ERCP with PD STENT placement
2
Q
What are the RISK factors for POST-ERCP pancreatitis?
A
CONTRAST injection, YOUNG age, SOD indication
3
Q
What should be done for ALL pancreatic cysts whether or not they are thought to be pseudocysts or not?
A
EUS/FNA (CEA, lipase, cytology)
4
Q
What is the recommended TREATMENT for LARGE BILOMAS?
A
PERCUTANEOUS DRAIN and BILIARY STENT
5
Q
In a patient with CHRONIC PANCREATITIS and a BILIARY STRICTURE, what is the CRITERIA for ERCP treatment?
A
CBD >12 mm and ALP >3 X normal
6
Q
What is the BEST association for SOD?
A
BILIARY PAIN post-CHOLECYSTECTOMY
7
Q
In which SOD TYPE is the use of Sphincter of Oddi Manometry (SOM) predictive of good outcome with ERCP/Sphincterotomy?
A
SOD Type-II
8
Q
When is EUS/FNA needed for a MALIGNANT BILIARY OBSTRUCTION?
A
If planning on PRE-OP NEOADJUVANT therapy or there is a DELAY in SURGERY
9
Q
If a patient presents with a MALIGNANT BILIARY OBSTRUCTION and has SURGERY planned soon, do they require biliary DRAINAGE (T.Bili <14)?
A
NO
10
Q
Wht MUST be done PRIOR to an ERCP when a HILAR MALIGNANCY is suspected?
A
MRCP
11
Q
Besides biliary obstruction, what can AMPULLARY TUMORS and pancreatic ADENOCARCINOMA cause?
A
Idiopathic PANCREATITIS
12
Q
Prior POST-ERCP pancreatitis, FEMALE, previous ACUTE RECURRENT pancreatitis, suspected SOD, young age <40, ABSENCE of CHRONIC PANCREATITIS, NORMAL BILIRUBIN are all risk factors for?
A
Post-ERCP PANCREATITIS
13
Q
At what AGE should a patient with a LYNCH genetic mutation be SCREENED for COLON cancer?
A
At the age of 20-25 and every 1-2 years thereafter
14
Q
During the FIRST WEEK of treatment of ACUTE PANCREATITIS, what determines SEVERITY and PROGNOSIS?
A
The presence of ORGAN FAILURE (renal, pulmonary, cardiovascular)
15
Q
How elevated do the AMYLASE/LIPASE values need to be to diagnose ACUTE PANCREATITIS?
A
3 X upper limit of normal
16
Q
If concerned for NECROSIS in a patient with ACUTE PANCREATITIS, when should a CT scan WITH CONTRAST be performed?
A
At least 3 DAYS AFTER the diagnosis of pancreatitis
17
Q
What should be performed in ALL patients in whom GALLSTONE PANCREATITIS is suspected?
A
US
18
Q
Acute pancreatitis grade WITHOUT ORGAN FAILURE (renal, pulmonary, cardiovascular) WITHOUT LOCAL COMPLICATIONS (fluid collection, necrosis) WITHOUT SYSTEMIC COMPLICATIONS (worsening of an uderlying medical condition)?
A
MILD
19
Q
Acute pancreatitis grade WITH TRANSIENT ORGAN FAILURE <48 HOURS (renal, pulmonary, cardiovascular) WITH LOCAL COMPLICATIONS (fluid collection, necrosis) WITH SYSTEMIC COMPLICATIONS (worsening of an uderlying medical condition)?
A
MODERATE
20
Q
Based on an ADMISSION CT, can MILD ACUTE PANCREATITIS be radiologically diagnosed within the first 48 HOURS?
A
NO
21
Q
Acute pancreatitis grade WITH PERSISTENT ORGAN FAILURE >48 HOURS (renal, pulmonary, cardiovascular)?
A
SEVERE
22
Q
A patient who is >60 yo, BMI >30, first ACUTE PANCREATITIS attack, multiple COMORBIDITIES, PLEURAL EFFUSIONS, and SIRS have what type of prognosis?
A
MUCH HIGHER RISK for SEVERE PANCREATITIS
23
Q
TWO or more of: Pluse >90 bpm; TEMP <36 C or >38 C; WBC <4,000 or >12,000; RESPIRATIONS >20 bpm; PCO2 <32 mm Hg is indicative of what?
A
Systemic Inflammatory Response Syndrome (SIRS)
24
Q
Do the levels of AMYASE/LIPASE correlate with SEVERITY of ACUTE PANCREATITIS?
A
NO
25
What **LABORATORY** findings are **SUGGESTIVE** of **SEVERE PANCREATITIS** and likely the develoment of **NECROSIS**?
**Hct \>44**, **RISE** in **BUN** after the FIRST 24 HOURS, **ELEVATED Cr** (**\>1.8**)
26
In the setting of **PERSISTENT MULTIORGAN FAILURE**, what is the mortaity **RISK** for **ACUTE** **PANCREATITIS**?
**50%**
27
How does the presence of **NECROSIS** affect **PROGNOSIS** of **ACUTE** **PANCREATITIS**?
It does **NOT**, only if **INFECTED** **NECROSIS**
28
**WHEN** is **HYDRATION** the most important when treating **ACUTE PANCREATITIS**?
In the **FIRST** **6-12 HOURS** (250 - 500 mL/hr)
29
How long **CAN** you wait in **SEVERE PANCREATITIS** before starting **PO** or **TUBE FEEDS** (preferred over parenteral)?
**5 DAYS** (only if PO not tolerated)
30
In **MILD** (no organ failure, no localized complications, no systemic complications) acute pancreatitis, **WHEN** should you **FEED** the patient and how?
**EARLY ORAL** (**LOW FAT**) when **SYMPTOMS IMPROVE**, without having to advance (for **SEVERE**, can wait 5 days but optional and via **NGT** if not tolerating PO)
31
A **\>3 X ELEVATION** of **ALT/AST** in the presence of **ACUTE PANCREATITIS** is suggestive of what **ETIOLOGY**?
**Gallstones**
32
In a patient with **ACUTE PANCREATITIS** and **COEXISTENT CHOLANGITIS**, **WHEN** should the **ERCP** be performed?
WITHIN **24-72 HOURS**
33
What **DIFFERENTIATES** a pancreatic **PSEUDOCYST** from **WALLED-OFF PANCREATIC** **NECROSIS**?
The **LOCATION** of the fluid collection (**outside of the pancreas - pseudocyt**, inside - necrosis)
34
What **MUST** be done when a pancreatic **PSEUDOCYST** becomes infected (abscess)?
**DRAINAGE**
35
What is it called when on a **CONTRAST-ENHANCED CT** in a patient with **ACUTE** **PANCREATITIS**, there is **\>30% of non-enhancement** of the pancreas?
PANCREATIC **NECROSIS** (needs ICU monitoring) - avoid lines, parenteral nutrition to avoid infection
36
**ACUTE PANCREATITIS**, **7-14 DAYS** after presentation, develops **FEVER** and **LEUKOCYTOSIS**?
**INFECTED NECROSIS** (**biopsy** to direct antibiotic choice)
37
**WHEN** is **SURGICAL NECROSECTOMY** (debridement) indicated for infected pancreatic necrosis?
**4 WEEKS** after initial hospital admission
38
**WHEN** is **CHOLECYSTECTOMY** indicated for a patient with **ACUTE BILIARY PANCREATITIS**?
**SAME ADMISSION**
39
Can **PANCREATIC CANCER** present as the **FIRST ATTACK** of **PANCREATITIS**?
**YES** (rarely)
40
What is the **TIME** frame for **PREDICTING** and for **DEFINING** severity in **ACUTE** **PANCREATITIS**?
**48 HOURS** (can predict before, can only define after)
41
Which **CRYSTALLOID** suspension is preferred but **NOT MANDATORY** for resusscitation of **ACUTE PANCREATITIS**?
**Lactated Ringers** (or NS)
42
Drinking **ALCOHOL** **4-5 drinks/day** for **5-10 years** with or without **SMOKING** (synergistic) can result in what **CHRONIC** condition of the **PANCREAS**?
**CHRONIC PANCREATITIS**
43
Mutations in which **GENES** are implicated in **HEREDITARY** chronic pancreatitis?
PRSS1, SPINK1, CFTR, CTRC, and claudin-2
44
**PANCREATITIS** presenting in a patient with **BILIARY STRICTURES**, **HILAR LYMPHADENOPATHY**, **SCLEROSING SIALADENITIS**, **RETROPERITONEAL FIBROSIS**, **PSEUDOTUMORS** and **TUBULOINTERSTITIAL NEPHRITIS** is what type?
**AUTOIMMUNE PANCREATITIS TYPE-I** (AIP type I) - **IgG4** (\>2 X ULN)
45
**\>10 IgG4 PLASMA** cells per **HPF** in **PANCREATIC BIOPSY** means what?
**TYPE-I AIP**
46
How does **AIP TYPE-II** differ from **AIP TYPE-I**?
**AIP TYPE-II** occurs **ONLY** in the **PANCREAS** and is **ASSOCIATED** with **IBD**
47
Which **AIP TYPE** is associated with **IBD**?
**AIP TYPE-II** (pancreas involvement only)
48
**PAINLESS JAUNDICE** or **ACUTE PANCREATITIS** due to obstruction of the intra-pancreatic bile duct in a patient with **NO OBSERVABLE** pancreatic mass?
**AIP**
49
**SAUSAGE-SHAPED** pancreas with **LOW-DENSITY RIM** around the pancreas seen on **CT**?
**AIP**
50
Suggestive **IMMAGING** of the **PANCREAS** and pancreatic **DUCT**, **SEROLOGY**, **OTHER ORGAN INVOLVEMENT**, **HISTOLOGY** and response to **STEROID THERAPY** (the treatment) are the diagnostic criteria for what?
**AUTOIMMUNE CHRONIC PANCRATITIS**
51
Which **TYPE** of **AIP REQUIRES** a **PANCREATIC BIOPSY**?
**AIP TYPE-II**
52
What **MUST** be **RULED OUT FIRS**T before initiating **STEROIDS** for presumed **AIP**?
**PANCREATIC MALIGNANCY**
53
What is the **TREATMENT** and its **DURATION** for **AIP**?
**PREDNISONE 40 mg PO dail**y, tapering off by **5-10 mg/week** for a total of **10-12 WEEKS**
54
Which **TYPE** of **AIP REPLAPSES** (biliary strictures, jaundice) in **30-50%** of patients and how is it treated?
**AIP TYPE-I** (repeat steroid taper) as azathioprine does not work and **RITUXIMAB** is used in **REFRACTORY** disease
55
A patient from **SOUTHWEST INDIA** presents with mutations in **SPINK1** and **CTRC**, **youth** to early adulthood, abdominal pain, severe **MALNUTRITION**, **EXOCRINE** and **ENDOCRINE** pancreatic dysfunction, **LARGE PD** and **PD STONES**?
**TROPICAL PANCREATITIS**
56
What are the most **SENSITIVE** tests for diagnosing **CHRONIC PANCREATITIS** (can detect disease prior to developing exocrine/endocrine insufficiency)?
**DIRECT HORMONAL STIMULATION TESTS** (secretin stimulation test), a **BICARBONATE** concentration **\<80 meq/L after 60 min** is **ABNORMAL**
57
What do **SERUM TRYPSIONGEN** (**\<20 ng/m**L) and **FECAL ELASTASE** (**\<200 µg/g**) signify?
Pancreatic **INSUFFICIENCY** due to **CHRONIC PANCREATITIS**
58
What are the RECOMMENDED initial IMAGING tests for dignosing CHRONIC PANCREATITIS?
**MULTIDETECTOR-CT** or **MRI with MRCP**
59
What are the **AGENTS** to use with CHRONIC PANCREATITIS **PAIN**?
**TRAMADOL**, **PREGABALIN**, TCA or **SSRI** or combined SSRI/NRI (duloxetine)
60
What is the **DIFFERENCE** between CELIAC PLEXUS **BLOCK** and CELIAC PLEXUS **NEUROLYSIS**?
**BLOCK** - **BUPIVICANE** only
**NEUROLYSIS** - addition of **ABSOLUTE ALCOHOL**
61
What can be done for chronic pancretitis **PAIN** if pt does not respond to medical or endoscopic therapy?
**SURGERY** (lateral pancreaticojejunostomy - **modified PUSTEOW** procedure) - with Roux-en-Y and immediate pain relief in 80% of patients
62
What are the **TWO** most significant causes of **CHRONIC PANCREATITIS**?
**ALCOHOL** and **SMOKING**
63
What should be considered in **ALL** patients after **SUBTOTAL PANCREATECTOMY** performed for chronic pancreatitis or otherwise?
Pancreatic **ENZYME** **supplementation** for likely sublte exocrine pancreatic defficiency
64
How many **UNITS** of **LIPASE** are delivered by the pancreas with a meal?
~**900,000 USP** (**90,000 are required to eliminate steatorrhea**)
65
What is **IMPORTANT** to keep in mind when prescribing pancreatic **ENZYME** supplementation?
Pancreatic **ENZYMES MUST BE ENTERICALLY COATED** or patient must be **PRESCRIBED** **H2**-blockers or **PPIs**
66
What **ELSE** must be done in patients with pancreatic exocrine insufficiency with **STEATORRHEA** besides **ENZYME** supplementation?
Supplementation of the **FAT-SOLUBLE** vitamins (**D**, E, K, A) as well as **BONE DENSITY** to prevent osteopenia and osteoporosis
67
What is **DM** **Type 3C**?
It is **DIABETES MELLITUS** associated **DIRECTLY** with **ISLET CELL LOSS** due to **CHRONIC PANCREATITIS** or other pancreatic diseases
68
What is the **PREFERRED** medication to use in patients with **DM** due to chronic pancreatitis?
**METFORMIN** (prevents adenocarcinoma)
69
The development on an **ACUTE GIB** in the presence of a **PANCREATIC PSEUDOCYST** is idicative of what?
**PSEUDOANEURYSM** (erosion of the pseudocyst into a vessel) **40% MORTALITY** - emergent CT with IV contrast (high-density material) after negative EGD - small **sentinel bleed** followed days to weeks later by massive bleed
70
Which **PANCREATIC CYSTS** require **SURGICAL** removal?
**MUCINOUS CYSTIC NEOPLASMS** and **IPMNs** (**\>3 cm** , growth of **\>3 mm/year**, or if **PD is \>10 mm**) or **SOLID COMPONENT**
71
**SPLENIC VEIN** thrombosis, **SIBO**, **GASTROPARESIS** are all complications of this condition?
**Chronic Pancreatitis**
72
Which **AIP** type is associated with **IgG4**?
**TYPE-I** (systemic and not just involving the pancreas)
73
In a patient with **CHRONIC PANCREATITIS PAIN**, if no stricture, no stone, s/p surgery but still with pain, why?
**CNS sensitization**, a nerve problem
74
Which pancreatic **CYSTS** have an **OVARIAN-LIKE** stroma?
**MUCINOUS CYSTIC NEOPLASMS** (**MCN**, not ipmn)
75
A **CEA** value of **WHAT** is considered elevated for a pancreatic **CYST**?
**CEA \>192**
76
What is the recommendation for **SURVEILLANCE** (CT, MRI, EUS) of pancreatric **CYSTS**?
\<10 mm, every 12 MONTHS
10 - 20 mm, 6-12 MONTHS
\>20 mm, 3-6 MONTHS
IF NO CHANGE after 2 YEARS, lengthen the interval
77
What follow-up is required for a **PANCREATIC REST**?
**NONE**, its a benign lesion
78
In a patient with **IDIOPATHIC PANCREATITIS**, if **EVERYTHING** including **EUS** has been done without explanation, what would be the recommended next step?
**EMPIRIC CHOLECYSTECTOMY**
79
What should be done as far as **FEEDING** for a patient with **NECROTIZING PANCREATITIS** even if hypoactive bowel sounds?
**TRIAL of PO FEEDING**
80
In a patient with **ACUTE NECROTIZING PANCREATITIS**, with a **FEVER** and **LEUKOCYTOSIS**, when should you think of **INFECTED NERCOSIS**?
With **ORGAN FAILURE** and **~1 WEEK** out, **NOT EARLY** in the process
81
Which **GENE** is **MOSTLY** associated with **HEREDITARY** (family members) **CHRONIC** **PANCREATITIS**?
**PRSS1** (autosomal dominant)
82
In a patient with **IDIOPATHIC PANCREATITIS** but **NO FAMILY HISTORY** of heredity, which **GENE** is most likely mutated?
**CFTR**
83
**HOW** are **GASTRIC VARICES** (fundic) caused by **SPLENIC VEIN THROMBOSIS** treated?
These **RARELY BLEED** if caused by splenic vein thrombosis, and unless they do, **NO INTERVENTION** is required. If they do bleed, treat with **SPLENECTOMY**
84
4 cm **CYST** in TOP, with **SEPTATIONS** and scattered **CALCIFICATIONS**?
MUCINOUS CYSTIC NEOPLASM (**MCN**)
85
**3 cm** **SIMPLE** (no **INTERNAL** **NODULES** or **SEPTATIONS**) pancreatic **CYST** with **ELEVATED CEA** and **MILD PD DILATION**, what should be done **NEXT**?
**IMAGING in 1 YEAR** (**SIMPLE** cyst, even if mucinous)
86
Which **IVF** is the **BEST** for preventing **ORGAN FAILURE** and **MORTALITY** in a patient with **ACUTE PANCREATITIS**?
**NONE**, all the same (NS or LR)
87
Which **FINDINGS** on **IMAGING** of the pancreas correlate best with **PANCREATIC PAIN**?
**NONE**
88
What is the **RECOMMENDED TREATMENT** for a **HEMORRHAGIC** pancreatic **PSEUDOCYST**?
**ANGIOGRAPHY** with embolization
89
In **ACUTE PANCREATITIS**, which **ENZYME** (amylase or lipase) decreases to the reference range **MUCH FASTER** because that enzyme comes from **MULTIPLE SOURCES** and which of the **TWO** is **SPECIFIC** for PANCREATITIS?
**AMYLASE** normalizes **MUCH FASTER** (multiple sources)
**LIPASE** is **SPECIFIC** to the **PANCREAS**
90
At which **LEVEL** of **HYPERTRIGLYCERIDEMIA** is **PANCREATITIS** **POSSIBLE**?
**\>1,000** (with suppression of the rise amylase)
91
**ACUTE LFT** (**ALT**) elevations in a patient with **PAIN**, are **STRONGLY** **INDICATIVE** of what etiology of **ACUTE PANCREATITIS**?
**BILIARY** (stones, sludge)
92
What are the **RISK FACTORS** for **SEVERE PANCREATITIS**?
A pt's **AGE** (\>55), **WEIGHT** (BMI \>30), **HEMOCONCENTRATION** and **RESIRATORY** **COMPROMISE** (organ failure at admission i.e. renal or pulm)
93
What is the **RECOMMENDED** **INITIAL** management of **ACUTE** **PANCREATITIS**?
**AGGRESSIVE FLUID HYDRATION** and **CLOSE MONITORING**
94
The **DEGREE** of **HEMOCONCENTRATION** is predictive of what in **ACUTE** **PANCREATITIS**?
**HIGHER RISK** for **SEVERE COURSE**
95
The **HARMLESS ACUTE PANCREATITIS SCORE** (**HAPS**) consists of **WHAT** values that can predict with **98%** certainty that the pancreatitis course will be **MILD** to **MODERATE**?
**ABSENCE** of **REBOUND**, **NORMAL Hct** and **NORMAL Cr**
96
**CT CHARACTERIZATION** of **ACUTE PANCREATITIS** **IF ACTUALLY NEEDED**, should be done **WHEN** after presentation?
**48-72 HOURS**
97
**WHEN** should **NUTRITION** be instituted in **ACUTE PANCREATITIS**?
**EARLY**, within the **FIRST 24-48 HOURS** to maintain **GUT INTEGRITY**
98
HOW should ANALGESIA be administered for a patient with ACUTE PANCREATITIS?
(**P**ATIENT-**C**ONTROLLED **A**NALGESIA) **PCA** **PUMP**
99
In a patient with **ACUTE PANCREATITIS** who develops **FEVER**, **LEUKOCYTOSIS**, **RESPIRATORY** **COMPROMISE**, **RENAL FAILURE** (elevated Cr), **HYPOTENSION**, **TACHYCARDIA**, with **CT** demonstrating **NECROSIS** and **FLUID CONSOLIDATION**, what should be done?
**ICU CARE** and **CT-GUIDED** **ASPIRTATION** of **PANCREAS** (rule out infection) and **ANTIBIOTIC** therapy
100
**YOUNG** pt with **ABDOMINAL PAIN**, **OBSTRUCTIVE JAUNDICE**, and a **DIFFUSELY ENLARGED PANCREAS** on **IMAGING**, with **NORMAL IgG4**, no other organ involvement, NO STONES, **NO ALCOHOL**?
**TYPE-2 AIP** (**GRANULOCYTE EPITHELIAL LESION** with **NEUTROPHILIC** **INFILTRATE** in the **PANCREATIC DUCT** epithelium, **OBLITERATING** the **LUMEN**)
101
**MUTATION** in **WHICH** of the **HEREDITARY** **CHRONIC PANCREATITIS GENES** is most **SPECIFIC** for this **CONDITION**?
**PRSS1** (R117H and N21I)
102
**MUTATIONS** in **SPINK1** and **CFTR** are associated with what **TYPE** of **PANCREATITIS**?
**IDIOPATHIC PANCREATITIS**
103
**PERSISTENT**, **MILD** increase in serum **AMYLASE** levels may indicate **WHAT** if the **LIPASE** is normal?
**MACROAMYLASEMIA** (BENIGN)
104
**WHAT** **ONE** **IMAGING** **FINDING** of the **PANCREAS** (CT, EUS, ETC) is **HIGHLY**-SUGGESTIVE for **CHRONIC** **PANCRETITIS**?
**INTRA-DUCTAL STONES**
105
**HOW MUCH** of the **PANCREATIC EXOCRINE FUNCTION** must be **LOST** in order to have **STEATORRHEA**?
**\>90%**
106
**WHEN** **SHOULD PANCREATIC ENZYMES** be taken when eating?
**THROUGHOUT the MEAL**, NOT BEFORE or AFTER (**30,000** to **45,000** units of **LIPASE** per meal)
107
**CORRECTION** of **STEATORRHEA** with **ORAL ENZYME SUPPLEMENTS** is associated with **CORRECTION** of **WHAT** else?
**CORRECTION** of **CARBOHYDRATE** and **PROTEIN** **MALABSORPTION**
108
For patients who have **PAIN** due to **CHRONIC CALCIFIC** (pancreatic duct **STONES**) **PANCREATITIS** with a **DILATED DUCT**, what is the **RECOMMENDED** **INTERVENTION**?
**LATERAL PANCREATICO-JEJUNOSTOMY**
109
What is the **RECOMMENDED** management for a **GALLBLADDER** **ADENOMA \>18 mm** (fixed, hyperechoic lesion, protruding into the GB lumen without shadowing)?
**OPEN** **CHOLECYSTECTOMY** (HIGH-LIKELIHOOD of ADVANCED CANCER)
110
In a patient who presents with **ALCOHOLIC ACUTE PANCREATITIS** and **GB** microlithiasis is found, what is done for the **MICROLITHIASIS**?
**NOTHING**, unless **SECOND** episode of acute pancreatitis occurs **WITHOUT** **ALCOHOL** involvement or another etiologic factor
111
What is the **RECOMMENDATION** for management of a **PREGNANT** woman with **SYMTOMATIC** **GB** disease?
**CHOLECYSTECTOMY** (laparoscopic, when possible)
112
Which **PARASITES** cause **RECURRENT** **PYOGENIC** **CHOLANGITIS**?
**ASCARIS** and **OPISTHORCHIS**
113
What **COLORED** **BILIARY** **STONES** are seen in patients with **CYSTIC** **FIBROSIS**, **CHRONIC HEMOLYSIS**, **MECHANICAL** **HEART VALVES**, **CIRRHOSIS** and **GILBERT's SYNDROME** or who are on **TPN**?
**BLACK** - colored stones
114
What **COLORED** **BILIARY** **STONES** are seen in patients with **BACTERIAL** or **PARASITIC** infestation of the **BILIARY SYSTEM**?
**BROWN** - colored stones
115
What is a **MICRO GALLBLADDER** (2-3 cm in size) **ASSOCIATED** with?
**CYSTIC FIBROSIS** and **NEONATAL HEPATITIS**
116
What **CONGENITAL GALLBLADDER TYPE** is associated with risk of **TORSION**?
**WANDERING GALLBLADDER** (long mesentery, no firm attachment to the liver)
117
**PHARYGIAN CAP**, **HOURGLASS GALLBLADDER**, **WANDERING GALLBLADDER** and **GALBLADDER AGENESIS** are all which **TYPE** of variants?
**CONGENITAL ANOMALIES** (macro-galbladder is NOT congenital)
