ABSITE - Biliary – Questions and
Answers 100% Correct
A 44-year-old woman with a body mass index of 38 presents to the emergency department with
fever, nausea, vomiting, and right upper quadrant pain. A right upper quadrant ultrasound shows
an obstructing cystic duct stone and a normal-appearing common bile duct. You undertake a
laparoscopic cholecystectomy but the case is difficult, requiring conversion to an open approach
due to severe chronic inflammation and fibrosis in the hepatocystic triangle and porta hepatis.
You unintentionally enter the duodenum during your dissection and close it in two layers. It
appeared to be in continuity with the gallbladder, which is then removed. Four days later the
nasogastric tube output is persistently elevated. An aqueous contrast upper gastrointestinal
series with small bowel follow-through shows no proximal stricture or leak, but contrast does not
reach the cecum after 12 hours. A CT scan shows a high-grade obstruction in the di - ANSWER
- Meticulous intraoperative examination of the small bowel
Correct.
When a cholecystoenteric fistula is known or encountered at operation, it is important to
carefully examine the entire small bowel at the time of surgery to ensure that any and all stones
are removed.
Reproduction of biliary colic with which of the following tests best identifies patients likely to
benefit from transduodenal sphincteroplasty?
A. Secretin stimulation test
B. Morphine-neostigmine (Nardi) test
C. Glucagon stimulation test
D. Cholecystokinin (CCK) test
E. Corticotropin stimulation test - ANSWER - Morphine-neostigmine (Nardi) test
Correct.
Reproduction of pain with morphine (resulting in sphincter contraction) and neostigmine
(resulting in biliary contraction) has been historically used to identify patients with sphincter of
Oddi dysfunction that would benefit from transduodenal sphincterectomy.
Which of the following statements is true concerning the anatomy of the common bile duct?
A. The blood supply of the common bile duct is segmental with longitudinal collateral vessels
that run in the 5- and 11-o'clock positions.
, B. The supraduodenal bile duct resides in the hepatoduodenal ligament lateral to the hepatic
artery and anterior to the portal vein.
C. The common bile duct may enter the duodenum directly (in 50% of patients) or join the
pancreatic duct in 50% of the patients to form a common channel.
D. The normal bile duct is approximately 1 cm in diameter. - ANSWER - The supraduodenal bile
duct resides in the hepatoduodenal ligament lateral to the hepatic artery and anterior to the
portal vein.
Correct.
The common bile duct is approximately 8 to 10 cm in length and 0.4 to 0.8 cm in diameter. The
common bile duct can be divided into three anatomic segments, supraduodenal, retroduodenal,
and intrapancreatic. The supraduodenal segment resides in the hepatoduodenal ligament lateral
to the hepatic artery and anterior to the portal vein. The common duct may enter the duodenum
directly (25%) or join the pancreatic duct (75%) to form a common channel, termed the ampulla
of Vater. The blood supply of the common bile duct is segmental in nature and consists of
branches from the cystic artery, hepatic artery, and gastroduodenal arteries. They meet to form
collateral vessels in the 3- and 9-o'clock positions.
A 64-year-old male is TPN-dependent 2-weeks status post bowel resection for perforated
duodenal ulcer. He develops right upper quadrant pain, and abdominal ultrasound suggests
acute acalculous cholecystitis. Which are correct risk factors for the development of acalculous
cholecystitis?
A. Critical illness, parenteral nutrition, sustained narcotic therapy, and trauma
B. Parenteral nutrition, history of cholelithiasis, burns, and trauma
C. Critical illness, history of biliary colic, sepsis, and sustained narcotic therapy
D. Previous cholecystectomy, recent surgery, sepsis, and parenteral nutrition
E. Critical illness, known cholelithiasis, parenteral nutrition, and trauma - ANSWER - Critical
illness, parenteral nutrition, sustained narcotic therapy, and trauma
Correct.
Acute acalculous cholecystitis is a rare condition, typically seen in patients who are hospitalized
and critically ill. It has been reported in 0.7-0.9% of patients following open abdominal aortic
reconstruction, in 0.5% of patients following cardiac surgery, and in as many as 4% status post
bone marrow transplantation. Risk factors include: critical illness, trauma, surgery,
sepsis/hypotension, and total parenteral nutrition (TPN). Predisposing factors include
gallbladder ischemia (in patients with shock or trauma) and biliary stasis (in prolonged fasting,
hyperalimentation, and sustained narcotic therapy).
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